Long-Term Care Health Benefits and Your Disability Insurance Policy

Welcome to Season 5, Episode 1 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Long-Term Care Health Benefits and Your Disability Insurance Policy."

Join host Nancy L. Cavey, an experienced attorney specializing in disability claims, as she delves into the complexities of Long-Term Care health benefits and their relationship with your disability insurance policy. Although their names may seem similar, Long-Term Disability insurance and Long-Term Care insurance have distinct differences, which Nancy will break down. She’ll also highlight critical policy language and expose the tactics insurance carriers often use to deny benefits. 
In this episode, we'll cover the following topics:

1 - The Four Differences between Long-Term Disability Insurance and Long-Term Care Insurance

2 - Typical Long-Term Care Policy Terms That You Should Be Familiar With, and Why the Devil Is in the Policy Terms

3 - Games Disability and Long-Term Care Carriers Play in Denying Benefits

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Resources Mentioned In This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Need help with your Long-Term Disability or ERISA claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Nancy Cavey [00:00:13]:
 Welcome to Winning Isn't Easy. I'm Nancy Cavey. I'm a national Individual Disability at ERISA Disability Attorney. Before we get started, I've got to give you a legal disclaimer. This podcast is not legal advice. The Florida Bar association says I have to say this, so nothing will prevent me from giving you an easy to understand overview of the disability insurance world, the games the carriers play, and what you need to know to get the disability benefits you deserve. So off we go now. I'm going to talk today about long term care benefits in a long term disability policy.
 
 Nancy Cavey [00:00:48]:
 Typically, a disability insurance policy doesn't cover long term care services and what we'll normally see is the employer offering a suite of employee benefits. It's disability policies, life insurance, health insurance, and even a pension. But there are some disability policies that, within the body of the policy, will offer long term care benefits. Recently, I have been involved in the appeal of several such cases where the disability carrier pays for the long term disability benefits but denies the long term care coverage in the policy. Now, long term care benefits cover the cost of out of pocket expenses for long term care assistance with basic activities of daily living like bathing, dressing, toileting, transferring and other activities that may be specified in the policy. So in this week's episode I'm going to talk about the interaction between long term disability benefits and long term care benefits in a disability policy and what you need to know. So specifically, I'm going to talk about three things. First, the four differences between long term disability insurance and long term care insurance, two typical long term care policy terms that you should be familiar with and why the devil is in the policy terms.
 
 Nancy Cavey [00:02:08]:
 And lastly, I'm going to talk about the games that disability and long term care carriers play in denying benefits. Got it. Let's take a break.
 
 Speaker B [00:02:17]:
 Have you been robbed of your peace of mind by your disability insurance carrier? You owe it to yourself to get a copy of Robbed of your peace of Mind which provides you with everything you need to know about the long term disability claims process. Request your free copy of the book@kvlaw.com today.
 
 Nancy Cavey [00:02:39]:
 Welcome back to Winning Isn't Easy. Let's talk about the four differences between long term disability insurance and long term care insurance. Now, long term disability benefits provide for the payment of disability benefits if you're unable to perform your own occupation and generally after two years, an inability to perform any occupation. There are no uniform disability policies or plans in the United States. Each is different. So I always urge people to get a copy of their policy or plan and read it cover to cover so you understand the definition of disability, the definition of occupation, what you've got to prove to get your benefits, how your benefits might be coordinated with other benefits, whether there's any policy limitations for mental, nervous or subjective medical conditions, and how long you might be eligible for benefits. Think of this as a form of income replacement, because a typical disability insurance policy will pay 50 to 60% of your income that you had before you became disabled. Now, on the other hand, you might have individual or group long term care insurance benefits that cover expenses that you incur if you're not able to take care of yourself.
 
