Common benefit triggers in Long Term Care insurance policy which qualify a policyholder for coverage


Common benefit triggers in Long Term Care insurance policy which qualify a policyholder for coverage

Although insurance policies vary, the most common "triggers" or "benefit qualifiers" in long term care insurance policies are:

  • Medical Necessity
  • Loss of Functional Capacity and
  • Cognitive Impairment.
  • Very often, these are the conditions which trigger benefits. Usually only one of these triggers need exist in order to qualify for benefit payments. The way benefit triggers are defined in your policy can have an impact on how easily you qualify for benefits. Benefit triggers vary between policies and the same policy might use a different trigger for home care than it does for nursing home care. Be sure to read your policy.

    The following is an example of benefit triggers from an actual long term care insurance policy:

    To be eligible for any type of benefit under this policy, your Physician must show that you meet one of the three following benefit qualifiers:
    • Medical Necessity: You must require covered care due to Sickness or Injury. The care prescribed must be consistent with accepted medical standards for treating the diagnosed condition and could not have been omitted without adversely affecting your condition.
    • Loss of Functional Capacity: You need active personal assistance to perform at least two of the six defined Activities of Daily Living.
    • Cognitive Impairment: You require supervision and direction because of Cognitive Impairment.
  • However, the very same long term care insurance company which issued the policy above, also issued a policy which required the loss of ability to do three out of six ADLs instead of two out of six ADLs. That's why you must read your own policy to see what is specifically required for you.

    These examples are for illustration only. They do not take the place of the language which is contained in your policy.
  • Les Robinson CLTC does Long term insurance in New York and Pennsylvania

    Call for Long Term Plan  today 1-800-836-2040 ext. 3014


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