How to make a claim for Long Term Care Insurance

Making claims – Long Term Care Insurance

As the advisor, you are responsible for helping the insured person submit a claim. Before providing the claim forms, please review the advisor information sheet attached to the Long term care insurance claimant's statement (form E221).

There are 3 steps to making a Long Term Care (LTC)/ Retirement Health Assist (RHA) claim.

  1. Completing the claim forms.
  2. Collecting additional medical information.
  3. Making the claims decision.

Step 1: Completing the claim forms

For LTC, the insured person should inform us if they believe they are physically dependent and eligible for benefits immediately after the end of the waiting period. For RHA, the insured person should inform us as soon as they believe they are dependent after the coverage effective date. If they become

dependent before the coverage effective date, they must wait until the coverage effective date to inform us.

The advisor is responsible for sending the following forms to the insured person:

For LTC, it's a good idea to wait until the waiting period has been met before having these forms completed in case recovery occurs before the waiting period is over.

The insured person is responsible for having their doctor complete the Attending Physician's statement.

Please ensure the questions are fully answered and medical reports are attached to the forms. The completed claim forms should be sent to:

Sun Life

PO Box 1601 Station Waterloo

Waterloo, ON N2J 4C5

Sun Code 300A50

E221 - Long Term Care Insurance Claimant's Statement

The insured person must complete and sign the form.

If the insured person is competent but physically unable to complete the form, another person may help complete the form by fully recording the insured person's answers. The insured person must sign the form.

If the insured person is unable to answer the questions, the Power of Attorney for property (financial affairs) can complete and sign the form. A copy of the Power of Attorney for property document must accompany the form.

If the insured person is unable to answer the questions and doesn't have a Power of Attorney for property, the person who is looking after their financial affairs will have to get legal advice. A court order is needed. When the court has all the documentation required, it can appoint a person to manage the insured person's affairs.

E222 - Long Term Care Insurance - Attending Physician's Statement

The insured person or, when appropriate, the Power of Attorney for property must complete and sign the section that authorizes the release of medical information - found on the first page.

The insured' person?’s treating doctor must complete the form.

This form should include current medical information that supports the claim. The form asks that all reports be attached and we cannot assess the claim without the attached reports.

The insured person is responsible for any costs.

E35 - Confirming date of birth

We will need to verify the insured person's date of birth if this information was not provided at the time of application. In these cases we will notify you that form E35 - Date of birth - confirmation is required.

Step 2: Collecting additional medical information

In all cases where the objective medical information supports the need for activities of daily living (ADL) assistance, our claims assessor will phone the insured person, the caregiver and other health care professionals to gather more information. Let the insured person know that this contact may be made.

If the claim is made within 2 years of the policy date of the long term care policy, we'll request a copy of the insured person's medical records for the 5 years prior to the policy date to check for any undisclosed pre-existing conditions.

Under some circumstances, we may request an in-home assessment to help us understand the type and frequency of assistance needed.

We may make a written request for additional medical information from the doctor if the claim forms did not include all the information we need.

The advisor and the insured person will be informed when we need an in-home assessment and if we write to the doctor for additional information.

Step 3: Making the claims decision

Once we receive all information, we will assess the insured person's eligibility for benefits.

We look at physical limitations, diagnosis, medical information and guidelines for average expected recovery time.

If we are unable to approve a claim, the insured person and the advisor will be told in writing. Medical information is only shared with the insured person.

How long does the claims process take?

Documents are reviewed within 5 business days of arrival in the claims area.

If an in home assessment is being done it is completed after the waiting period has passed and the Claimant's statement (form E221) and the Attending Physician's statement (form E222) have been received.

Once the claim is approved, we establish the date on which the insured person was first dependent; the waiting period is determined from this date. The insured person receives a payment retroactive to one day past the waiting period. For LTC issued after December 9, 2013 the first payment will include the first payment bonus as described in the contract. For RHA the payment will begin after the waiting period has been met.

Tips for speeding up the claims process

Ensure the insured person completes all the information and fields on the claims forms and signs and dates the form.

The most common missing information is:

  • the full address, including postal code and phone number, of all doctors the insured person has consulted.
  • verification of the insured person’s date of birth (form E35 - Date of birth - confirmation) if proof of age wasn't submitted when they applied for LTCI.

If the claim is approved, the benefit is paid in 4 week lump sum payments.

For example, if the policy provides a $500 weekly benefit, we'll issue a cheque for $2,000 ($500 x 4 weeks).

  • Every 4 weeks, we'll issue a cheque for $2,000 until the claim ends, or
  • The insured person reaches the end of the policy benefit period