Long term care insurance provides benefits for the elderly or infirm who need care in nursing homes, assisted living facilities or at home. Benefits are typically triggered when policyholders suffer from cognitive impairment or when they can no longer perform activities of daily living (ADLs). If you are concerned about your parent’s (or other loved one’s) safety due to a decline in their mental capacity, it may be time to file for long term care benefits. But as insurance companies often challenge claims of cognitive impairment, it is vital that you submit a thorough application supported by convincing evidence.
Cognitive impairment is typically defined as a deterioration or loss in mental capacity that requires supervision to protect oneself or others. It is measured by impairment in short-term or long-term memory; deductive or abstract reasoning; and confusion about who or where one is and what day or year it is. Cognitive impairment in the elderly is most commonly caused by Alzheimer’s disease, which accounts for 60 to 80 percent of dementia among older adults and is a degenerative disease of the brain characterized by gradual onset and progressive decline of intellectual, cognitive and functional capabilities.
Though medication may slow its progression, there is no cure for Alzheimer’s, which afflicts about 5.8 million Americans, or about 1 in 10 people over age 65. Besides Alzheimer’s and other dementia diseases, cognitive impairment may result from stroke, traumatic brain injuries or other causes.
Interplay with ADLs
While cognitive impairment is a benefit trigger on its own, it often impacts one’s inability to independently perform one or more of the six ADLs – eating, dressing, bathing, transferring (such as from a wheelchair to a bed), toileting and continence – which are also used to determine eligibility. Individuals with dementia often suffer from problems with toileting and incontinence for a variety of reasons, such as inability to react quickly enough to the sensation of needing to use the bathroom, inability to find the toilet or remember how to use it, or lack of motivation to find the toilet.
Further, some older adults with cognitive impairment also have mobility problems, which may render them physically unable to dress themselves, for instance. But beyond physical limitations, insurance companies may judge an individual as unable to perform an ADL without assistance if that person needs to be directed or prompted to do so. If your parent is unable to perform one or more ADLs as defined in the insurance policy, this should be added to your claim to strengthen the likelihood of approval.
Diagnosing cognitive impairment
To apply for benefits, you will need a diagnosis from a physician, typically a neurologist, and several tests supporting objective evidence of cognitive impairment. To diagnose dementia, the doctor will take a medical history, inquiring if dementia runs in the family and asking about changes in the patient’s behavior, and perform physical and neurological tests. The doctor should also perform cognitive and neuropsychological tests to assess memory, problem-solving skills and other abilities to determine mental capacity.
In addition, the doctor will look for signs of treatable underlying conditions, such as vitamin deficiencies, thyroid disorders or depression, that may contribute to dementia symptoms. The doctor will likely order bloodwork as well as a brain MRI or CT scan to identify strokes, tumors or other problems that can cause dementia and to identify changes in the brain’s structure. Genetic testing may also be ordered, as some dementias are caused by a genetic defect.
In addition to the doctor’s diagnosis and supporting test results, the application should include a statement from you (or another close family member) detailing the cognitive impairment, with several examples of how it has impacted the insured’s life and how it compromises the insureds safety. Include a statement from the applicant as well, if the applicant is willing and able to give one. If your parent is also unable to perform one or more ADLs, address this in your statement and present additional evidence. This can include a doctor’s report and an assessment by a nurse or physical therapist, who can come to your parent’s home to observe him or her mimicking the actions required for, say, bathing or dressing.
Prepare for the insurance company assessment
The insurance company will most likely send a nurse or other health care professional to your home to perform its own assessment of your parent’s cognitive ability (and ADL ability if applicable). Prior to the visit, read and understand your rights and obligations under your policy. Consider consulting with an attorney that concentrates in long term care insurance claims prior to the visit, so that the attorney can prepare you and/or be present during the visit to protect your rights.
In any event, your loved one should not meet the insurance company’s representative alone. You or a trained advocate should be present to take detailed notes and ensure that the insurance company gets a full picture of the problem.
If you are considering filing a long term care insurance claim, or if your claim is being challenged or has been denied, give us a call. We have the experience, knowledge and tenacity to make insurance companies keep the promises they make to you and your loved ones. Contact us today.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack