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Has Your Insurance Company Denied
Your Disability Claim?

Whether an insurance company, employer, union or other ERISA governed
plan has denied your insurance claim, we can help.

What Activities of Daily Living (ADLs) Trigger Long-Term Care Insurance Benefits?

Long term Care Insurance BenefitsActivities of daily living (ADLs) are a list of general activities necessary for one to function and live independently in a household. The six standard ADLs are generally recognized as bathing, dressing, toileting, transferring (getting in and out of bed or chair), eating, and continence. ADLs are the most common triggers used by insurance companies to determine eligibility for long-term care insurance benefits. The standard criteria is that when an individual cannot perform at least two ADLs without assistance, they then qualify for long-term care insurance benefits.

Activities of daily living (ADLs)

  1. Bathing – ability to clean oneself, get in and out of shower or bath, and perform other activities of personal hygiene such as shaving or brushing one’s teeth.
  2. Eating – feeding oneself by getting food into the body from a receptacle such as a plate, cup, or table, by a feeding tube, or intravenously.
  3. Dressing – ability to put on clothes, and not struggle significantly with common clothing accessories such as buttons or zippers. This also includes putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs.
  4. Transferring – ability to walk and get in and out of bed, or chair.
  5. Toileting – ability to use and get on and off the toilet and performing associated personal hygiene.
  6. Continence – ability to control one’s bladder and bowel functions, or, when unable to maintain control of bowel or bladder function, the ability to perform associated personal hygiene, including caring for a catheter or colostomy bag.

Resources Available (Assessments) 

If family members suspect that their loved one would qualify for long-term care benefits because of inability to perform ADLs, then there are several options available for a proper assessment. There are many free online assessments available that allow untrained professionals to fill them out and properly assess the results. For formal ADL assessments, family doctors, or an occupational therapist can properly assess the individual’s medical well-being and ability to perform certain activities.

How To Qualify for Long-Term Care Benefits? 

If one is unable to individually perform at least two of these ADLs  or inability to perform at least two ADL’swithout “hands-on assistance,  then one would typically be eligible for long-term care benefits.  “Hands-on assistance,” the physical assistance, minimal, moderate, or maximal, without which the individual would not be able to perform the activities of daily living. It is rare that a policy specifies, now often or how many times in a day that the insured must need ADL “hands-on assistance.”

The individual applying for benefits or a close family member should include a written statement detailing their inability to perform these ADLs, and how it affects their everyday life and independence. The level of detail about how much assistance is needed for each activity should also be included. For certain activities, an individual may require minimal or moderate assistance, or greatly depend on another person for assistance. Aside from physical limitations, insurance companies can still consider an individual as unable to perform a certain ADL if they need to be directed or prompted to perform them.

An experienced Boston long term care attorney retained early in the process can help you with your claim. For a complimentary consultation to review your claim and to learn how we can help you to obtain the benefits you are entitled to, contact us today.

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