LTC Benefit Triggers, ADLs and Cognitive Impairment (F.S. 627.9404)

Eligibility must appear in a separate paragraph labeled "Eligibility for the Payment of Benefits." Acceptable triggers: loss of ability to perform activities of daily living and cognitive impairment (any required physician certification of functional dependency must be specified). The six ADLs: bathing, dressing, toileting, transferring (bed/chair/wheelchair), continence (bowel/bladder control or related hygiene, incl. catheter/colostomy care), and eating. Cognitive impairment = a deficiency in short- or long-term memory; orientation to person, place, and time; deductive or abstract reasoning; or judgment relating to safety awareness. Trigger standards may be no more restrictive than requiring hands-on assistance to perform ADLs, or — for cognitive impairment — supervision including verbal cueing to protect the insured or others. Assessments must come from licensed/certified professionals (physicians, nurses, social workers), and the policy must describe the appeal process for benefit determinations. Related definition: chronically ill = certified as unable to perform at least 2 ADLs for at least 90 days, or requiring substantial supervision due to severe cognitive impairment.

The policy pays when the body or the mind can no longer run daily life — measured by six named activities or a memory/judgment deficit, judged by licensed professionals, with a right of appeal.