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Long Term Care (LTC) Program
Program Information>Claims


If you have been determined as eligible to receive benefits, you will need to submit a claim to MetLife to begin receiving benefits.

The information below describes how to obtain your benefits should you need them.

Obtaining Your Benefits
You will be considered eligible for benefits when MetLife has determined that you have been certified by a licensed health care practitioner as being chronically ill (and the illness is expected to last at least 90 days) and you have fulfilled a Waiting Period.

Waiting Period
The Waiting Period is the amount of time you must wait from the date MetLife determines that you are eligible to receive benefits until the date benefits can be paid to you. The Waiting Period under the LTC Program is 90 days.


Chronically ill means:

  • Being unable to perform, without substantial assistance from another individual, at least 2 out of 6 of the following Activities of Daily Living for at least 90 days due to a loss of functional capacity:
    • Bathing 
    • Dressing 
    • Toileting 
    • Continence 
    • Eating 
    • Transferring

or

  • Requiring substantial supervision to protect from threats to health and safety due to a cognitive impairment Covered services need to be received during the Waiting Period. No benefits can be paid until the Waiting Period is satisfied.

Benefits will be paid for services included in a Plan of Care prescribed by a licensed health care practitioner. A Plan of Care identifies ways of meeting the qualified LTC benefit. If you suffer from a disability resulting from organic brain diseases including Alzheimer’s disease or a similar disorder,
you are eligible for benefits. The Plan also pays benefits in cases where your need for long-term care results from mental or nervous disorders, as determined by a licensed physician.


Requesting Payment of Benefits
You, your doctor or representative must contact MetLife and request a determination of benefit eligibility based on your inability to perform the Activities of Daily Living on your own. MetLife must approve the request for benefit eligibility and may also require access to your medical records.  MetLife will pay benefits only upon receipt of written proof deemed adequate by MetLife, in its discretion, that expenses for covered services were incurred.

Written proof of claim must be submitted no later than 90 days after the end of the calendar year in which the expenses were incurred. Failure to submit proof of claim within the time limit may result in a claim denial, unless it is shown that it was not reasonably possible, as determined by MetLife, to provide the proof of claim within the time period or that the proof of claim was submitted as soon as reasonably possible. Claim forms are available from MetLife.

If MetLife approves the request for payment of benefits, MetLife will send written notice of the decision no later than 10 business days after all necessary information is received.

Payment of Benefits
After MetLife has approved your request for payment, reimbursement for covered services will be paid directly to you. Payments for most services can be made directly to the provider at your request and the request of the providers.

The Daily Benefit Amount (DBA) selected by you determines the maximum amount that can be received each day. The amount payable will not exceed the DBA selected for expenses incurred during any day you receive covered services.

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