Long Term Care Policy Eligibility

MHWood

How "bad" does someone's dementia/cognitive impairment need to be before they qualify for long term care insurance?

My mother's physician seems to believe that a patient needs to be almost completely incapacitated and living in a home before he would certify that she is chronically ill. Meanwhile she cannot drive anymore, can no longer do finances, and cannot be left alone at home because we are scared for her safety.

I have read the policies and the definitions, but would love to hear real-life examples of people who have had a doctor certify that they are chronically ill and therefore begin to be able to use the benefits of their long term care plans to pay for things like driving my mom, and overnight care when my dad is out of town.

Thank you very much in advance for your thoughts.

fmb

You will need to contact the LTC insurance company to learn their specific procedure for activating the policy and exactly what it will cover. My DH has a policy with Genworth, and they require an exam by their affiliated medical provider service, though in his case the exam was waived because he was in hospice care.

Marta

If what you mean is: when does a patient qualify for long term care that is reimbursed by a LTC policy, that depends on the policy itself. Typically there has to be significant cognitive impairment plus loss of a specific number of ADL’s (activities of daily living .) The LTC insurance company will send their own evaluator to determine whether the person qualifies. A physician’s assessment may not even be needed.

I recommend you file a claim now. It’s up to you to get the ball rolling. I was pleasantly surprised when I filed a LTC claim for my husband that not only was MC covered entirely, but they also reimbursed me retroactively for the in-home care that I had funded for two years prior. YMMV. Best of luck. You’re in charge.

SusanB-dil

I agree that if you are looking to purchase, it would be too late. However, if you already have it, you need to check into the policy itself.

MIL has genworth, and they have been being difficult!! Her policy states that dementia is a qualifier to activate, but when we called, they said the policy also states that she has to 'not be able to do 3 of the 5 adl's (activities of daily living). Well, she can, sort of, none of it very well, and we've been going around with them for over a year, now. Meanwhile, we are doing what we can without the extra help. Since the policy does have a cap, I guess the longer they put it off, it will ultimately help some when we need it the most. I guess the longer we wait, the longer we will have some funds from this policy. We really could use just some of the funding now, (if we ever get to use it at all).

MHWood

Thank you for your comments.

Couple things - 1) She already has the policy.

2) Her policy states she needs to have EITHER cognitive impairment which requires 24 hour substantial supervision OR loss of 2 ADLs. She's OK on the ADLs mostly. But not ok to be left alone for more than a couple hours. Not ok to drive.

The insurance company is waiting for a doctor to sign that she meets either of those 2 qualifications. They sent their own people to do an assessment, but also need the doctor's certification.

I am trying to figure out how hard to fight this - if no policy will kick in until she is significantly worse off than now, then I don't want to keep banging my head against the wall. But the impression we got when talking to the claims people was that she did not need to be ready for a memory unit in order to start to use the benefits. Similar to the above poster, it would be great to start to use the benefits now given that she's been paying for this for years.

Again, thank you!

xinyi

In addition to all the previous comments, here's what I found helpful in my mom's case:
(1) get a neurologist's evaluation now. This will help with filing a claim, and back-date the start-of-claim for the elimination period.
(2) the insurance company required that we are already using a service, before they'll process the claim. They said this was to demonstrate a need. This was a big surprise to me.
(3) getting the medical records took over a month. Get that started right away.