Long Term Care Insurance: Toileting and Your Right to Benefits

As their profits decline, Long Term Care insurance companies like Prudential, John Hancock, MetLife,  Brighthouse, MassMutual and Mutual of Omaha are applying a heightened level of scrutiny to avoid paying claims under generous long term care policies they sold in the 80’s and early 90’s.      

These long term care policies typically promise pay their insureds a benefit when they are unable to perform 2 out of the following activities of daily living:

  • bathing
  • dressing
  • toileting
  • transferring
  • continence
  • eating

To deny long term care claims and preserve their bottom line, insurance companies count on the fact that their vulnerable, aged pool of claimants will not be familiar with the provisions in their policies that will entitle them to benefits.  This article, devoted to “toileting,” is the first of five articles discussing how one can demonstrate their inability to perform one of the activities of daily living.  

What is Toileting?

Did you ever think about how important toileting is?  First thing you just asked is: What is toileting?  Well, most long term care policies define toileting as: getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene.  Thus, if you can demonstrate that you are unable to safely enter the bathroom, sit on or stand next to the toilet, wipe and flush without the assistance or standby assistance of another person, you may satisfy 1 out of the 2 activities of daily living that will entitle you to benefits under your long term care policy. 

Typically, we take this simple act of toileting for granted. Unfortunately, when you are not capable of toileting on your own, due to illness or injury, it can become a crisis, as this is an essential function which does not always permit a lot of leeway when the time comes for execution. Further, without someone to assist, this can become a very unpleasant and unfortunate situation..

Documenting Your Inability to Toilet

Understandably,  many claimants under-report or fail to report their inability to “toilet,” as described above, out of embarrassment or out of a reluctance to admit that they have reached that stage in their life where they need help with this fundamental activity. 

If you are considering making a long term care claim or if you are in the middle of making a long term care claim, you may document and prove your inability to “toilet” in number of modest and discrete ways.  First, a spouse, partner, family member or other close companion can furnish the insurance company with a written statement containing their observations and experiences with your need for assistance with toileting.   Alternatively, you can hire a physical therapist or nurse to observe you physically simulate the motions required of toileting, even while fully clothed and in a non-bathroom setting.   

Long term care insurance companies hire nurses to evaluate you in your home, to determine whether you are entitled to benefits under long term care policy.  It is very important for you to be prepared for this evaluation.   We strongly recommend that you read and understand your rights and obligations under your long term care policy, prior to allowing this in-home evaluation, and also to have a witness take notes during this process,,  documenting the event, along with the questions asked and responses provided.  Preferably, you should have a trained advocate prepare you for your in-home evaluation and protect you during the course of that evaluation. 

Keeping the insurance companies in check when it comes to in-home evaluations or at any stage of a long term care claim requires experience, knowledge and tenacity.  Our firm manages these issues on a daily basis.  We know how to keep your long term care benefits flowing and how to get them approved.  

Don’t hesitate to contact us today if you are having these or other problems with your long- term care claim or your long-term care insurance company.


Evan S. Schwartz
Founder of Schwartz, Conroy & Hack