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Insurance Long Term Care Exam

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INSURANCE LONG TERM CARE EXAM

Applicant / Insured Information

Date of Birth:   Sex:

Policy Information

Coverage Amount:

Daily Benefit / Maximum:

Deductible / Elimination Period (days):

Monthly Premium:

Policy Period: From to

Examiner Information

Exam Date:   Exam Location:

Medical History and Current Status

Functional Assessment (Activities of Daily Living)

For each activity indicate the current functional level: Independent, Requires Assistance, or Dependent.

Bathing:

Dressing:

Toileting:

Transferring (bed/chair):

Continence:

Feeding:

Cognitive and Behavioral Assessment

Mobility, Vitals and Sensory

Height:    Weight:

Blood Pressure:    Heart Rate:

Home Environment and Care Support

Are there environmental hazards noted (stairs, poor lighting, rugs)?

Is there a primary caregiver available?

Coverage Options Selected






Exclusions and Limitations (Representative Examples)

Benefits under this policy do not apply to care arising directly from: (a) intentionally self-inflicted injury; (b) war or acts of war; (c) attempted suicide; (d) treatment for conditions arising prior to the effective date when specifically excluded by endorsement; (e) care provided by immediate family members without documented medical necessity. This list is illustrative and not exhaustive; final coverage is governed by policy language.

Applicant acknowledges the exclusions and limitations described above:

Beneficiary Designation

Relationship:    Percentage:

Relationship:    Percentage:

Declaration, Authorization and Certification

I certify that the information provided on this Long Term Care Examination is true, accurate, and complete to the best of my knowledge. I understand that any intentional misstatement or omission may be cause for denial of benefits or rescission of coverage as permitted by the policy and applicable law. I authorize the examining clinician and any health care provider, facility, or practitioner to release to the insurer any medical records or information relevant to the evaluation of eligibility for benefits under the policy. I authorize the insurer to obtain further information or reexaminations as necessary for claims or underwriting review.

Applicant hereby consents to release of medical information and to the examination described above:

Applicant Name:

Signature:

Date:

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What the Insurance Long Term Care Exam Is and when it matters

The Insurance Long Term Care Exam is a standardized assessment used by insurers and underwriters to evaluate an applicant's functional status, medical history, and risk factors specifically for long-term care insurance coverage. It typically combines a medical questionnaire, a brief physical or cognitive screening, and records verification to determine eligibility, appropriate benefit levels, and premium classification. The exam can be completed by a licensed clinician, paramedical examiner, or via telehealth protocols where permitted; results are incorporated into underwriting files and policy issue decisions.

Why a professional Long Term Care Exam improves underwriting accuracy

A complete exam reduces underwriting uncertainty by documenting current health, functional limitations, and medication use, which helps set appropriate premiums and limits claims exposure.

Why a professional Long Term Care Exam improves underwriting accuracy

Who prepares, completes, and reviews the Long Term Care Exam

Typical participants include the applicant, a licensed clinician or paramedical examiner, the insurance agent or broker, and underwriting or medical review staff.

  • Applicants and caregivers — provide accurate medical history, medications, and functional details
  • Paramedical examiners and clinicians — conduct vitals, mobility and cognitive screens and record objective findings
  • Underwriters and medical directors — interpret results to determine eligibility and premium class

Clear role separation and accurate handoff between these participants reduce rework and speed decisions.

Essential sections included in a professional Long Term Care Exam

A well-structured exam captures demographic and contact data, a detailed medical history, medication and allergy lists, functional assessments (ADLs/IADLs), a brief physical or cognitive screen, and examiner observations with timestamps and signatures.

Demographics

Basic identity and contact fields needed for underwriting and verification.

Medical History

Chronic conditions, hospitalizations, surgeries, and relevant specialist care.

Medications

Current prescriptions, dosages, start dates, and any recent changes.

