Getting LTC Insurance to pay for home care.

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Losingthebattle Asked May 26, 2025

Getting LTC Insurance to pay for home care.

My Mom does not have dementia or any checklist problems from their forms. What she has is limited vision at times, and she is unable to drive because of it. She needs home care to do basic things like take her to the grocery store and be her eyes to find items, help her read receipts, and clean house. Maybe also walk with her to make sure she does not fall on things she can't see.

The insurance company does not look at this as a reason for them to pay a claim or cover getting home care. Any suggestions?

Elder Law Home Care Long Term Care Insurance Paying for Care Vision Loss

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score 0 · Answer 1

Be sure to have documentation from her eye MD describing her disability.
Contact the licensing bureau of the (/her) insurance company and ask them to investigate.
Look at your (/her) contract.
Hire an attorney specializing in these areas.

Gena / Touch Matters

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score 0 · Answer 2

Contact your county Office for the Aging. There are programs to provide such in-home assistance. Based on income. In NYS, we have EISEP. https://aging.ny.gov/expanded-home-services-elderly-eisep

There are also some programs under Americore (if it still exists) which pairs volunteers with seniors in need.

And in regard to the LTC coverage, as many have said, it's all about the coding. Make sure you/ medical providers know the proper medical codes and buzz words that might qualify your mom for services. Don't assume doctors/nurses know this. They know medicine, but not necessarily how the elder care sytem operates.

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score 1 · Answer 3

Her condition is largely non-medical and that’s why home help is self-pay. Use your mothers funds to pay.

Verify her LTD care policy with her agent since coded conditions for LTC must match the diagnostic codes to get benefits paid.

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score 4 · Answer 4

Pay privately for home care with your parent’s money. You will need your money for your own care when the time comes. Read the policy that your parent signed. LTC usually needs proof an insured needs help with 2-3 activities of daily living like dressing, toileting, feeding, ambulating and medications. Read the policy and get the supporting documentation in order. They want medical records from hospitals and pcp and rehab. If your mother doesn’t meet their criteria, they keep her premiums and they win. LTC is not a guaranteed care when You want it, like many people think. And my parents policy was facility only care. Only if they went to a skilled nursing home. No home care. Read and learn and be wise. Save your money and live below your means, to self insure.

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score 0 · Answer 5

Contact Amada Senior Care. They help people file long-term care insurance claims. I used them for when my mother-in-law needed care and the claim was approved in three weeks after we contacted them.

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score 1 · Answer 6

Perhaps you can contact the person who sold you the long-term care policy. I obtained mine through my financial advisor (after my elderlaw/estate planning attorney checked it over). My financial advisor and his staff are awesome. I'd call them w/any issues.

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score 4 · Answer 7

Not, really. This is common. LTC doesn't pay for these needs usually. The contract she signed will tell what they DO pay for and under what circumstances. What other options are you considering?

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I agree that the situation described isn’t something that I would expect LTC to cover.

I would suggest investigating services for helping the visually impaired to obtain and use assistive equipment: voice aided computer for online shopping, white cane for walking, bump dots for household appliances, maybe an Echo Show for “what am I holding?”

My aunt worked with a very helpful group in Seattle.

(1)

score 3 · Answer 8

Unfortunately, I’ve never heard of a long-term care policy that didn’t require someone to need assistance with two ADLs, such as dressing, bathing, toileting. As Geaton says though, you need to read the policy and if it’s not clear, then seek assistance.

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I seem to recall reading about coverage for a person claiming for something called a complex yet stable medical condition. It was someone with visual impairment and a condition that required frequent at home blood testing and medication adjustments, probably an especially tricky version of diabetes. It may have been a court case and, if so, I don’t know how it turned out.

I can’t see an insurance company paying out for failing vision alone.

Here is the language from one contract:

“Complex, Yet Stable Medical Condition means that twenty-four (24) hour a day nursing observation, or
professional nursing intervention more than once a day, in a setting other than the acute care unit of a hospital is
medically necessary, that is, the observation or intervention has been prescribed by a Physician and it is not
designed primarily for the convenience of You or Your family.”

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score 3 · Answer 9

Have you actually read the contract to know what constitutes eligible care? It may be worth consulting with a contract law attorney to review the policy.

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score 3 · Answer 10

They make the rules, so no. This is why I’m not in favor of anyone getting an LTC policy. Better to earmark a special account - CDs, savings, mutual fund - wherever you can get a good rate of interest or earnings - contribute regularly and never touch it. When you’re ready for home care YOU decide how to use it for yourself. No company to refuse to pay. No forms to file. No agency or facility needs to be approved by the insurance company.

But, since you are stuck with the insurance company, see if you can have a personal conversation with a client care rep and find out if there are any options for you. I have learned that they try to weasel out of paying any way they can. They delay processing, paying, and communicating. But you can try.

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I have John Hancock insurance and having problems. They delay, delay, delay. I am very stressed, as I have depleted my savings in order to pay my caregivers. I’m at my wits end and ready to give up as I have advanced MS. I cannot cope anymore.

(0)

Getting LTC Insurance to pay for home care.

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