Dressing is one of the activities of daily living (ADLs) contained in most long term care insurance policies. ADLs are used as triggers to determine whether individuals covered by long term care insurance policies are eligible for benefits. According to the U.S. National Health Interview Survey, 20.7 percent of adults age 85 or older, 7 percent of those ages 75-84 and 3.4 percent of people in the 65-74 age range need help with ADLs, which besides dressing include bathing, eating, toileting, continence, transferring, and cognitive impairment.
Insurance companies often count on the fact that their vulnerable, aged pool of claimants will not understand their policies. They then manipulate the facts, in conjunction with policy language, to dispute, deny, and terminate long term care benefits. If you or a loved one is struggling with dressing, here’s a look at what you can do to get benefits paid.
Examine your policy closely
Start by reviewing the definition of “Dressing” in your long term care policy. Dressing is defined slightly differently in different policies.
For instance, in one older policy issued by First Unum, dressing is defined as “Putting on and taking off all items of clothing and any necessary braces, fasteners or artificial limbs.” A more recently issued policy by Brighthouse defines dressing more broadly, as “the ability to put on and take off items of clothing that are worn daily, including the ability to obtain and replace those items from their normal storage area in the immediate environment.”
Under the Brighthouse policy, someone who is not able to retrieve pants from an armoire or remove a shirt from a hanger would be considered incapable of dressing, even if the individual has no difficulty doing things like pulling up the pants or buttoning the shirt. But under the First Unum policy, this individual would be considered capable of dressing, because the definition is limited to the act of putting on and taking off clothes (and other items that are worn on the body).
Other policies discuss putting on shoes, socks, compression socks, and fastening button, snaps or other fasteners.
So, review the policy and make sure you understand the definition of “Dressing” and how coverage will be triggered by you or your loved one’s inability to dress.
Document your inability to dress
Dressing difficulties go underreported. Many people are embarrassed to discuss the problem because of its intimate nature, or they are reluctant to admit that they have reached the stage in their life when they can no longer dress independently. When people finally decide to admit the problem and file a claim for long term care benefits, it comes as a surprise to some that the insurance company will make them jump through hoops to prove that they cannot dress themselves.
If you are considering making a claim, you need to document and prove your inability to dress. Besides detailing it yourself if you are the claimant, you can have your spouse, family member or close companion provide a written statement documenting their observations or experiences with your need for dressing assistance. Another option is to hire a physical therapist or a nurse to observe as you physically simulate the motions required of dressing (including retrieving items from your closet or drawers, if applicable, based on your policy). Note that you can be fully clothed throughout this simulation.
Prepare for your evaluation
Long term care insurance companies typically send a nurse to the insured’s home to evaluate whether the claimant is entitled to benefits. We strongly recommend that you read and understand your rights and obligations under your long term care policy prior to the visit. The claimant should not meet with the nurse alone. Seniors in some cases will underreport problems they are having out of embarrassment, nervousness and forgetfulness. It’s important to have a witness present to take notes of the questions asked and the responses given throughout the interview. In fact, it’s best to have a trained advocate prepare you for the in-home evaluation, and then protect you during the course of the evaluation.
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 sure insurance companies keep the promises made to you or your loved one. Contact us today for a free consultation.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack