Looking for input on this subject from those with experience or knowledge in LTC policies. Mother-in-law was diagnosed with dementia awhile back. We moved her into a Senior Assisted Living Facility last year after she flooded her apartment. She is still mobile and dresses herself and keeps her studio clean. She eats her meals in the dining room but can make a peanut butter & jelly sandwich. She cannot manage her medication routine and the facility brings her meds multiple times a day. She will ask the same questions over and over within minutes. She is unable to manage her medical, financial and daily decisions. She has difficulty answering what her name is and tells a long story on how her name changed at baptism and marriage, yet never really directly answers "Jane Doe." She has difficulty with time. If we visit her directly after her lunch, she will tell us she needs to get ready for dinner - which is in 4 hours. The list goes on and on.

We have been attempting to initiate a claim for her LTC since January 8 and have been receiving the run-around for months. It took us 3 months for them to approve Power of Attorney. In March, they finally sent out a representative to do a cognitive test on her which was so incredibly simple, it was clearly designed to deny any cognitive issues. (The nurse testing her even commented on how she had not seen a test like this.) Not surprising, when calling them last Friday to ask what is the status of the claim, the out-sourced foreign call center person said her claim was denied based on their evaluation. They never bothered to contact her doctor or read the letter from her doctor.

Mother-in-law's LTC policy has a benefit eligibility criteria of: You need substantial assistance from another individual to perform at least 2 of the Activities of Daily Living due to loss of functional capacity; OR You need substantial supervision due to the presence of a severe cognitive impairment.

The way my LOML and I read this, it means you are physically incapable of eating/dressing/bathroom/mobility OR you have cognitive issues. It does not mean you have to have dementia and no longer be able to dress or feed yourself. Is that correct?

We plan to appeal their determination, but we are not certain if submitting the appeal form, with a document listing all the cognitive issues she is having, and her doctor's cognitive assessment, and letters from two doctors will be enough. Considering how difficult this LTC company has been to deal with all these months to even receive paperwork to initiate a claim, we think they are going to come back with some other reason to deny it so they can keep the money for profit.

Any advice on how to deal with this or is she truly not "severe" enough in cognitive decline because she can still dress and feed herself?