 Nancy Cavey [00:03:51]:
 Normally, long term care benefits will begin if you're no longer able to perform two or three of the six activities of daily living, such as hygiene, dressing, eating, toileting, transferring, walking, having a cognitive impairment. And so the long term care policy will pay for the costs and expenses associated with that care that may not be covered by your group health insurance policy or even by Medicare. This can include extended stays in a nursing home or rehabilitation facility, or even home care. Now, long term care and disability insurance is not just for the elderly. You might become disabled as a result of a progressive medical condition or as a result of an accident. The long term care insurance, particularly if you buy it as an individual, can be very expensive compared to other types of insurance products. And and many times the long term care costs will far exceed the premiums, but the premiums can increase, unlike a disability insurance policy. Now, in a long term care policy, you can decide how much care you want to purchase, the nature of the benefits, how much benefits will be paid, the length of time, and ultimately the long term care insurance company will determine the premium based on your age and health.
 
 Nancy Cavey [00:05:04]:
 If we're talking about an ERISA type situation, the long term disability carrier offers your employer a group rate that's far less than what you could pay for if you bought an individual disability policy. And sometimes, as I've said, there are long term disability policies that offer within it long term care benefits. But generally, let's talk about the four fundamental differences between long term disability insurance and long term care insurance. First, long long term care insurance protects your asset from being used or dissipated because of the need for long term care. Disability insurance, on the other hand, protects your income in the event you can't work. Long term care covers the cost of home care, assisted living, nursing home, and maybe modifications to stay at home. It won't pay your mortgage if you stay at home or your normal household bills. That's where the long term Disability benefits will pay you an income that you can use any way you see fit.
 
 Nancy Cavey [00:05:59]:
 Pay your mortgage, pay your bills, pay your groceries, whatever it is you want to do with that money. Number two, Long term care provides benefits when your doctor confirms that you can't generally do two out of six activities of daily living or have a cognitive impairment due to dementia or Alzheimer's, long term disability will normally have an elimination period which is 90 days long and you get no benefits in that period of time. When you satisfy that benefit, then you become eligible for coverage. So the process is different and you get paid long term disability benefits if you meet the definition of disability, which is not always the same as it really isn't the inability to do two out of six activities. Number three, long term care can be paid for by your employer or can be offered to you as a voluntary benefit for you. Now, more often than not, as I've said, I don't see that type of coverage in a disability insurance policy. And more often than not, people will will buy an individual long term care policy. So the way you get them can be completely different.
 
 Nancy Cavey [00:07:01]:
 You can buy an individual disability policy, an individual disability long term care policy, very expensive. Or you can get a long term disability policy through your employer, governed generally by the ERISA law and generally, as I've said, it does not provide for long term care benefits. Now number four, long term care benefits can be used during your working years to pay for care if you're unable to perform ADLs. And it doesn't matter the period of time you're disabled or can't do those activities unless of course, when you purchase the policy, you put limits on the amount of care, the length of care or the cost of care. Disability insurance, on the other hand, is generally used during your working years as an income replacement if you're disabled and it will normally stop at retirement age. So you can see that there are some very fundamental differences. And what I'm going to talk about next is long term care benefits within a disability insurance policy and the problems that you can face. Got it.
 
 Nancy Cavey [00:08:05]:
 Let's take a break. Welcome back to Winning Isn't Easy. Let's talk about typical long term care policy terms that you should be familiar with that you might find in a long term disability policy and why the devil is in the policy terms. Now typically if you see any type of long term care benefits within a long term disability policy or plan, they're going to be called CAT benefits. Not as in cat, cat as in catastrophic disability benefits. And normally what you'll see is a rider that will pay benefits in addition to the disability benefits. This can come in a couple different forms. It can actually come in the form of specific benefits for specific services.
 
