Benefit trigger

What it means

A typical trigger is being unable to perform two of the six activities of daily living without substantial assistance, or requiring supervision because of cognitive impairment.

The policy defines its own terms, and the definitions differ between policies. Whether standby assistance counts, and who may certify the need, are policy questions.

Meeting the trigger is not the same as being paid: the elimination period runs afterwards.

Why it matters

Claims are refused on definitions rather than on facts. A family that reads the trigger before the claim can gather the right evidence the first time.

It is also the reason to read a parent's policy before it is needed rather than after.

When you are likely to meet it

• When considering a long-term care insurance claim.
• When a parent's needs are increasing.
• When an insurer asks for a physician's certification.

Related terms

• Activities of daily livingThe everyday self-care tasks — bathing, dressing, eating, using the toilet, moving from a bed to a chair, continence — that care assessments and insurance policies measure.
• Assisted livingHousing with help for daily tasks and staff on site, but without the licensed clinical care a nursing facility provides.
• CapacityWhether somebody is able to understand a decision and its consequences well enough to make it. It is decided decision by decision, not once and for all.
• Custodial careHelp with everyday living rather than medical treatment — bathing, dressing, eating, moving about. It is what most long-term care actually is.
• Elimination periodA waiting period after a long-term care claim is approved, during which the family pays and the policy does not.
• Instrumental activities of daily livingThe harder-to-see tasks — money, medication, cooking, transport, the telephone. Difficulty here usually appears long before difficulty with bathing or dressing.
• Long-term care insuranceA policy that pays toward help with daily living — at home, in assisted living, or in a nursing facility — which health insurance and Medicare do not cover.

Sahvelo guidance that uses this

• Long-term care insurance