My mother has moderate dementia and has had her driving privileges taken away by her state's DMV. Unfortunately, her insurance company (which will not be named) is one of the worst in the country for paying out claims (it has 5% of the LTC market but 30% of the complaints filed.) The company is vague about what is required: At one point they told me that to qualify she would need to have 24 hour a day supervision or they would not consider her dementia serious enough for the policy to kick in. (The policy does not state a requirement that the patient need 24/7 care for benefits to kick in; it talks about "continual care" which to me is rather vague.) Her doctor does not think she needs 24/7 care. At most at this point she needs someone in for a couple of hours every other day to remind her/assist her to bathe, oversee medication, light housekeeping, and driving her. One person in the company said 24/7 supervision did not necessarily mean someone had to be physically with her all day but was vague about what it did mean. Any suggestions? She is stil in her 90 day exclusion period and the company is giving me time for a doctor to write up a plan of care. If his plan only has someone in every other day for a couple of hours each visit, do you think they will deny the claim?
There is a difference between ADLs and IADLs .
There are 2 sections of the policy that determine if the co. will pay:" Eligibility for payment of benefits" and "Covered Services". Mom's policy defines who qualifies as a caregiver (nurse, cna, etc.) and it cannot be a family member.
If your mom's policy isn't clear, ask for written detailed criteria for those sections. Also, ask for a written explanation of denial. Not just that she was denied, but what criteria did she fail to satisfy.
Good luck. Dealing with insurance companies is so stressful on top of the illness itself.
I would ask the insurance carrier for another copy of the LTC policy and any riders which have been added since your mother bought the policy.
There usually is a certain number of "visits" which the policy will pay for a person. If she only needs limited hours a couple of days, it might be worth "saving" the days for when you need someone there more hours each day.
Good luck. The LTC policies aren't perfect but they can be helpful in making it possible for an elder to remain in their home.
Elizabeth
My post wasn't clear because a link I included that defines the difference between ADLs (Activities for Daily Living) and IADL's(Instrumental Activities for Daily Living) was deleted. If you google these terms, you will see the difference. My mom's policy only covers deficiency in ADL's. It's very specific.
For the short term, you (or mom) may have to pay for a few hours of aide help until your mom progresses to a more advanced level of care. The LTC policy has a time limit also. My mother's only lasts for 3 years of payouts.
Call your state insurance commissioner, get his name, and use it in your next conversation with the insurance company. I predict they will pick up the pace.
Every month they can postpone payment means one less month of benefits.
Some of the older policies wouldn't pay at all toward the cost of "home care." Some will pay for care provided by family members; some will not. My husband and I have purchased policies that WILL pay if care is provided by a family member, but because we are both probably (with luck!) 20 years away from needing such care, we won't know until then whether the policy actually pays as promised, or even if the company will still be in business by then.
LTC insurance is expensive, but can be a financial live-saver when it comes to dementia. If you don't get dementia, statistically, you're unlikely to get out of an LTC policy what you've paid into it. If you do get dementia, it's likely the insurance company will have lost the "gamble." The companies are notorious for dragging their feet on actually paying, so you either have to advocate on behalf of the patient, or hope that you have someone who will advocate on your behalf.
And yes, it's impossible to get LTC insurance if you already need it. My Dad's policy is modest, because my parents bought it assuming neither of them would need more than 2 years of skilled nursing care at the end of their lives (this is the national average). So it taps out at a couple hundred thousand. With a progressive dementia, this wouldn't pay for more than a couple of years of facility "memory care."
I tried to get my Dad a secondary LTI policy before his dementia diagnosis, but if the applicant is over a certain age, they will do an in-person interview. It is impossible for someone with any short-term memory deficiencies to fake their way through this interview (which includes delayed memory recall questions). The company declined to offer my Dad additional insurance based on his "poor score on delayed memory recall questions" and also on the fact that he had had a knee replacement (insurance companies are also very concerned about mobility issues, as these have a big impact on a person's long-term ability to perform ADLs).
If you have a family history of dementia, I recommend looking into LTC insurance well before you need it.
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