Activities of Daily Living (ADLs)

A specified number, commonly two or more — Standard LTC policies define six ADLs — bathing, dressing, eating, toileting, transferring, and continence — and typically require the insured to be unable to perform a specified number of them, most commonly two, in order to trigger benefits. The policy states the exact number and defines what unable means, often requiring substantial assistance from another person. The number required affects both the price of the policy and how readily benefits are triggered: a one-ADL trigger is more liberal and more expensive, while a higher threshold delays eligibility and lowers price. Understanding the ADL trigger is central to counseling clients about when coverage will pay.

National insurance concept

Excluded because it is custodial care, not medically necessary treatment — Major medical policies cover medically necessary treatment and exclude custodial care — assistance with activities of daily living such as bathing, dressing, and feeding that does not require skilled medical services. A physician's order does not convert custodial care into a covered benefit, because the policy pays for treatment of sickness or injury, not for maintenance care. This exclusion is one reason long-term care insurance exists: major medical stops where custodial care begins. Agents must therefore distinguish skilled care, which major medical covers, from custodial maintenance, which it does not, when counseling older clients about their coverage needs.

National insurance concept