With a Diagnose of Mild Cognitive Impairment and an MRI stating presence of cerebral amyloid angioplathy, moderate chronic small vessel ischemic changes in the supratentorial white matter and innumerable chronic lobar micro hemorrhages could be accepted as prove of need for a cognitive impairment LTC claim approval ?
What is the definition or description of "cognitive impairment" in your policy? Just remember, it's the policy that determines if your loved one qualifies for benefits - that's what guides the insurer and it's the standard the insurer will need to prove you met or did not meet.
Generally, LTC policies define "cognitive impairment" as "severe cognitive impairment requiring substantial supervision to protect the insured from threats to health and safety." I do not know if your loved one is at the point of needing substantial supervision for their health and safety. All I can say is that my MIL started off with a very similar diagnosis and testing results. I put in the claim about 8 months later after that diagnosis/testing, and she did have the claim approved.
Your licensed health care professional would have to certify your loved one is chronically ill (either hands-on or standby assistance for at least 2 ADLs or cognitive impairment). The LTC insurer may very well obtain medical records. The insurer may very well send its own assessor to your home to perform an assessment for both ADLs and Cognitive Impairment. They will perform some mental function testing (MoCA and MMSE are very common in the industry) and provide the score to the insurer. This information will help the insurer determine if your loved one is eligible to go on claim.
The diagnosis itself won't be enough to just put someone on claim - many people do quite well and are safe while under that MCI diagnosis. It's the determination if the impairment requires substantial supervision to maintain their health and safety.
That doesn't mean you shouldn't apply. The worse that would happen is that it is denied and you can appeal or wait and do it again when there's a decline. And at least you'd know how the process works. Another thing to consider is how long your benefit period is versus your loved one's condition and age and the kind of policy you have (indemnity or reimbursement) - some people wait to go on claim to make sure the money is available when you have to go into a memory care or skilled nursing or similar living situation, which is far more costly.
That is a lot of words to say "I don't know if it would be approved". It's more than the diagnosis but how it is impacting your loved one and if that impact qualifies as a chronically ill situation (2 ADLs or Cognitive Impairment).
I think it would help if you could explain the situation further. Is the person in a facility? There are many factors but your question is very basic. My reply would be based on if this person is in a facility or not?
I submitted a LTC claim twice. Both times she was qualified to go on claim for cognitive impairment (dementia).
This policy was a nursing home policy (what was typically sold in 1986). The policy did have an alternative place of care provision, though.
We had to closed the first claim because we didn't move her into assisted living or memory care, instead we had full time home health care (long story mostly my MIL refused and we could manage as is for a while). The insurer was not willing to consider that home health care in her current unit under the alternative provision.
The second time, we had to move her to memory care due to a rapid decline in her dementia and I filed for her claim right before the move so that they could approve the facility before moving cross-country. The insurer did check the licensing and staffing immediately and approve it. Then we finished the rest of the claim process, and the claim was approved. Benefits were paid after the 100 day elimination period. I did have to submit invoices for the facility and certify she was still living there. But it was no issue once in the facility for the 100 days required by the policy.
Both times, the insurer sent out their own assessor to assess her condition, despite the prior assessment and the move into a locked-down facility. I work on the legal side for my company, and LTC claims is one area I am highly involved in - assessments are standard for us now if the claim submitted doesn't "look" right (i.e., young claimant, something generic like "back pain" and the medical records not lining up to the claimed need for substantial ADL assistance). Cognitive impairment, I hate to say, is a lot easier to assess for an insurer. So, while I was annoyed a bit about the assessment given the records available (and obtained by the insurer), it wasn't a surprise either that an assessor came out to do the evaluation and certification. At least because the vendor my company uses for its LTC claims is the one my MIL's insurer uses, I knew what would happen and wasn't concerned (LTCG is involved in many company's LTC claims). The assessment is simply another tool used along with medical records.
The bottom line is read your policy, as mentioned earlier. It contains the requirements, and insurers will stick to the policy terms. If you have any particular questions on your policy language, please feel free to contact me - it's literally my day job. My MIL died in November, I've been through the claims process 2 times, one appeal and one re-certification. That has provided me a lot of perspective and education as it relates to my day job handling policy drafting and claims administration.
Thank you for your response . I am trying to stay ahead before we need to make a claim. Gathering as much info as possible . I would like to contact you with some questions soon if you don’t mind. How can I do that without using this site? Thanks again.
JanBro, at Alzheimer's support group meetings I've heard people talk about how hard it was for them to get LTC insurance companies to pay what the contract says it should pay. One person even said their LTC insurance company kept insisting it didn't cover assisted living for cognitive impairment -- right up until the family finally found a copy of their contract that said it provided such coverage -- then the company finally relented. Good luck.
