Eligibility For Payment of Long Term Care Insurance Benefits

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.

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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.

Case Studies – Navigating Eligibility for Long Term Care Insurance Benefits

Case Study 1: ADL Dependency and Long Term Care Insurance

Jane, an elderly individual, has a long term care insurance policy in place. Due to a decline in her health, she becomes unable to perform two or more Activities of Daily Living (ADLs), such as bathing, dressing, or eating, without substantial assistance from another person. As per the terms of her policy, Jane meets the criteria for being chronically ill and is eligible to receive benefits.

Her long term care insurance will provide coverage for the necessary care and assistance she requires, easing the financial burden associated with long term care services.

Case Study 2: Cognitive Impairment and Long Term Care Insurance

David, an individual diagnosed with severe cognitive impairment, requires substantial supervision to protect himself from potential harm. His long term care insurance policy includes provisions for coverage in case of severe cognitive impairment.

As David’s condition places him in jeopardy and requires constant supervision, he qualifies for long term care insurance benefits. The policy will assist in covering the costs of his care and supervision, ensuring his safety and well-being.

Case Study 3: Regular Assessment and Eligibility Reevaluation

Sarah, a long term care insurance policyholder, experiences a decline in her health and requires assistance with multiple ADLs. Initially, she meets the eligibility criteria and starts receiving benefits. However, her condition improves over time, and she no longer requires substantial assistance for the ADLs.

As per the terms of her policy, the insurance company reassesses her eligibility for benefits at least once every twelve months. Upon reassessment, it is determined that Sarah no longer meets the criteria for eligibility. Her benefits are discontinued, aligning with the policy’s requirement for ongoing evaluation of eligibility.