Bulletin 435 - Long-Term Care Insurance Claims

The Superintendent directs this bulletin to the attention of long-term care (“LTC”) insurers doing business in Maine and entities that pay claims on their behalf.

Since 2013, Maine has had a comprehensive law regulating the payment of LTC claims.[1] The law requires that, upon receiving a notice of claim under an LTC policy, the insurer must send the insured a sufficiently clear statement outlining what documentation the insurer needs to process the claim. The insurer may require the following documentation:

(1) A brief statement by or on behalf of the insured describing the basis of the claim for benefits;

(2) A signed release permitting the insurer to obtain personal health information about the insured pursuant to the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA);

(3) A statement from the insured’s physician, including the appropriate diagnosis and a treatment and care plan for the insured;

(4) A statement from the long-term care provider rendering services to the insured, including an itemized bill for services, the provider’s license number, and any daily nursing notes;

(5) A copy of any power of attorney executed by the insured; and

(6) Other information that the insurer determines is reasonably necessary to evaluate before making a determination on the claim and that is not readily available from sources other than the insured [2]

Read Bulletin 435 in full