 Nancy Cavey [00:09:02]:
 Or you might see the typical cat rider that says, hey, we will provide you with an extra $2,000 in addition to your long term disability insurance benefits. And by the way, we're going to have a 180 day elimination period. And your long term disability benefits may have a 90 day elimination period. And by the way, there's going to be a 24 month cumulative maximum benefit for these benefits. And by the way, the definition of disability would be the inability to do two out of six activities of daily living. Now that should be contrasted with what you'll normally see in the disability policy. So the CAT is going to have basically the payment of extra benefits, an elimination period, normally a limitation as to the amount of benefits or the period that they will pay. And the long term disability policy will say, okay, here's the definition of disability.
 
 Nancy Cavey [00:10:03]:
 It's not can't do two out of six activities of daily living. It's your inability to do the material and substantial duties of your own occupation or any occupation. And by the way, we're going to limit benefits for subjective medical conditions to just two years or mental nervous conditions to just two years. And you can see that the definition of disability is completely different. One is based on ADL's, that's the cat. And the Ltd is based on an inability to do your own or occupation benefits. And if you want to be paid both benefits, you got to meet the definition of disability as it's defined. Now again in the long term care policy, the relevant definitions are going to include the definition of activities of daily living, cognitive impairment, standby assistance and substantial supervision.
 
 Nancy Cavey [00:10:53]:
 The long term disability policy is going to define the term disability and the term occupation. It might be that the definition is an inability to do the material and substantial duties of your own occupation. There are a number of different types of definitions of disability, but that's just one of them. And you can see that's completely different. Now another thing that's really important again when you're looking at the long term care benefits is to look at the actual definition of each of these activities. Bathing, dressing, toileting, transferring, continence, eating. And you have to actually meet each one of those definitions. And if you don't meet those definitions, then you don't potentially meet the requirement of the inability to do or need assistance with two out of the six activities of daily living.
 
 Nancy Cavey [00:11:46]:
 The other Key difference here is that there are three ways to be entitled to the cat benefits. And again, you have to go back to the definition. Catastrophic disability or catastrophically disabled could mean that you are cognitively impaired, that you're unable to perform two or more activities of daily living safely without standby assistance of another person, or that you're presumptively disabled because you have met the requirement for the loss of vision or the loss of limbs. Now, sometimes you will also see policy limitations on catastrophic disability benefits. What you'll commonly see is limits on a person's mental nervous condition. So benefits will be limited to just two years or it will require evidence of objective proof. Or if it's a subjective medical condition like fibromyalgia, benefits will be limited to just two years. Now, there are similar limitations in the context of a CAT benefit.
 
 Nancy Cavey [00:12:46]:
 So it might be that it's excluded if the disability is contributed to or caused by a diagnosis that involves sleep disorders, learning or attention deficits, substance abuse use, schizophrenia, mood anxiety, somatoform disorders, psychiatric disorders. So there might be internally, under the catastrophic benefit provision, a limit on the definition, if you will, of the activity of daily living, but also a limitation on the amount of benefits or entitlement to benefits based on a contribution. What's also important is that you're looking at definitions of what standby assistance is, substantial supervision. Again, all these definitions are really, really crucial for you to understand because the proof inherently is different than the proof for the long term disability benefits. So what I like to do is when I'm reading one of these policies is I'm outlining, okay, here's the definition of disability for the disability benefits. Over here is the definition of disability or policy terms that I need to understand to go about proving that they're entitled to the assistance with activities of daily living. Two completely different types of benefits. Two completely different types of proof.
 
 Nancy Cavey [00:14:09]:
 And it all starts, of course, with looking at the applicable policy or plan, understanding what you have to prove, and the differences. So as you're looking at this case, you're able to fashion together a theory that establishes not only you're entitled to your disability benefits, but benefits for the activities of daily living and understanding policy limitations. I know it sounds confusing and involved and it is, it takes, I think, careful analysis of the policy terms and careful analysis of the medical records to understand what it is that needs to be proven. Got it. Let's take a break and I'm going to talk about the games that disability and long term care carriers play in denying benefits.
 
