Understanding Alzheimer’s Disease as a cause of long-term care claims

The need for long-term care is expected to rise. According to the U.S. Department of Health and Human Services, 70 percent of people who reach age 65 will need LTC services at some point in their lives. Even more troubling is the prediction that the prevalence of Alzheimer’s will rise as well.

More than five million Americans are living with Alzheimer’s disease, which is a leading cause for needing long-term care. That number could rise as high as 50 million by 2050.

Many Americans may turn to long-term care insurance to help them alleviate the financial burden of having Alzheimer’s, or caring for a loved one who does. But does simply having Alzheimer’s mean you’re automatically qualified to receive long-term care benefits?

If you or your loved one is suffering from Alzheimer’s disease or another form of dementia and is seeking long-term care insurance benefits, there are several issues to be aware of.

Understanding Alzheimer’s

Alzheimer’s – the most common form of dementia – damages and eventually destroys brain cells, causing problems with memory, thinking and behavior. It usually develops slowly and gradually gets worse as brain function declines and brain cells eventually wither and die.

Unfortunately, the disease is ultimately fatal and currently has no cure. It is also more common than you might think; it is estimated that someone in the United States develops the disease every 66 seconds.

The National Institute on Aging says Alzheimer’s symptoms very widely from person to person, but can include:

• Memory problems
• Difficulty with word-finding
• Vision/spatial issues
• Impaired reasoning or judgment

Learn more about the 10 early signs and symptoms of Alzheimer’s from the Alzheimer’s Association.

Qualifying for long-term care insurance benefits

Long-term care insurance may help ease the financial strain of caring for a loved one with Alzheimer’s or some form of dementia. However, it may not be as easy to qualify for benefits as you may think.

Most long-term care insurance policies require that you be certified “chronically ill” by a licensed health care practitioner within the last 12 months. In this case, chronically ill means that you are unable to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance for at least 90 days due to loss of functional capacity. The six ADLs are:

• Bathing: washing oneself by sponge bath; or in either a tub or shower, including the task of getting into or out of the tub or shower
• Continence: maintaining one’s control of bowel and bladder function; or, when unable to maintain control of bowel or bladder function, the ability to perform one’s own associated personal hygiene (including caring for catheter or colostomy bag)
• Dressing: putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs
• Eating: feeding oneself by getting food into the body from a receptacle (such as a plate, cup or table) or by a feeding tube or intravenously
• Toileting: getting oneself to and from the toilet, getting on and off the toilet, and performing associated personal hygiene
• Transferring: moving oneself into or out of a bed, chair, or wheelchair

You may also qualify for long-term care insurance benefits if it is determined you have a severe cognitive impairment.

Most policies define severe cognitive impairment as deterioration or loss of intellectual capacity, which requires substantial supervision by another person to protect yourself or others from threats to health and safety.

This is measured by clinical evidence and standardized tests that reliably measure your impairment in:

• short or long term memory;
• orientation as to person (such as who you are), place (such as your location) and time (such as day, date and year); and
• deductive or abstract reasoning.

What to look for in your long-term care policy

It’s important to read the fine print when it comes to care. Beware of the waiting period, as policies can differ on when benefits kick in and create a headache for caregivers.

Let’s say you’re seeking in-home care for your loved one – the most common form of care for most people with Alzheimer’s.

Typically, a patient must wait 60 to 90 days before benefits kick in, but policies often have different parameters for when that happens.

In some cases, the waiting period begins on the day the patient is declared cognitively impaired by a doctor, and the benefits kick in exactly 60 or 90 days later.

In other cases, a policy may only count the days a patient receives care from a “qualified” caregiver during that waiting period. This means that if the caregiver only visits three days each week, only those visits count toward the waiting period.

For a policy with a 60-day waiting period, that would mean benefits would not kick in for 20 weeks, and the patient’s family would be financially responsible for care until then.

Before you hire a caregiver, it is also vital to double-check the fine print in your policy to confirm what type of caregiver is covered. For example, some policies will pay for any caregiver who is not a family member, but others may only cover a licensed caregiver hired through an agency.

The challenges of cognitive LTC claims

When it comes to cognitive LTC claims, insurance companies are notorious for having records reviewed by clinical consultants who have never examined the claimant.

Many courts consider a psychiatrist or psychologist’s opinion invalid if it is based purely on record review, especially when it directly contradicts the opinion of an examining physician. Yet insurance companies still deny claims on this basis. We see such denials at DarrasLaw all the time.

Sometimes the insurance company will have the claimant examined by a medical doctor of its choosing who will opine there is not enough objective medical evidence of cognitive impairment.

The insurance company’s examiner may have even administered the same tests the claimant’s own doctor used to establish severe cognitive impairment, but came up with a different result.

The claimant is then forced to pay an expert to review the raw data from the insurance company’s standardized tests and refute the inconsistent findings.

What follows is an expensive and time-consuming battle of the medical experts – not in the context of litigation where one expects such battles and is armed with a skilled attorney, but early in the claim. Few LTC claimants and their families have the fortitude to fight such battles alone.

Have questions about your long-term care claim?

If you are seeking long-term care insurance benefits for yourself or a loved one, or have questions about LTCI policies, contact our top-rated, highly experienced long-term care insurance attorneys for a free consultation or free policy analysis.