A call came into the office today from an assessment group out east. They coordinate screenings for insurance companies and insurance companies. It was apparent who was calling as soon as the thick Bostonian accent rang through. This company asks for one thing when they call. “Do you have a Registered Nurse available to do an assessment?” they ask. They want an expert to visit their clients prior to approving a long term care, LTC, claim.

The skilled nurses view of the clients situation at home is often the deciding factor in the approval or denial of claims. After performing these visits myself for the last eight years I have become somewhat of an expert in LTC claims. I can tell when a client is having a good day or a bad day and can often predict their level of need for care in the near future.

Clients who have long term care insurance policies often want to access their policy just for help with housekeeping or errands assistance. When it gets difficult for them to accomplish what we call instrumental activities of daily living, IADL’s, like meal preparation and laundry it is true that living at home can be difficult, but your LTC insurance does not consider this type of assistance as a covered benefit. They expect you to be more debilitated first.

Only when you need assistance with activities of daily living, ADL’s, like bathing, dressing, ambulating, toileting or feeding yourself will they approve a claim, and often they want you to need help with 2 or more from this list of five. This level of care often has clients and their families considering placement in an institutional setting for care.

The good news is that a skilled nurse will judge a client based on what they see during one visit, but they will take into consideration their medical history and be able to judge their need knowing what a good and a bad day will look like. The average day may include help with a shower and verbal cues to get dressed. That would count for the two ADL’s needed for a claim to be approved.

Your LTC insurance may have other hurdles related to elimination days or maximum daily reimbursement, but you will be reimbursed for the cost of in home care. Staying at home is possible and the TLC offered by an In Home Care agency can make it easier. Give us a call for information.