Long Term Care Insurance — It’s All about the Contract

If you purchased a long-term care insurance policy, (LTCI) make sure you keep that contract and the annual update notices in a safe, accessible  place and that you let your important persons know where they can find these papers. When it comes time that hands-on care, supervision and cueing are required, it will be necessary to scrutinize the contract to see just what conditions must be met to trigger the policy benefits. A Claim will have to be submitted with copious written proofs. medical records and opinions. No one has a crystal ball, but the stronger the evidence at the time the claim is submitted, the greater the likelihood that the claim will be approved so that benefits can start to flow.

A policy may say that the contract holder must require “substantial assistance in three or more of the Activities of Daily Living,” or perhaps two, or even four. The ADL’s are dressing/grooming, feeding, toileting, transfers/ambulation [with or without assistive devices], bathing, and continence. The policy holder’s needs could be the result of physical disability, or could be the result of severe cognitive impairment due to Alzheimers disease, Parkinsons disease or other dementias. Some policies cover in-home care; others only cover care in a skilled nursing facility (nursing home). The daily benefit is usually different depending on the setting. Some contracts require that in-home caregivers be licensed; others do not have that requirement. The length of the policy benefit is spelled out in the contract — five years? Lifetime? Only until a certain pool of benefit dollars is used up?

After the claim is filed, you can expect the insurance company to send out someone who will perform a functional assessment to see whether the criteria are met. As we have discussed in this space on the subject of applying for Medicaid (the PAS clinical screening) or arranging for in-home care services after Medicaid eligibility has been approved (interaction with the Case Manager from the Medicaid Managed Care Organization), self-advocacy and knowledge of the applicable standards are vital.

There is typically an elimination period such as sixty or ninety days once the claim is approved. Some policies then pay the benefit to the individual as a reimbursement, only after receiving additional proof each month that care was paid for in the prior month. This may require cooperation from the care provider, such as the nursing home or the assisted living facility or home care agency. Sometimes benefits can be assigned — some companies will pay the benefit to the facility or agency after receipt of a properly signed Assignment of Benefits. Other policies may just start paying benefits monthly after the benefits begin.

It’s all about the contract. The contract itself and information about the policy should be kept with your other important financial documents such as your power of attorney and list of assets, so that if the need arises, and your trusted person knows how to start.

For advice on elder care planning involving long-term care insurance benefits, and advice on claims issues, call us at ………. 732-382-6070

Camp Lejeune Presumption of Service Connection Proposed Regulation

On September 9, 2016, the Department of Veterans Affairs (DVA) proposed regulation governing the presumption of service connection for veterans stationed at Camp Lejeune, North Carolina, between August 1, 1953 and December 31, 1987. A link to the PDF copy of the proposed regulation can be located at https://www.gpo.gov/fdsys/pkg/FR-2016-09-09/pdf/2016-21455.pdf

The DVA set a thirty (30) day public comment period pursuant to the Administrative Procedure Act (APA) so the expectation is the final rule will be published on or about October 11, 2016.

For simplicity purposes, a veteran/claimant filing a claim for one of the covered conditions below will need to satisfy the following elements to be entitled to the proposed presumption:

(1) Have service at Camp Lejeune for at least thirty-days (30) between August 1, 1953 and December 31, 1987.  In calculating the 30 days, the DVA will consider both consecutive and non-consecutive days (for example two separate TDYs of 15 days at Camp Lejeune will satisfy that regulatory element).  Reserve component and National Guard on inactive duty for training or active duty for training for at least 30 days would also qualify for this specific presumption;

(2) The location of Camp Lejeune covers “the entirety of the United States Marine Corps Base Camp Lejeune border” to include Marine Corps Air Station New River;

(3) Has been diagnosed with one of the following conditions: (a) kidney cancer; (b) liver cancer; (c) non-Hodgkin’s lymphoma; (d) adult leukemia [not otherwise limited to B-Cell/CLL like the AO presumption]; (e) multiple myeloma; (f) Parkinson’s disease; (g) bladder cancer; (h) aplastic anemia; and (i) myelodysplastic syndromes.

In terms of effective date of award, the proposed regulation sets an effective date of award as the date of final rule and not retroactively.  Accordingly, if a veteran has a pending claim or a prior final claim previously denied for one of the above disabilities, I highly recommend that the veteran/claimant speak to there VSO.  I suspect, for most, the easiest mechanism will be to file a Fully Developed Claim with a Disability Benefit Questionnaire (http://benefits.va.gov/COMPENSATION/dbq_ListByDBQFormName.asp) completed for the listed condition immediately after the proposed rule becomes final.

Finally, I realize many folks have been in a gentle disagreement with the DVA regarding their claim for service connection related to Camp Lejeune for years and are concerned about losing an effective date of award.  If this is your concern and you just want to triage the issue with me (there will be a discussion of direct service connection and available medical evidence), please don’t hesitate to contact me at (732) 382-6070 or via electronic mail at sdirector@finkrosner.com.