More than 10% of people over the age of 65 are living with Alzheimer’s disease. This number is expected to rise in tandem with the projected 50% increase in the senior population over the next 30 years. Such growth will present both challenges and concerns for families and caregivers navigating long-term care options.
For those impacted by an early-onset Alzheimer’s diagnosis, the journey can be particularly challenging. In fact, for anyone living with Alzheimer’s, long-term care insurance (LTCI) makes access to necessary care more affordable.
In this discussion, we’ll look at the essential steps and considerations to maximizing the chance your loved one’s LTC claim is approved. (We presume that if someone with Alzheimer’s needs care, the required steps to successfully pursue a long-term care insurance claim will be beyond them.) Our goal is to empower you with the knowledge and resources you need to secure access to the care and support that are essential for managing Alzheimer’s disease.
How To Get Doctor Support for Your Alzheimer’s Long-Term Care Claim
The complexities of an Alzheimer’s long-term care claim can be challenging to navigate. A physician’s backing is invaluable to prove your loved one’s eligibility and necessity for long-term care. For instance, the costs of residential facilities and assisted living can be prohibitively expensive. But getting support from long-term care benefits can put these quality resources within reach.
This professional validation becomes a cornerstone in ensuring your claim’s approval. To meet long-term care policy eligibility requirements, your doctor should provide thorough documentation of symptoms and diagnoses. This will affirm the medical necessity of long-term care services. They should underscore the need for assistance with daily living tasks and support with other skills essential for independent living.
If your doctor is hesitant to cooperate, to might be time to consult with a lawyer who has the ability to get these things done for you. emphasize the significance of their role. Be clear that their support directly impacts your loved one’s quality of life and care possibilities.
The Importance of Compliance With Long-Term Care Policy
When filing an Alzheimer’s long-term care claim, it’s crucial to understand and adhere to the terms of your long-term care policy. Each policy has specific requirements and features that dictate how and when benefits are provided. Not complying with these can lead to significant challenges, such as the denial or reduction of benefits, termination of coverage, and potential legal disputes.
Benefit Triggers
First, familiarize yourself with the “benefit triggers” of your policy. Many long-term care policies require the policyholder to need hands-on assistance with at least two activities of daily living (ADLs), such as eating, dressing, and bathing. The other triggers which are typically more applicable to those with Alzheimer’s result from cognitive impairments. While policy terms may differ, an insured being a danger to themselves is a standard which most LTC insurance companies will accept as a basis for paying benefits.
SATISFYING POLICY REQUIREMENTS FOR CARE PROVIDERS
Long term care policies often have very specific requirements for care received in a facility, and for care received in one’s home. Many LTC carriers will attempt to avoid paying what should be clearly payable claims via the assertion that the care facility is not properly licensed, or does not have the necessary on site caregivers. Only an experienced attorney will be able to advise you if the insurance company denies a claim on these grounds. If care is provided in the home, it is essential that the caregivers meet the policy requirements for an eligible caregiver. Some policies allow family members to provide care (usually under indemnity policies) while reimbursement policies typically will not cover care provided by a child, spouse, or sibling. Again, it is essential to know and understand policy terms prior to incurring care expenses and submitting claims.
Benefit Distribution
Understanding the payment method of your policy will help you gauge how to file a claim. Some policies use a reimbursement method and pay up to a daily maximum to reimburse costs actually incurred to pay for care. Others use an indemnity method and offer a monthly benefit which is payable upon establishing a need for care.
In addition, the duration of benefits varies. These are either capped by a dollar amount or for a length of time. Others provide lifetime benefits with no maximum time or dollar cap on benefits. This is particularly important in Alzheimer’s care, as the disease’s progression can span many years. Later stages often require more intensive and costly care.
The benefits page of the policy will typically provide the information you need as to the benefits available to your loved one. (Caveat: As the premiums for these policies have skyrocketed over the years, many insureds have opted for less in benefits in exchange for lower premiums, so it is essential you know that you are looking at the most up to date version of the policy.)
Elimination Period and Premium Waivers
Be aware of the “elimination period.” This is the time frame in which the policyholder must cover care costs before the insurance benefits begin. This period can range from 0 to 120 days, depending on the policy. However, as a financial perk, many policies include a premium waiver clause, eliminating the need to pay premiums once the claim is approved. Unfortunately, for reimbursement policies, expenses have to be incurred during the elimination period, and only then will you know if the insurance company will pay benefits for the claim.