Functional Assessment

Activities of daily living (ADLs) and instrumental ADLs (IADLs) scored for dependence level.

Cognitive & Physical Screen

Brief tests (e.g., MMSE variant, gait/mobility) and vitals recorded by examiner.

Examiner Notes

Observations, follow-up recommendations, and signature/date for audit trail.

Step-by-step: completing the Insurance Long Term Care Exam

Follow this sequence to complete and submit the exam with minimal delays.

  • 01
    1. Gather documents: Collect IDs, medication lists, and recent medical records.
  • 02
    2. Schedule examiner: Book a clinician visit or approved telehealth slot.
  • 03
    3. Conduct exam: Complete vitals, cognitive screen, and ADL/IADL checklist.
  • 04
    4. Submit to underwriter: Attach signed report and supporting records to the application file.

Configuring an online exam workflow

Set up fields, authentication, and routing so completed exams flow directly into underwriting systems.

Field Configuration
Patient ID Auto-validate with DOB and SSN partial match
Exam Template Use a standard template with required ADL fields
Signer Order Examiner signs before applicant acknowledgment when needed
Routing Auto-send PDF + audit trail to underwriting inbox

Where completed exams are sent and how they are processed

Completed exam files should be routed to the insurer's underwriting queue, retained in the applicant file, and made available to the medical director for review.

  • Examiner uploads: Signed exam and attachments uploaded to the secure portal.
  • Automated checks: System validates required fields and flags omissions.
  • Underwriting review: Underwriter or medical director reviews and annotates file.
  • Decision recorded: Eligibility, rating, or request for more info logged with timestamp.

Technical requirements for eSubmission and digital handling

Ensure the platform you use supports secure upload, audit trails, and appropriate signer authentication for healthcare data.

  • File formats: PDF and DOCX supported
  • Integrations: Works with EHRs, underwriting systems, and CRMs
  • Security: TLS in transit; AES-256 at rest

Platforms that integrate with core systems and preserve audit trails reduce manual entry and speed underwriting.

Typical timelines and processing expectations

Timelines vary by carrier, but planning for prescribed windows reduces delays and prevents application lapses.

Scheduling exam:

Within 7–21 days of application submission

Exam completion:

Often within 24–72 hours of scheduled visit

Underwriting review:

3–10 business days after receipt of completed exam

Requests for additional records:

Expect 5–10 business days response window

Policy issue:

Typically within 1–3 weeks after underwriting clearance

Common mistakes to avoid when preparing an exam

  • Incomplete medication lists — omit durations or dosages
  • Unsigned pages — missing examiner signature invalidates report
  • Vague functional answers — avoid non-specific terms like 'some difficulty'
  • Incorrect dates — mismatched dates delay verification

Risks and consequences of incorrect or incomplete exams

Underwriting delays: Additional documentation required
Premium misclassification: Incorrect rate assignment
Claim disputes: Inaccurate baseline increases litigation risk
Policy rescission: Material misrepresentation may lead to rescission
Regulatory exposure: HIPAA violations risk penalties
Application lapse: Missing info can void the application

Real-world exam scenarios and outcomes

Two concise examples show common exam workflows and results.

Case Study 1

A 72-year-old applicant completed an in-home paramedical exam documenting minimal ADL assistance

  • Examiner recorded gait instability during mobility test
  • Underwriter rated the policy with a moderate surcharge; clear documentation prevented a later claim dispute.

Case Study 2

An applicant omitted a recent hospitalization but the clinician noted surgical scars and medication changes during the exam

  • Underwriting requested records and clarified the condition
  • The corrected file led to an adjusted premium rather than a rescission, avoiding litigation.

Vendor pricing snapshot for eSignature and exam workflows

This table summarizes typical starting prices and key feature availability among common eSignature providers; signNow is listed first per vendor comparison conventions.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about the Insurance Long Term Care Exam

Answers to common questions about completion, eSign use, notarization, and recordkeeping for long term care exams.


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