A full breakdown of the insured event in long-term care policies: the six daily activities, how many are required, what counts as "unable to perform", what mental frailty is, and why two policies with a similar name can differ substantially.
Everything begins and ends with the definition
In a long-term care claim the only question an insurer asks is whether the definition written in the policy has been met. Not how serious the illness is, not how hard it is for the family, and not what National Insurance decided.
A family that files without reading the definition is therefore working blind. It may describe in minute detail areas that are not relevant, while neglecting precisely what is being assessed.
This page breaks the definition into its components, so you know exactly what to look for and what has to be shown.
The first route: the six daily activities
Most policies in Israel rest on a list of six basic activities. The definition sets how many of them the insured person must be unable to perform — commonly three, though it varies. This is exactly where the precise wording in the policy is critical.
Alongside the six, the need for supervision is assessed separately. Someone technically able to perform the activities but unsafe alone because of cognitive decline may enter the definition through the mental frailty route.
- Getting up and lying down — transfers between bed, chair and wheelchair
- Dressing and undressing — including buttons, zips, socks and shoes
- Washing — getting in and out of the shower or bath, washing the body and drying
- Eating and drinking — bringing prepared food from the plate to the mouth and swallowing
- Continence — control of bladder and bowel and the care required in case of incontinence
- Mobility — the ability to move from place to place inside the home
"Unable to perform" — the wording that decides
This is the point at which files stand or fall, and it hides in the wording. Some policies require the insured person to be entirely unable to perform the activity. Others are satisfied by a need for substantial help from another person. Others again recognise a need for supervision while the activity is carried out.
The difference is dramatic. Someone who showers alone but only while another person waits outside meets some definitions and not others. Someone who dresses alone but has their clothes laid out and needs help with socks — the same.
So before writing a functional description, read the exact wording and make sure the description addresses it. A description saying "manages with help" may be read as independence under a strict policy.
The second route: mental frailty
Almost every long-term care policy contains an additional route that does not require any inability to perform physical activities at all. It relates to a state of cognitive decline requiring supervision.
The definition varies between policies, but it generally concerns impairment of cognitive capacity — orientation, recognition, judgement — at a level that requires the supervision of another person for most hours of the day.
This route is often forgotten. Families caring for someone with dementia concentrate on trying to prove physical incapacity, when the cognitive route fits their situation far better.
One route is enough
An important point that gets missed: in most policies, meeting one of the two routes is sufficient. You do not need both.
The practical implication is that it is worth examining both and choosing the route on which the situation is stronger — or describing both where both are relevant.
If a claim was refused on one route, it is worth checking whether the second was considered at all. There are cases where the family presented only the physical side, and the cognitive side — which was the stronger — was never mentioned.
Why two similar policies are not identical
The product name tells you nothing about the terms. Two policies sold by the same company, under the same name, five years apart, may differ substantially in their definition.
In addition, regulatory changes over the years have affected how definitions are worded in newer policies. An older policy may be worded entirely differently, and sometimes more favourably.
So do not rely on what a relative or neighbour told you, and do not rely on a general summary online — including this page. The document that applies to the insured person is the only one that governs.
Frequently asked questions
How many activities must a person be unable to perform to be considered in an LTC condition?
The number is set in the policy and is not uniform. Many policies require an inability to perform three of the six activities, but you must follow the wording in the document that applies to the insured person.
What counts as "unable to perform"?
It depends on the wording. Some policies require complete inability, others are satisfied by a need for substantial help from another person, and others recognise a need for supervision while the activity is carried out.
What is mental frailty in the insurance definition?
A state of cognitive decline — in orientation, recognition and judgement — at a level requiring the supervision of another person. It is a separate route that does not require any inability to perform physical activities.
Do we have to meet both routes?
In most policies meeting one is enough. It is worth examining both and concentrating on the route where the situation is stronger, or describing both where both are relevant.
Two policies with the same name — the same terms?
Not necessarily. Policies sold under the same name in different periods may differ substantially in their definition, partly because of regulatory changes over the years.
Official sources for further checking
This is general information and does not replace personal medical, legal or insurance advice. Eligibility is determined by the documents and rules that apply to each case.
