Avoid these traps to make sure you meet the Substantial Assistance requirement of LTCi claims

Avoid these traps to make sure you meet the Substantial Assistance requirement of LTCi claims

One of the most common ways to trigger LTCi benefits is through demonstrating the need for "Substantial Assistance With 2 or more Activities of Daily Living." In the legal world, that phrase is also referred to as "Loss of functional capacity."

However, what you or I might think of as Substantial Assistance may be very different from the legal definition used by your insurance company. Knowing the difference will increase your likelihood of getting a claim approved, your ability to unlock maximum reimbursement, and the odds that your bills will be paid in full every month.

Your claims handler or customer service representative does not get to tell you what qualifies. If you're sent any materials in the mail, those materials don't matter either. Neither does anything on a website. The words in your policy contract are the only ones that matter.

Substantial Assistance basics

Every insurer defines Substantial Assistance differently. However, the two most common policy variations are

  • Hands-on Assistance; or
  • Hands-on OR Standby Assistance

Examples from two actual contracts

As I'm writing this article, I'm looking at two different policy contracts that were sold by one of the major insurers. Each contract is 43 pages long. I found the Substantial Assistance definitions deep within the contracts and written in single-space, 10-point font. Here they are:

Policy #1

Substantial assistance: the physical assistance (minimal, moderate or maximal) of another person without which You would be unable to perform the Activity of Daily Living

Policy #2

Substantial assistance: the physical assistance (minimal, moderate or maximal) of another person without which You would be unable to perform the Activity of Daily Living; or - which is the presence of another person within arm's reach of You that is necessary to prevent, by physical intervention, injury to Yourself while You are performing the Activity of Daily Living

Policy #2 allows you to qualify with either Hands-on OR Standby. Of course, the insurer doesn't emphasize that fact or do anything to point out how meaningful the difference is.

Common sense may cost you

In the real world, the difference between Hands-on and Standby is virtually non-existent. Whether the caregiver is directly assisting or standing nearby, they still need to be present. If a caregiver is present, they need to charge you.

In the insurance world, it's a distinction with a big difference. The difference is very easy to miss and it's often used as a trick to cheat policyholders out of payment. It's another example of how insurers use common sense against you.

A contract that only mentions Hands-On will require a slightly more detailed assessment and care plan and closer attention to invoice submissions. It's an instance where the legal wording is essential, even when practical considerations are relatively minor.

How to avoid the trap

To ensure that you meet the Substantial Assistance requirement, two things must happen:

  • The care plan must specifically match the definition of Substantial Assistance contained in the contract. If the contract is broader (like Policy #2) and allows either type of assistance, that won't be too difficult. But if it only lists Hands-on (like Policy #1), your physician or healthcare provider must specifically state which ADLs require Hands-on assistance, matching the exact words of the policy definition. You may need Hands-on with two ADLs and Standby with three, and the assessment must make those distinctions.


  • Each invoice sent to the insurer must note that Substantial Assistance was made every day you received care. Most of the blank invoices sent out by insurers contain boxes for both Hands-on or Standby (they are not pre-filled). Even if your claim has already been approved because your care plan matched the definition wording, you won't be paid unless each invoice confirms the type of assistance performed. If you need Hands-on with two ADLs and Stand-by with three, the correct two and correct three need to be matched on each invoice.

With health insurance, billing software standardizes claim and invoice submissions. Professional billers can efficiently identify minor differences in policies and ensure that all claim documents are complete, clean, and compelling.

With LTCi, the process is entirely manual and more closely resembles a legal matter than anything to do with your health. Providers don't have the time, or necessarily the training to read 40+ pages of fine print legalese. It would be a very steep burden to ask of them.

Because so many different policies exist and providers are serving a lot of people, those fine details are easy to miss and they're a big reason why insurers underpay.

The claims handler or customer service representative will never say "to make sure you get paid every dollar, make sure your assessment matches this word and that word, etc." If you submit a claim and it doesn't perfectly comply, they will simply reject it and leave you to guess why.

Similarly, their payment processors will not correct invoices for you. They won't call you and to say "I see you marked 'standby.' Did you mean to mark 'hands-on?' I'm here to help you and want to make sure you get paid."

Worse yet, it's completely legal for them to underpay in this manner because they're simply following the letter of the law in the contract and exploiting what you don't know.

The good news

When we analyze a policyholder's contract and pre-qualify a claim, we give policyholders and providers a comprehensive, step-by-step guide to ensure compliance and approval. The guide covers exactly what needs to be stated in assessments and care plans, as well as each invoice. We carefully review every submission and invoice and assist providers in making corrections before sending documents off to the insurer.

In other words, we're doing what the insurance company should but never will do. We know contracts and our nurses speak the language of providers and can walk them through each step that needs to be done, which saves them time and makes their jobs much easier.

We're here for you at The Long Term Care Advocacy Experts. Reach out today, schedule a free consultation, and discover everything you have to gain with LTCAE.

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