Common benefit triggers in the insurance policy which qualify a policyholder for coverage

Although insurance policies vary, the most common "triggers" or "benefit qualifiers" in long term care insurance policies are:

1. Medical Necessity
2. Loss of Functional Capacity and
3. Cognitive Impairment.

Very often, these are the conditions which trigger benefits. Usually only one of these triggers need exist in order to qualify for benefit payments. The way benefit triggers are defined in your policy can have an impact on how easily you qualify for benefits. Benefit triggers vary between policies and the same policy might use a different trigger for home care than it does for nursing home care. Be sure to read your policy.

The following is an example of benefit triggers from an actual long term care insurance policy:

To be eligible for any type of benefit under this policy, your Physician must show that you meet one of the three following benefit qualifiers:

1. Medical Necessity: You must require covered care due to Sickness or Injury. The care prescribed must be consistent with accepted medical standards for treating the diagnosed condition and could not have been omitted without adversely affecting your condition.
2. Loss of Functional Capacity: You need active personal assistance to perform at least two of the six defined Activities of Daily Living.
3. Cognitive Impairment: You require supervision and direction because of Cognitive Impairment.

However, the very same long term care insurance company which issued the policy above, also issued a policy which required the loss of ability to do three out of six ADLs instead of two out of six ADLs. That's why you must read your own policy to see what is specifically required for you.

These examples are for illustration only. They do not take the place of the language which is contained in your policy.

Qualifiers/Triggers Defined

The definitions below are guidelines for you to follow when examining your insurance policy. Every long term care insurance policy will define the significant terms. These definitions will be found within the policy but these tips can be useful when trying to decide if you meet the insurance company's definitions. For more help go to our section called "Common reasons for denial and what to do about it".

Cognitive Impairment

Conditions such as Alzheimer's or dementia are common conditions that can trigger long term care insurance benefits; these conditions cause a person to need supervision in order to protect themselves or others. That means the ability to remember to not leave the stove on or roam the neighborhoods. Although they might not need someone to physically help them, they need supervision to make sure they and others are safe.

Medical Necessity

Medical necessity is frequently defined as: "you must require covered care due to sickness or injury. The care prescribed must be consistent with accepted medical standards for treating the diagnosed condition and could not have been omitted without adversely affecting your condition".

Medical necessity is the broadest of all the triggers. It is almost always the most helpful to the policyholder, thus, it is the benefit trigger most often ignored by the insurance companies. Quite simply, there comes a time for elderly people when they need assistance, and if they don't get it, their health will be affected. They don't need to be bedridden, or significantly impaired, in order to still need assistance. For instance, an elderly person living at home, alone, can easily become depressed. Depression leads to apathy. Apathy leads to poor eating. Poor eating leads to a weakened physical condition. If the person sometimes has trouble making it to the bathroom, it is not uncommon for them to limit drinking in order to limit trips to the bathroom. Over a period of time, and it doesn't take long, malnutrition and dehydration set in. That causes weakness and dizziness, making the person more susceptible to falling and suffering broken bones.

ADLs

See Activities of Daily Living defined.