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 Benefits only if:
- We (the insurance company) are given proof, satisfactory to Us, that You (the insured) are
Chronically Ill;
- A Licensed Health Care Practitioner has certified in writing to Us in the last twelve
months that You are Chronically Ill; and
- 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 Supervision by 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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