Long Term Care Insurance Claim Eligibility

Why Your Long-Term Care Insurance Policy Is So Important

7 out of every 10 people will need some form of long-term care in their lifetime. This number becomes more relevant when you factor in the baby boomer generation is already beginning to reach retirement age. It is estimated that every day until 2030, there will be an additional 10,000 Boomers reaching the age of 65. The rapidly aging boomer population means that the United States is at the precipice of a long term care crisis. The rising demand for services will inevitably lead to rising costs for care. The shortage of qualified caregivers and the rising costs mean that long-term care may be too costly for many seniors.

long term care insurance claim eligibility

According to Genworth, the annual median costs related to long-term care in 2020 in the state of Florida broke down into the following:

  • $50,336 for homemaker services, which is a 4.76% increase since 2019. It is estimated that this cost could go up to $67,647 by 2030 in the state of Florida.

  • $51,480 for a home health aide, which is a 2.27% increase since 2019. It is estimated that this cost will go up to $69,185 by 2030 in Florida.

  • $44,400 for an assisted living facility, which is a 5.71% increase since 2019. They estimate that this cost could go up to $59,670 by 2030.

  • $104,025 for a semi-private room in a nursing home facility, which is a 1.42% increase since 2019. They estimate that Floridians will pay $139,801 for the same service by 2030.

  • $117,804 for a private room in a nursing home facility, which is a 4.59% increase since 2019. Genworth estimates this cost will rise for Floridians to $158,319 by the year 2030.

 

As evidenced above, the cost of long-term care is growing exponentially. Thankfully, many seniors anticipated this and prepared by buying their long term care insurance decades ago. However, the difficulty associated with perfecting a claim can mean that seniors with policies may face denials, resulting in costly out-of-pocket expenses as they work to get their claim approved and their care covered. 

How to Qualify for Long-Term Care Insurance Benefits

Long-term care insurance is a unique and nuanced insurance product. These policies were designed with the intention to cover costs of care associated with aging. As such, they function differently than most insurance products you may be familiar with. In order to qualify for benefits under a long term care insurance policy, the insured must meet one of two possible triggers. 

 

The first potential trigger is if the insured has suffered a loss of functional capacity. In other words, the insured must prove that their health issues necessitate assistance with their basic activities of daily living as they are defined in the policy. 

 

The second trigger is if the insured is suffering from a cognitive impairment like dementia or Alzheimers. The threshold issue for this trigger is whether the insured is suffering from a cognitive impairment to the extent that they risk harming themselves or others. 

 

Loss of Functional Capacity

The loss of functional capacity trigger in a policy deals with an insured’s ability to manage their activities of daily living. The standard activities of daily living defined in most policies are; 

 

  1. Eating: The insured may require a feeding tube or may need assistance with bringing food from their plate to their mouth

  2. Bathing: The individual may need assistance with getting in and out of the shower or tub or may require a sponge bath

  3. Dressing: Needing assistance with not only putting on and taking off items of clothing but also medically necessary braces, fasteners, or artificial limbs

  4. Toileting: The ability to get to and from the toilet

  5. Transferring: Getting in and out of bed, chairs, and a wheelchair

  6. Continence: The individual may no longer be able to control their bladder or bowel movements and may need assistance with personal hygiene 

 

If an insured requires assistance with two or more of these activities, then they should qualify for benefits under their policy. However, it is important to note that each policy is unique and can have different interpretations as to what constitutes “assistance”. For example, some policies consider stand-by assistance enough to trigger benefits, while others require hands-on assistance. There is a substantial difference between stand-by and hands-on assistance. It is imperative that an insured understand this aspect of their policy. 

Cognitive Impairment

The second trigger for benefits in a long-term care policy is cognitive impairment.  The cognitive impairment trigger in most policies states that if an insured suffers from severe cognitive impairment, evidenced by objective clinical evidence, they will qualify for benefits under their policy. 

 

Cognitive impairment affects a person's executive function, memory, orientation, reasoning, and decision-making skills. The impairment will make it difficult for the person to:

 

  • Plan or follow the steps necessary to complete a task

  • Learn or remember how to perform daily activities

  • Know where and when to perform those daily activities

 

Some common behavioral examples of cognitive impairment include; 

 

  • Leaving their home, even getting into their car and going driving, but then getting lost

  • Ingesting spoiled or rotten food

  • Ingesting harmful or toxic substances, including taking the wrong amount of a medication

  • Using household objects in an unsafe manner

A person suffering from cognitive impairment may be able to carry out their activities of daily living, but due to their impaired cognitive or mental abilities, they cannot complete them without prompting or cueing from a caregiver or loved one. 

 

A claim under the cognitive impairment trigger is more difficult to perfect than a claim under the functional capacity trigger. As mentioned above, the claim must be accompanied by objective clinical evidence that an impairment exists. Objective clinical evidence can be a mini-mental exam or another similar exam, or a complete neuropsychological evaluation. It is important to rely on an expert when presenting a claim under the cognitive impairment trigger. 

How Our Attorneys Can Help You

Understanding long-term care insurance eligibility can be very difficult. Each policy has its own unique set of policy terms and conditions. Those terms and conditions also need to conform to state laws and regulations. The result is that the policies are extremely difficult for the average person to interpret and understand. The inability of policyholders or their families to understand the policy leads to devastating long-term care insurance denials. Delays and denials can be catastrophic for policyholders' physical and financial well-being. 

 

Florida Long-Term Care Insurance attorney Steven M. Dunn has specialized in long-term care insurance matters, helping hundreds of policyholders get the benefits they’ve paid for. 

Over the years, he has not only helped hundreds of policyholders and their families understand their long-term care insurance policies but has also successfully secured policy benefits for them as well. 

 

With over 30 years of experience practicing law and over 16 years exclusively focused on long-term care insurance, he can get insureds the care they need. If you or your loved one is having issues with their claim eligibility, he can help. Your initial consultation is free and gives you the chance to explain your circumstances and get the support that you need, so call now.