Finally, recognize the scope of care covered by your policy. This can include assisted living facilities, in-home care, skilled nursing care, and even home modifications. Misunderstanding the extent of coverage can lead to unexpected out-of-pocket expenses. If you find yourself in need of additional assistance when navigating this process, get in touch with Kantor & Kantor and see how one of our specialized long-term disability attorneys can assist.
The Importance of Documentation for Alzheimer’s Long-Term Care Claims
Meticulous documentation is the foundation of a successful Alzheimer’s long-term care claim. It helps the insurance company determine if your loved one qualifies for long-term benefits, and will help an attorney fight for your rights if the claim is denied. Comprehensive documentation both supports the claim and expedites the process of receiving benefits.
In general, you’ll need four documents:
- Policyholder Statement: This statement forms the narrative of your loved one’s daily struggles and care requirements. It should encompass a thorough description of the assistance required for ADLs and a summary of both mental and physical impairments. Get as specific as possible about the Alzheimer’s symptoms, including memory impairment, disorientation, language issues, and personality changes. Also, document behavioral patterns, potential risks, current interventions, and details of medications and treatments. If the insured has gotten lost on a walk, forgotten your name, or left the stove on after boiling water for tea, WRITE IT DOWN. TIME, DATE, AND CIRCUMSTANCES. These are the type of events which demonstrate cognitive impairment requiring supervision and justify the submission of a claim and the payment of benefits.
- Attending Physician’s Statement: Your doctor must complete a form asserting the medical necessity of the care. This might include test results, medical notes, and other pertinent records that reinforce the claim and highlight the severity and specific needs arising from Alzheimer's. This is often called a Plan of Care.
- Nursing Assessment: This is a report following a home visit by an RN trained in recognizing when an individual requires care to either perform Activities of Daily Living, or supervision to keep them safe. It might also outline the type of care that’s required and ensures that the proposed care aligns with the patient’s specific needs. It can often serve as a roadmap for what kind of support is necessary.
- Provider’s Statement: A statement from the potential care providers must confirm their ability to deliver the services outlined in the nursing assessment or care plan. This assures the insurance company that the care environment is suitable and prepared and is covered under the terms of the policy.
How To Protect Your Rights and Get the Benefits You Deserve for Your Alzheimer’s Long-Term Care Claim
Caring for a loved one with Alzheimer’s is taxing and heartbreaking. If you need it, seek additional support for navigating the logistics of filing a long-term care claim. This will both take some of the stress off your shoulders and will increase the chances that the insurance company will pay the claim without having to involve legal counsel. However, if you have even a hint that the insurance company is looking for a way NOT to approve benefits, that is the time to seek legal help to ensure that your loved one gets all the benefits to which they are entitled.
A lawyer that specializes in long-term care insurance brings a wealth of expertise, especially in complex Alzheimer’s cases. If they have the proper experience in assisting insureds with long term care disputes, they will have an in-depth understanding of the legal landscape, policy nuances, and the specific challenges that Alzheimer’s claims present. Their guidance through the intricacies of policy language and claims processes can be invaluable in avoiding common pitfalls. What’s more, their expertise can continue to support you if you need to file appeals and negotiate the terms of care.
When seeking legal advice, look for lawyers with a solid background in long-term care insurance law, ideally with some experience in dealing with Alzheimer’s and dementia cases. Check their credentials, professional standing, and client reviews.
It’s also important to understand the lawyer’s fee structure. Those that work on a contingency basis will only charge you if you win your claim. Others may charge an hourly fee or flat rate.
Two helpful resources for finding support with your long-term care claim are the Alzheimer’s Association Community Resource Finder and the Eldercare Locator. Both tools help you search for legal experts and services to assist you with your long-term care claim.
Get Specialized Support With Kantor & Kantor
If your loved one is showing symptoms of Alzheimer’s disease, our hearts are with you. While this is a common diagnosis with an aging population, that doesn’t make it any less difficult to see a parent or relative suffer.
Filing a long-term care insurance claim can relieve some of the stress of caregiving so you can focus on spending quality time with your loved one. If you need help navigating the jargon and intricacies of insurance claims, a legal expert can help you file a comprehensive claim and get the benefits you deserve.
At Kantor & Kantor, we have unparalleled experience and success getting long-term care insurance claims paid. Reach out today to talk with one of our specialized long-term disability attorneys and see how we can support you and your family.
