March 24

Class Certified in Case Against LTC Insurer that Denied Coverage to Assisted Living Residents

A U.S. district court in Connecticut certifies a class action against a long-term care insurance company by policyholders who claim they were unfairly denied coverage because they lived in a managed care community or assisted living facility. Gardner v. Continental Casualty Company (U.S. Dist. Ct., D. Conn., No. 3:13cv1918 (JBA), March 1, 2016).

A group of individuals purchased long-term care insurance from Continental Casualty Company. The policies provide that in order to qualify for benefits, claimants must demonstrate that the facility they live in meets the definition of a long-term care facility. The policy defines a long-term care facility as one that is licensed by the state. The individuals moved into managed care communities or assisted living facilities and applied for benefits. The company denied benefits on the grounds that the facilities were not licensed facilities.

The individuals filed a lawsuit against the company, arguing that the insurance company wrongly denied them benefits. They asked the court to certify a class of all people who currently own two specific types of long-term care insurance policies and a subclass of all people who owned long-term care insurance and were denied care at a managed care community or assisted living facility.

The United States District Court, District of Connecticut, grants class certification. The court rules that the class is easily ascertainable and including all current policyholders is not too broad. In addition, the court finds that the subclass is not too small to meet the numerosity requirement because the class will consist of at least 29 people. The court also rules that the plaintiffs have demonstrated commonality and typicality because they have shown that class members’ claims depend on a common contention that is capable of class-wide resolution.

For the full text of this decision, go to: https://ecf.ctd.uscourts.gov/cgi-bin/show_public_doc?2013cv1918-168

December 24

Activities of Daily Living Measure the Need for Long-Term Care Assistance

Most long-term care involves assisting with basic personal needs rather than providing medical care. The long-term care community measures personal needs by looking at whether an individual requires help with six basic activities that most people do every day without assistance, called activities of daily living (ADLs). ADLs are important to understand because they are used to gauge an individual’s level of functioning, which in turn determines whether the individual qualifies for assistance like Medicaid or has triggered long-term care insurance coverage.   

The six ADLs are generally recognized as:

  • Bathing. The ability to clean oneself and perform grooming activities like shaving and brushing teeth.  
  • Dressing. The ability to get dressed by oneself without struggling with buttons and zippers.
  • Eating. The ability to feed oneself.
  • Transferring. Being able to either walk or move oneself from a bed to a wheelchair and back again.
  • Toileting. The ability to get on and off the toilet.
  • Continence. The ability to control one’s bladder and bowel functions.

There are other more complicated tasks that are important to living independently, but aren’t necessarily required on a daily basis. These are called instrumental activities of daily living (IADLs) and include the following:

  • Using a telephone
  • Managing medications
  • Preparing meals
  • Housekeeping
  • Managing personal finances
  • Shopping for groceries or clothes
  • Accessing transportation
  • Caring for pets

Long-term care providers use ADLs and IADLs as a measure of whether assistance is required and how much assistance is needed. In order to qualify for Medicaid nursing home benefits, the state may do an assessment to verify that an applicant needs assistance with ADLs. Other state assistance programs also may require that an applicant be unable to perform a certain number of ADLs before qualifying. In addition, long-term care insurance usually uses the inability to perform two or more ADLs as a trigger to begin paying on the policy.  

May 7

Cost of Private Nursing Home Room Now Averaging $91,250

The median cost of a private nursing home room in the United States has increased 4.2 percent to $91,250 a year, according to the 2015 edition of a Cost of Care survey that the insurer Genworth has conducted for the past 12 years.  Genworth reports that the median cost of a semi-private room in a nursing home is $80,300, up 3.8 percent from 2014.

The price rise was slightly more modest for assisted living facilities, where the median rate ticked up 2.9 percent, to $3,600 a month.  The national median rate for the services of a home health aide was $20 an hour, representing a 1.3 percent increase over 2014, and the cost of adult day care, which provides support services in a protective setting during part of the day, rose from $65 to $69 a day. 

Once again, Alaska was the costliest state for nursing home care, with the median annual cost of a private room totaling $281,415. Oklahoma again was found to be the most affordable state, with a median annual cost of a private room of $60,225.

The 2015 survey was based on responses from more than 15,000 nursing homes, assisted living facilities, adult day health facilities and home care providers. The survey was conducted by phone during January and February of 2015.

For more on Genworth’s 2015 Cost of Care Survey, including costs for your state, click here.

For more articles on senior living, including alternatives to nursing homes, click here.