Perhaps I can assist. Most policies that cover LTC are very similar in how one qualifies for benefits, either needing help with 2 activities of daily living, or having a cognitive impairment.
Lets start with the activities of daily living (ADL’s) trigger. Typically the requirement is that you need help with two out of six; eating, bathing, dressing, toileting , transferring, or continence. In most cases the care need not be hands on, simply “stand by” assistance is sufficient. Bear in mind that it is quite difficult to bathe or use the toilet without removing some clothing first, and putting it back on afterwards, so often two of these are the first to require assistance.
The cognitive impairment trigger is a bit more complicated, you must require monitoring or cueing to do things that you would otherwise do on your own. Being told to take medications, being confused on your medications, wandering off, leaving the stove on all day are some examples of cognitive impairments.
Typically, if you are having difficulty in shaking loose benefits from a LTC insurance policy, it is because you only need assistance with one ADL. As I mentioned above, some ADL’s require a second one, so you are not soggy from showering with your clothes on, or forgetting to remove trousers before using the toilet. If your care provider or coordinator simply stated that you need help bathing, without mentioning the help to undress and redress, a claim could be denied. Getting the claim information to mention both ADL’s will often fix this denial quickly.
Some LTC insurance policies cover all setting; nursing home, assisted living type facilities, adult day care, and home care. Others may have been purchased covering only a nursing home. Since today, less than 20% of LTC is done in a nursing home, such a policy could be less than useful. Nobody wants to go to the expensive nursing home if they do not have to.
There were also a few policies sold that only covered home care. These were bought by optimists that thought they would never need a LTC facility, wishful thinking. If they only cover home care, and home care does not work for you, then the policy will be of little value.
So, if you are questioning what your LTC insurance policy will cover, read the declaration page to see the requirements. Then be sure to point out all the care that is needed.
One more hint that can save you money at claim time. Some people want to wait until they are in a facility before claiming. If you have a 90 day elimination (deductible) you must pay for the first 90 days of care yourself before the policy kicks in. Most policies do not care how much or how little those 90 days cost. Thus, if family is providing care, and able to do so, consider hiring help to come into the home, even if family can do it, to meet the deductible at a lower cost per day, versus waiting until the more expensive facility care is needed.
For more information, visit www.TheLongTermCareGuy.com