 Speaker B [00:14:53]:
 Are you a professional with questions about your individual disability policy? You need the Disability Insurance Claim Survival Guide for Professionals. This book gives you a comprehensive understanding of your disability policy with tips and to dos that will assist you in submitting a winning disability application. This is one you don't want to miss for the next 24 hours. We're giving away free copies of the Disability Insurance Claim Survival Guide for Professionals. Order yours today@disabilityclaimsforprofessionals.com.
 
 Nancy Cavey [00:15:30]:
 Welcome back to Winning Isn't Easy. Let's talk about the games that disability and long term carriers play in denying Benefits. Now there are many games that long term disability carriers will play in denying benefits. They will look at the policy or plan terms and say, hey, you don't meet the definition of disability. You don't have restrictions and limitations that would prevent you from performing your own or any occupancy patient or your benefits are limited subjective medical condition that's listed in this policy or plan. Those are some of the common games that you will see in the context of a long term disability claim. But let's talk about the long term care games. We've been talking in this series about long term disability policy, what we call long term care benefits.
 
 Nancy Cavey [00:16:17]:
 And normally the requirement is that you are able to do two out of six of the basic activities of daily living such as bathing, toileting, transferring, that sort of thing. And in each instance the carrier or plan administrator is going to be looking at the applicable definitions in the policy or plan for each one of those benefits and kind of outlining them and checking the evidence to establish whether or not the person is meeting the elements of the proof for the disability benefits and for the CAT benefits. So let me tell you a hypothetical situation. Let's say that you have a person who is disabled as a result of psychological issues and the disability carrier starts to pay the long term disability benefits because of the psychological conditions. But there's a CAT provision in the policy and in this plan the person has to submit documentation of their inability to do two or more of the activities of daily living without standby assistance or cognitive impairment requiring substantial or continual supervision. And let's say that the disability carrier is paying the disability benefits but is looking at the CAT benefits and they look at the medical records and they have a psychiatrist take a look at it. And that psychiatrist concludes that at least temporarily, the person, because of their psychological issues are unable to perform two or more of the activities of daily living and the claim gets approved. But then at some point they wake up and Realize that the policy or plan actually does not allow for the payment of catastrophic benefits for psychological conditions, but could pay for benefits if there was a cognitive impairment.
 
 Nancy Cavey [00:18:08]:
 So the game has now changed from what it is you have to prove to whether there is even coverage. And sometimes what you will see is a denial that things like, well, the records don't reflect an inability to do the ADL's independently. You've got to take a look at the basis of this claim. Well, if because of cognitive impairment, the person needs supervision or other assistance, the medical records need to document the person's inability to perform those activities of daily living without assistance and with cueing. And of course the evidence has to establish that the person has a cognitive impairment, not just a psychological impairment, a cognitive impairment. Secondly, denial might say something like, well, there's no documentation of any focal, neurological, motor or sensory impairment that could result in the inability to perform ADLs or that they require assistive devices. Well, again, this goes back to the fine print in the policy. In the catastrophic provisions of the policy, there's no requirement that there be any neurological, motor or sensory impairment, particularly since at this point the claim is involving a cognitive impairment.
 
 Nancy Cavey [00:19:28]:
 So or plan will actually misapply what the proof is and try to mislead the policyholder or plan beneficiary because there is no neurological, motor or sensory impairment. It's a cognitive impairment. They also may suggest that there's no physical exam findings that show weakness, sensory loss, abnormal or unsteady gait that would suggest a need for ADLs. And again, they are misapprehending that the issue is cognitive impairment. And certainly you might see some problems with abnormal or unsteady gait or confusion because of cognitive impairment. But if the policy or plan doesn't require it, then really, who cares? So it might say, look, there's no for a severe deterioration in cognition or the loss of intellectual capacity that results in the need for substantial supervision. Again, you've got to analyze those records. Those records may in fact show a deterioration in cognitive function, may show a loss of intellectual functioning, and may show that because of that there are threats to their health.
 
