Health-Fund Long-Term Care Insurance: ADL Criteria and Benefit Claims

What is an insured long-term-care event?

The uniform policy for health-fund members defines a long-term-care condition under two main tracks: a functional condition assessed through activities of daily living (ADLs), or cognitive impairment diagnosed by an appropriate specialist physician that requires supervision during most hours of the day.

Following a change effective January 1, 2025, an insured event occurring on or after that date generally requires the insured person to be unable, independently, to perform a substantial part, meaning at least 50%, of four of the six activities, or three activities when one is continence. An earlier definition may apply to events occurring before that date, making the event date material.

The six ADLs

• Getting in and out of bed.
• Dressing and undressing.
• Bathing.
• Eating and drinking.
• Controlling bladder and bowel function.
• Mobility.

What else determines eligibility and payment?

In addition to functional status, the insurer checks whether the person was enrolled in coverage on the relevant date, the policy exclusions, and the end of the waiting period. The benefit amount is determined in part by the age at first enrollment in the group long-term-care insurance and whether the person resides at home or in an institution.

For residence at home, the benefit is generally defined as a fixed indemnity. For institutional residence, it may be reimbursement that is also limited by actual expenses. The payment period and amounts are determined by the uniform framework, policy wording, and event date, so an old table should not be relied upon.

How the process works

1. 01

   Identify proof of membership, enrollment date, insurer, and the policy in force on the event date.

2. 02

   Document each ADL: what can be performed, which part cannot, what assistance is required, and how often.

3. 03

   File a claim with the insurance company, attaching the medical and functional records and the documents required by the claim form.

4. 04

   The insurer investigates and may send a functional assessor or request additional documents.

5. 05

   Compile the stated reasons for the decision and conduct an administrative comparison with the records, activities assessed, and policy wording applicable on the event date, without providing an insurance-policy or legal interpretation.

Documents you may need

• Proof of insurance, enrollment date, and the policy wording applicable on the event date.
• Hospital summaries and records from a geriatrician, neurologist, ophthalmologist, occupational therapist, or rehabilitation professional, according to the condition.
• Documentation of assistance from others, falls, assistive devices, supervision, and functional change over time.
• For institutional residence: the agreement, invoices, confirmation of the type of setting, and actual expenses.

Common mistakes to avoid

• Using an outdated ADL definition without identifying the insured event date.
• Describing the person as "independent" or "needing help" without specifying which part of the activity is performed and how.
• Focusing only on ADLs when a cognitive impairment and related risk require assessment under the cognitive-impairment track.
• Confusing a National Insurance decision with contractual eligibility under the policy. Neither determination binds the other.