Policies differ. Call your agent and read the policy carefully. I am afraid for some elders the shocks arrive with the needs. Some LTC won't pay unless the person enters a place where there is a full time RN. That just doesn't happen without the cost being huge. So it is a matter of what your particular policy say. Good luck.
Just recently started this process with my mom. Called her LTC insurance. At least for them, she needs help with at least 2 ADL, or a cognitive impairment diagnosis. They said they contract with a company who would need to do their own assessment once she moves to her AL apartment. Which is annoying since she has an official diagnosis from a neurologist brain MRI, has had an assessment from a neurophyscologist, and the Assisted Living place also did an assessment. But once we pass the 90 day exclusion period during which we private pay, her AL will be completely covered up to her maximum lifetime cap on her policy.
Generally, LTC policies define "cognitive impairment" as "severe cognitive impairment requiring substantial supervision to protect the insured from threats to health and safety." I do not know if your loved one is at the point of needing substantial supervision for their health and safety. All I can say is that my MIL started off with a very similar diagnosis and testing results. I put in the claim about 8 months later after that diagnosis/testing, and she did have the claim approved.
Your licensed health care professional would have to certify your loved one is chronically ill (either hands-on or standby assistance for at least 2 ADLs or cognitive impairment). The LTC insurer may very well obtain medical records. The insurer may very well send its own assessor to your home to perform an assessment for both ADLs and Cognitive Impairment. They will perform some mental function testing (MoCA and MMSE are very common in the industry) and provide the score to the insurer. This information will help the insurer determine if your loved one is eligible to go on claim.
The diagnosis itself won't be enough to just put someone on claim - many people do quite well and are safe while under that MCI diagnosis. It's the determination if the impairment requires substantial supervision to maintain their health and safety.
That doesn't mean you shouldn't apply. The worse that would happen is that it is denied and you can appeal or wait and do it again when there's a decline. And at least you'd know how the process works. Another thing to consider is how long your benefit period is versus your loved one's condition and age and the kind of policy you have (indemnity or reimbursement) - some people wait to go on claim to make sure the money is available when you have to go into a memory care or skilled nursing or similar living situation, which is far more costly.
That is a lot of words to say "I don't know if it would be approved". It's more than the diagnosis but how it is impacting your loved one and if that impact qualifies as a chronically ill situation (2 ADLs or Cognitive Impairment).
the policy didn’t make any distinction between them. Either they qualified or not, basically handled the same once qualified.
This policy was a nursing home policy (what was typically sold in 1986). The policy did have an alternative place of care provision, though.
We had to closed the first claim because we didn't move her into assisted living or memory care, instead we had full time home health care (long story mostly my MIL refused and we could manage as is for a while). The insurer was not willing to consider that home health care in her current unit under the alternative provision.
The second time, we had to move her to memory care due to a rapid decline in her dementia and I filed for her claim right before the move so that they could approve the facility before moving cross-country. The insurer did check the licensing and staffing immediately and approve it. Then we finished the rest of the claim process, and the claim was approved. Benefits were paid after the 100 day elimination period. I did have to submit invoices for the facility and certify she was still living there. But it was no issue once in the facility for the 100 days required by the policy.
Both times, the insurer sent out their own assessor to assess her condition, despite the prior assessment and the move into a locked-down facility. I work on the legal side for my company, and LTC claims is one area I am highly involved in - assessments are standard for us now if the claim submitted doesn't "look" right (i.e., young claimant, something generic like "back pain" and the medical records not lining up to the claimed need for substantial ADL assistance). Cognitive impairment, I hate to say, is a lot easier to assess for an insurer. So, while I was annoyed a bit about the assessment given the records available (and obtained by the insurer), it wasn't a surprise either that an assessor came out to do the evaluation and certification. At least because the vendor my company uses for its LTC claims is the one my MIL's insurer uses, I knew what would happen and wasn't concerned (LTCG is involved in many company's LTC claims). The assessment is simply another tool used along with medical records.
The bottom line is read your policy, as mentioned earlier. It contains the requirements, and insurers will stick to the policy terms. If you have any particular questions on your policy language, please feel free to contact me - it's literally my day job. My MIL died in November, I've been through the claims process 2 times, one appeal and one re-certification. That has provided me a lot of perspective and education as it relates to my day job handling policy drafting and claims administration.
Best wishes...
Thanks again.
i had to send copies of all the bills and the payment stubs as proof.
it wasn’t a 6 week wait....it was 6 weeks of paying out of pocket.
the same for my Mom.
Thanks
But once we pass the 90 day exclusion period during which we private pay, her AL will be completely covered up to her maximum lifetime cap on her policy.