Long-Term Care Insurance Claims – Part 2 – What is Medical Eligibility?

“Long Term Care Insurance Claims

– The Basics”

Long Term Care Claims help


What is Medical Eligibility?

Medical eligibility is laid out usually in two different sections of the long term care policy.  One section gives precise eligibility requirements and the second section gives definition that are specific on how each word is understood. For instance, most tax-qualified policies will state that you are claim eligible when require you are “chronically ill” and need “assistance with 2 of your 6 activities of daily living.”

So….what are these daily living activities? And what constitutes chronically ill? To know that, you have to check the definitions section of the the long term care policy.

“Chronically Ill” frequently requires that a medical doctor thinks you will need help for 90 days or more (so if you have a broken hip and are likely to be fully recovered within two months, you are NOT chronically ill – even though for 2 months of healing you need help). Definitions on the activities of daily living can have high variability – especially on policies bought prior to 1996. However generally they are some combination of these: transferring (getting out of a from bed or chair, for instance), dressing, bathing, toileting (including personal hygiene), and incontinence.

Most policies also allow for cognitive impairment as a medically eligible long term care claim trigger. However, most policies will not allow a definition of “mild” impairment to trigger the policy. Typically it will read “severe cognitive impairment that requires supervision” – thus a claimant has to fail cognitive screening tests to document the severity of the impairment and it must be clear in medical records that this person can no longer live unsupervised.

Some Additional Links to help you with your long term care claim journey

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