Incontinence is a common problem associated with aging and certain illnesses. In order to live independently, individuals must be able to care for incontinence, which is considered one of the six activities of daily living that are used to trigger eligibility for long term care insurance benefits. If you are a policyholder and you struggle with incontinence or any of the other ADLs – which include eating, dressing, bathing, transferring and toileting – it may be time to file a claim.
How incontinence is defined
Before filing a claim, check the wording of your policy, as different policies define lack of continence in slightly different ways. Generally, incontinence is defined as the inability to maintain control over bowel and/or bladder functions. When someone is incontinent, as well as unable to perform associated personal hygiene tasks such as caring for a urinary catheter or colostomy bag, they are considered unable to care for incontinence.
Urinary incontinence is a pervasive problem that, to varying degrees, affects an estimated 10 to 35 percent of the population and is particularly common in women age 65 and older. The condition ranges from leakage of small amounts of urine when you cough or laugh, to having such a strong urge to go that you can’t get to the bathroom in time, to complete loss of bladder control. Age-related changes to the bladder, urinary tract and muscles supporting these organs are the culprit in many cases. Other potential causes include dementia, medication side effects or nerve damage caused by conditions such as diabetes, multiple sclerosis or spinal cord injury. Some patients need to use a urinary catheter, which is a tube placed in the body to drain and collect urine from the bladder and is usually connected to a drainage bag. Cleaning the catheter and emptying and changing the drainage bag can be challenging for people who struggle with mobility.
Bowel or fecal incontinence is similar to urinary incontinence in that it disproportionately impacts people over age 65, particularly women, and that it ranges from occasional leakage of stool to complete loss of bowel control. Causes include muscle or nerve damage from surgeries, childbirth, constant straining during bowel movements and conditions such as diabetes, multiple sclerosis, spinal cord injury or stroke. Some individuals have a stoma and colostomy bag to divert waste from the colon as a result of conditions such as colorectal cancer or Crohn’s disease. Like catheters, these devices require special care that some individuals may not be able to handle.
Get a doctor’s evaluation
Failure to care for incontinence can result in poor hygiene, infections, unsanitary living conditions, adverse social and emotional impacts, and overall decreased quality of life. Unfortunately, incontinence goes underreported because people are embarrassed to bring it up, even to their doctor. But discussing the problem with a doctor is the first step if you plan to file a claim, as your insurance company will require proof of your incontinence, which must include a doctor’s report. Your doctor should discuss your voiding patterns with you and review your medical history, with a focus on medical, neurological, genital, urinary and colorectal findings. Your doctor should also perform rectal, pelvic/genital and neurological exams and laboratory tests, which may provide objective evidence to support your claim of incontinence.
In some cases, incontinence can be treated and improved with interventions such as medication or pelvic floor muscle rehabilitation, but depending on the cause and a patient’s general condition and functional abilities, this may not be applicable.
Gather other evidence
In addition to your doctor’s report about your condition and supporting clinical and laboratory findings, you will need to provide your own statement detailing your incontinence and how it is impacting your daily life. Your application should also include a written statement from a close family member or companion who can speak about your inability to care for your incontinence.
Prepare for the insurance company assessment
The insurance company will most likely send a nurse or other health care professional to your home to evaluate your inability to care for incontinence and other ADLs, as 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, do not meet with the insurance company’s representative alone, as you may underreport some of your struggles because of embarrassment or forgetfulness. A trusted family member or trained advocate can help ensure the insurance company gets a full picture of the problem in addition to taking detailed notes, which will be useful if there are discrepancies between the insurance company’s report of the visit and what actually occurred.
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 their promises. Contact us today.
Evan S. Schwartz
Founder – Schwartz, Conroy & Hack, PC