How To Qualify For Long-Term Care Insurance

And Ways To Prove to Your Insurance Company You Need Assistance With Activities Of Daily Living


As you get older, and especially if you are seriously injured in an accident, chances are that you will need help with daily living. Statistics from the Department of Health and Human Services indicate that:

One in three people over the age of 65 will spend at least 2 years with special care needs.

Depending on where you live, that could cost up to $100,000 per year, and even more.

That’s where long-term care insurance is supposed to help. In principle, it’s designed to cover the costs of nursing home care, in-home care, and assisted living, which are expenses that aren’t covered by Medicare.

But, recent developments in the insurance industry indicate that denial of long-term care claims are common, and not every long-term care insurance policy is treated equally.

According to an article in “The Coast News Group,” thousands of complaints are filed every year with state insurance commissioners alleging long-term payment refusals by insurance companies. The article also states that about “25 percent of all long-term care claims go unpaid because insurance companies insist policyholders be so impaired that almost no one can qualify.”

So, if you have been refused coverage, or, if you are planning to file claims for coverage, here are important tips to qualify for long-term care insurance benefits.


Important Steps To Ensure You Qualify For Long-Term Care Insurance Benefits

You must have documented proof that you need help with at least two of six basic activities that a healthy person does every day without assistance, called activities of daily living (ADLs). Your primary care physician, or a licensed health care provider can provide this prior to your long-term care insurance claim process. You can provide proof by noting down in a daily diary or log book how long it takes (or what makes it impossible) to do these activities. You, or a family member, can record audio or video of your challenges to do these activities. Physician statements are also very compelling.

1. Dressing

Being able to put on and take off all clothing without difficulty with zippers and buttons, and any necessary braces, fasteners, or artificial limbs.

2. Eating

The ability to feed oneself with plates, cups, cutlery, sitting at a table; or by a feeding tube or intravenously.

3. Continence

Maintaining control of bowel and bladder function. Or, when unable to maintain control of bowel or bladder function, the ability to perform personal hygiene (including caring for a catheter or colostomy bag).

4. Toileting

Getting to and from the toilet. Or, getting on or off the toilet, and performing associated personal hygiene.

5. Transferring

The ability to move into or out of bed, a chair, or a wheelchair.

6. Bathing

Being able to wash oneself by sponge bath or in a tub or shower, including getting into or out of a tub or shower.


Fighting Your Insurance Claim Denial

If you have been denied by your insurance company, make sure that you have documented proof that you – or a family member – require long-term care insurance benefits. Here are additional steps to ensure you have a strong case.

  • Designate a family member to manage the filing process. Ideally, someone who has the time to make calls to doctors and the insurance company. It’s advisable to choose someone who is detail-oriented, clear-headed, and organized.
  • Partner with an experienced law firm who can help you with:
      • Becoming familiar with the policy before the claims process starts. Know its benefits and what it covers.
      • Know how benefits are triggered.
    • Draft and send letters to the insurance company.
  • Make sure you document your efforts. Avoid using the phone to solve your case with the insurance company. It’s easy to misunderstand important details in conversations. Always follow up after the insurance company phone call by summarizing key points in writing.
  • Make sure any home care service providers from an agency keep detailed “daily care notes,” which include the dates and times of their care for you and the care provided.
  • If the insurance company sends out a representative to do an assessment, make sure you or your parent isn’t alone. Sometimes a parent is reluctant to admit their need for assistance.


Call Donahue & Horrow

At Donahue & Horrow you will receive compassionate and highly skilled legal representation. We know how hard it can be for a family, and their loved one, to face the challenges of long-term care. We believe that a denial is unacceptable when a person has faithfully paid for their long-term care insurance benefits. Those benefits are deserved. When you reach out to us, we know that your dignity and respect are on the line. We will fight tenaciously to make sure you get what you deserve.


Know all your options – call today: 877-664-5407