Eligibility For Payment of Long Term Care Insurance Benefits

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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Written by Jeffrey Johnson
Insurance Lawyer Jeffrey Johnson

UPDATED: Jun 19, 2018

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Specific provisions in a typical long term care insurance policy govern your eligibility for benefits. These are defined below, with additional comment for clarification where needed.


You will be eligible for Benefitsonly if:

  1. We (the insurance company) are given proof, satisfactory to Us, that You (the insured) are Chronically Ill;
  2. A Licensed Health Care Practitioner has certified in writing to Us in the last twelve months that You are Chronically Ill; and
  3. A Plan of Care, including the Qualified Long Term Care Services You need, is in place.

“Chronically Ill means You are unable to perform, without Substantial Assistance from another person, at least two Activities of Daily Living (ADL) for an expected period of at least ninety days due to a loss of functional capacity; or You require Substantial Supervision to protect You from threats to Your health and safety due to Severe Cognitive Impairment.

COMMENT: The certification from a Licensed Health Care Practitioner is critical not only to document inability to perform certain ADLs, but also to confirm that this incapacity will last at least 90 days. Without this certification, you are not eligible for Benefits. Additionally, your practitioner must have a written Plan of Care in place to address your needs.

“Substantial Assistance” means Hands-On Assistance or Standby Assistance.

“Hands-On Assistance” means that You require the physical assistance of another person without which You would be unable to perform the Activities of Daily Living.

“Standby Assistance” means that You require the presence of another person within arm’s reach to prevent, by physical intervention, injury while You are performing the Activities of Daily Living.

“Severe Cognitive Impairment” means a deterioration or loss in intellectual capacity that: (a) places You in jeopardy of harming Yourself or others and, therefore, You require Substantial Supervisionby another individual; and (b) is measured by clinical evidence and standardized tests which reliably measure impairment in: (1) short or long-term memory; (2) orientation to people, places or time; and deductive or abstract reasoning.

“Substantial Supervision” means that You require continual supervision (which may include cueing by verbal prompting, gesture or other demonstrations) by another person that is necessary to protect You from threats to the health and safety of You or others (such as may result from wandering).

COMMENT: You may be physically incapable of performing two or more of the Activities of Daily Living or you may be mentally incapacitated. If the latter, the test for eligibility is not whether or not you are unable to independently perform a certain number of your Activities of Daily Living, but whether, because of loss of memory or other types of cognitive incapacity or disorientation, you have become a health or safety risk to yourself and/or others. Of course, an inability to independently perform some of the Activities of Daily Living, such as bathing, dressing appropriately and eating, may also accompany this mental incapacity Mental incapacity is, perhaps, more common than physical incapacity as we age.

We will reassess Your continuing eligibility for Benefits, based upon the criteria used to determine Your Eligibility for Benefits, at least once every twelve months, but no more frequently than every thirty days.

COMMENT: It would be totally unreasonable on the part of the insurance company, and bordering on harassment, if it were to insist on verifying your eligibility more frequently than every 30 days.

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