If you or a loved one is no longer able to bathe without assistance, you have met one of the criteria to be eligible for long term care insurance benefits. Bathing is one of the routine activities of daily living (ADLs) that are necessary for independent living and that trigger coverage when long term care policyholders can no longer perform them. Getting benefits is not as simple as completing a form, however. Your insurance company will require proof of your inability to bathe independently. And, more than likely, the company will try to manipulate facts and policy language to dispute or deny your claim.
Bathing is a complex task
Bathing is an important aspect of self-care, and disability in this area can lead to several adverse consequences. Bathing helps prevent infections while giving people the ability to feel refreshed and maintain an acceptable social standard of cleanliness. While healthy people do not give it a second thought, bathing is a complex task with many separate steps, and many older adults struggle with one or more of them.
For instance, they may have trouble climbing into and out of the tub or shower, and/or washing and drying their entire body. These limitations may lead seniors to bathe less often or less thoroughly, resulting in infections and adverse social and psychological impacts. Further, bathtub and shower accidents are common and can cause serious injuries, even death, and the likelihood of bathroom accidents increases with age and declining physical ability.
More than a third of adults over age 65 slip and fall each year, and 80 percent of those falls occur in the bathroom, according to the National Institute of Aging. Often, when people have trouble with bathing, they may also be struggling with the other ADLs (dressing, eating, transferring, toileting and caring for incontinence) that are also used as triggers for insurance benefits.
Examine your policy closely
Long term care insurance companies often differ in their definition of bathing and what constitutes impairment. While bathing is generally defined as the ability to wash one’s body and to get in and out of the shower or tub safely, some plans’ definitions specify body parts that the person must be able to wash, such as the hair or feet, and other tasks that they must be able to perform, such as turning the water on and off.
If you meet the criteria for inability to bathe independently under your policy’s definition, it may be time to evaluate your inability to perform any other of your policy’s ADLs and consider filing a long term care insurance claim.
To make a claim, you will need to document and prove your inability to bathe. In addition to your own statement about your bathing habits and ongoing struggles, your application should include a written statement from a close family member or companion about their observance of your limitations. You will also need a report from a licensed health care practitioner documenting and explaining your limitations.
In addition to self-reporting your inability to your doctor, you can hire a nurse or physical therapist to observe you attempting and showing the actions you take or attempt when bathing in your home, while you are fully clothed. You can show this professional how you struggle with the tasks related to bathing, such as getting in and out of the tub, lifting your arms to wash your hair or drying your entire body.
Prepare for the insurance company assessment
The insurance company will most likely send its own nurse or similar health care professional to your home to evaluate your ability to bathe and perform other ADLs you contend you cannot perform. Prior to the visit, read and understand your rights and obligations under your policy. It’s also advisable to consult with an attorney that concentrates in long term care insurance claims prior to the visit, so that the attorney can prepare you for what to expect and/or be present during the visit to protect your rights.
In any event, do not meet with the insurance company’s nurse alone. Many seniors have been known to underreport their challenges out of nervousness, embarrassment or forgetfulness, and having a trusted family member or trained advocate present can help ensure that the insurance company gets the full picture of what is going on. Further, the third party can and should take detailed notes of the evaluator’s questions and requests, and your responses. This will be useful later if discrepancies exist between what was said and done at the visit and what the insurance company said occurred.
If you are considering filing a long term care insurance claim, or if your claim is being challenged or has been denied, contact us today. We have the experience, knowledge and tenacity to make sure insurance companies keep the promises made to you or your loved one.
Evan S. Schwartz
Founder – Schwartz, Conroy & Hack, PC