Toileting Disability and Filing a Long Term Care Insurance Claim

toileting and long term care insurance

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Toileting is one of the activities of daily living (ADLs) that are used to trigger long term care benefits. The inability to toilet, along with the other ADLs contained in long term care insurance policies – eating, dressing, bathing, transferring and continence – are part of a combination of 2-3 ADLs needed to entitle you to benefits payable under these insurance policies. If you or a loved one is a long term care insurance policyholder and has a toileting disability, you have met one of those criteria for benefits.

Toileting Disability

Though healthy people take the ability to use the toilet for granted, toileting is a complex task that requires multiple steps. Toileting disability – which is generally defined as requiring assistance to get to the toilet, use it appropriately and/or clean oneself afterward – is a common problem associated with the aging process. Studies have found that 6 percent of the general population of community-dwelling adults age 65 or older suffer from toileting disability. This prevalence rises to 35 percent for residential care facility residents and 60 percent for older nursing home residents. Toileting involves many steps that can be problematic for older adults with limited mobility, including removing clothing, crouching to sit on the toilet or transferring from a wheelchair to the toilet, and/or wiping themselves properly.

Often, adults with toileting disability also struggle to perform one or more of the other ADLs independently. For many long term care insurance policies, benefits are triggered when you cannot perform two or more of the ADLs without assistance.

Complications of Toileting Disability

Toileting disability can cause urinary and/or fecal incontinence, poor hygiene, infections, unsanitary living conditions, adverse social and emotional impacts, and overall decreased quality of life. Additionally, struggling to use the toilet may lead to falls, which could cause serious injury and even death. 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. Unfortunately, many people living with toileting disability do not report it, whether due to embarrassment or a reluctance to admit that they have reached the point where they can no longer perform this fundamental activity.

Gather Evidence  

To file a claim for benefits, you will need to gather some evidence of your toileting disability, which should include a report from your doctor. Discuss your toileting limitations with your doctor, who should review your medical history and, if applicable, provide results of physical exams, neurological exams, imaging and/or other tests providing objective evidence in support of your disability in performing one or more of the tasks involved in toileting.

In addition, your spouse, family member or another close companion can provide a written statement about their observations and experiences with your need for assistance with toileting. Alternately, you can hire a nurse or a physical therapist to observe you as you mimic the motions required in toileting. This can be done while you are fully dressed and in a non-bathroom setting.

Prepare for the Insurance Company Assessment

The insurance company will most likely send its own nurse or other health care professional to your home to evaluate your toileting disability and your inability to perform other ADLs, as applicable. Prior to the visit, we strongly suggest that you 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 that the insurance company gets a full picture of the limitations and issues you are facing. Further, this person should take detailed notes in case there are discrepancies between the insurance company’s report of the encounter and what actually occurred.

If you are considering filing a long term care insurance claim in regards to your toileting disability, or if your claim is being challenged or has been denied, give us a call. We handle long term care claims on a daily basis and 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-Schwartz

Evan S. Schwartz
Founder of Schwartz, Conroy & Hack
800-745-1755
ESS@schlawpc.com

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