 Nancy Cavey [00:20:43]:
 And have the person has issues with bathing, toileting, incontinence, self care and eating. They may say, look, there's no clinical findings documenting memory loss, concentration or other abnormalities. Again, it goes back to the language of the of the CAT policy. Does the CAT policy actually require objective evidence of testing or clinical findings? If it doesn't, then they can't request that information. But of course that is strong support for the claim. Now, the denial might say, well, look, the caregiver doesn't live with the policyholder or plan beneficiary and therefore they couldn't necessarily require substantial assistance or supervision. Again, you got to look at the language of the policy. Does it require the caregiver to live with a policyholder or plan beneficiary? If it does, then that's an issue.
 
 Nancy Cavey [00:21:30]:
 But if it doesn't, that's an issue. They certainly should be entitled to those benefits, at least for the period of time in which they require the assistance. They may say, look, the policyholder plan beneficiary is making decisions about their own medical care and that's inconsistent with a claim of cognitive impairment. Again, you got to look at the policy or plan to see whether or not this equates with the inability to make medical decisions equates to a severe degree of cognitive impairment. There doesn't necessarily have to be a relationship, and there certainly may not even be that policy requirement in terms of the plan. One of the other things I sometimes will see is they'll deny a claim for CAT benefits. The policyholder plan beneficiary's ability to communicate with the carrier or the plan administrator is not consistent with the claim that they have cognitive impairment or the cognitive impairment is so bad that they require supervision. Again, most policies or plans don't have provisions that equate an inability to communicate with the claims department as a non severe degree of cognitive impairment.
 
 Nancy Cavey [00:22:42]:
 And again, normally what I'll see is that the plan beneficiary or the policyholder is having issues not only with cognition, but with getting along with people. They may demand changes in the claims examiner. They may claim that the claims examiner is exacerbating their need for care, that the claims examiner is handling the claim in such a way that's just making all of their cognitive symptoms worse. Again, you got to look at the policy or the plan to see whether those kinds of things are required. They also may argue that there's a lack of functionality in terms of complaints. In other words, sometimes people who have, for example, cognitive impairment don't necessarily think there's anything wrong with them, or they'll deny that there's something wrong with them. And you may see in the context of a medical report that the person denies having any problems when everybody around them knows that they're having problems and sometimes not will the disability carrier, but the cat claim examiner will seize things and say, well, my goodness, those are. The self report is inconsistent with this kind of claim.
 
 Nancy Cavey [00:24:00]:
 So you can see that in these instances there's an inconsistency between what the policy is requiring, the CAT benefit provision of the policy, and the reasons that they may raise for denying or terminating the benefits. They're a completely somewhat different set of reasons or rationales that they come up with denying long term disability benefits. So if you have a situation where you have a catastrophic benefit claim, again, I think you've got to coordinate the definitions of disability, the definition of activities of daily living. You've got to coordinate whether there's objective proof or not objective proof. So what does the policy say? What does it require? And then think creatively. I think there are many ways to overcome claims denials not only in terms of long term disability claims, but long term disability cat claims. You can get a statement regarding the care from family members or friends. You can get a statement of the policyholder plan beneficiary, you can get a statement of the doctor, you can get testing, you can even do a video.
 
 Nancy Cavey [00:25:06]:
 And obviously you have to write a detailed letter. So you can see again, the coordination of proof is really crucial if you're going to try to get both long term disability and CAT benefits in the context of a policy or plan that has both benefits. Got it. So you need to consider that this is the kind of case that's medically complex and one that you probably should have the assistance of an experienced long term disability and long term care attorney before you even apply for both your disability benefits and your CAT benefits. Proof has got to be coordinated. You need to know what to prove and not how to destroy either claim in attempting to maximize your benefits. Got it. I hope you've enjoyed this week's episode of Winning Isn't Easy.
 
 Nancy Cavey [00:25:51]:
 If you've enjoyed this episode, like our page, leave a review, share it with your family or friends, and subscribe to our podcast. I hope you tune in next week for another insightful episode of Winning Isn't Easy.