California Long-Term Care Insurance Claims Lawyer

Understanding Long-Term Care Insurance Attorney Serving California and Nationwide Clients

At Pillsbury & Coleman, LLP, our attorneys have taken the major long-term insurance companies to court, and won. Understanding your rights under your long-term care insurance policy is often quite difficult, because its wording and various provisions are often confusing. Our California Long-Term Care Insurance Claims Lawyer will explain your rights and benefits under the long-term care insurance policy.

This difficulty is often made worse by the fact that family members who were uninvolved in the purchase of the insurance policy, such as adult children, are usually the ones who have the responsibility of navigating the claims process on behalf of their sick and elderly parent.

In California, regulation of long-term care insurance is set forth at Sections 10231 through 10237.6 of the Insurance Code. Generally, long-term care insurance is designed to cover a host of services and expenses that are not covered by regular health insurance when the insured suffers from a chronic medical condition, disability or disorder, such as dementia. (See, §10231.2 [defining long-term care insurance as providing coverage for “diagnostic, preventative, therapeutic, rehabilitative, maintenance, or personal care services that are provided in a setting other than an acute care unit of a hospital.”].)

Injuries and illnesses can happen to any of us at any time. When those conditions are extremely serious and result in the need for long-term care, it can be hard to meet those expenses, especially if it makes it impossible for us to work. Fortunately, many people have long-term care insurance to help deal with the significant costs associated with any treatment required due to the injury or illness.

The problem is, many insurance companies often fail to honor the obligations required of them under their policies. They deny your request for long-term care benefits and make you fight them each step of the way in order to get the payments you deserve.

At Pillsbury & Coleman, LLP, in San Francisco, our attorneys have helped many California residents recover compensation from their insurance companies. With more than four decades of experience fighting insurance companies inside and outside of the courtroom, we are confident that we can help you with your case.

How Can Our California Long-Term Care Insurance Lawyer Better Serve You?

When you’re facing the complexities of long-term care insurance, you need experienced advocates who understand the intricacies of these policies and the laws that protect you. Pillsbury & Coleman stands ready to fight for your rights against even the largest long-term care insurance companies.

Comprehensive Legal Support at Every Stage:

Our attorneys provide expert assistance throughout the entire process, including:

• Expert Claim Filing: We meticulously prepare and file your long-term care insurance claim, ensuring all necessary documentation is presented accurately and effectively.
• Aggressive Claim Denial Disputes: If your claim has been unfairly denied, we leverage our deep understanding of insurance law to challenge and overturn those decisions.
• Resolution of Lapsed Policy Issues: We navigate the complexities of lapsed policies, seeking solutions to reinstate or recover your rightful benefits.
• Strategic Appeals: We construct compelling appeals that address the specific reasons for denial, maximizing your chances of a favorable outcome.
• Tenacious Litigation: When necessary, we are prepared to take your case to court, providing unwavering representation to secure the benefits you deserve.

Deep Understanding of Long-Term Care Insurance Law:

California, and numerous other states, have enacted specific provisions within their insurance codes to safeguard long-term care policyholders. Recognizing that individuals often purchase these policies while healthy but require them during periods of vulnerability, these laws are designed to protect claimants. However, these regulations are notoriously complex. Pillsbury & Coleman possesses the specialized knowledge and extensive experience necessary to effectively navigate these legal intricacies and protect your rights. Our deep expertise in this niche area of law ensures that we can provide the strongest possible advocacy.

Holding Insurers Accountable for Bad Faith Practices:

When long-term care insurance companies breach their duty of good faith and fair dealing by wrongfully denying legitimate claims, Pillsbury & Coleman takes decisive action. We specialize in holding these insurers accountable, leveraging our legal expertise to secure settlements that often exceed contractual benefits. We operate on a contingent fee basis, meaning you only pay if we successfully recover your benefits.

Prioritizing Your Needs, Not Profits:

It’s understandable to trust your insurance company, but unfortunately, many prioritize profits over policyholders. At Pillsbury & Coleman, we understand that insurance companies often fail to place your interests on equal footing with their own. This results in unjust claim denials. We are committed to reversing this trend. We have built a reputation that insurers recognize, because we are willing to take cases to trial. We prioritize your needs above all else, providing personalized attention and treating you as an individual, not just a file number. We are dedicated to fighting for your peace of mind and financial security.

Long-Term Care Frequently Asked Questions

The policy’s Benefit Schedule will set forth the dollar amount of the daily benefit, the elimination period (the number of days that expenses must be incurred before benefits become payable), the maximum duration that benefits are payable including any maximum benefit caps, and the amount of inflation increases, if any.

Many policies, particularly those sold in the late 1990s, provide for unlimited lifetime benefits, with compound 5% annual COLA increases. For an insured suffering a chronic illness at a relatively young age, these policies can provide a significant amount of benefits. Further, the benefits provided are critically important and vital to the most vulnerable among us, typically the elderly who can no longer live independently. And for the adult children of such insureds, securing benefits under a parent’s long-term care policy is critical to avoiding their own potential financial ruin. The cost of long-term care assistance is staggeringly high, particularly in California.

The Major Long-Term Care Insurance Companies

At Pillsbury & Coleman, LLP, our California Long-Term Care Insurance Claims Lawyer has taken the major long-term insurance companies to court, and won.

In the late 1990s and early 2000s, insurance companies competed with each other to sell as many long-term care insurance policies as they could. At the height of this selling spree, as many as 100 different insurance companies were selling long-term care policies. Today, only a handful still do. 90% of the policies still in force today were sold by the following companies, all of whom exited the market:

• Ability Re
• Aetna
• Allianz
• American Family Insurance Company
• American Fidelity
• CNA
• CUNA Mutual
• Employers Reassurance Corp.
• Equitable
• Great American Financial
• Guardian-Berkshire
• Hannover Life Reassurance Company of America
• Hartford
• Humana
• John Hancock
• MassMutual
• MetLife
• Munich Re
• Nationwide
• Principal
• Prudential
• RiverSource Life Insurance Company
• Sun Life
• Transamerica
• Unum

Improper Claims Handling Tactics

When a case isn’t handled properly, a California Long-Term Care Insurance Claims Lawyer can help you understand how to handle the claim properly.

Some long-term care insurers have implemented improper claims-handling tactics designed to delay or deny the payment of benefits that are owed. We have seen the following:

Use of illegal policy provisions to deny claims

California law provides the minimum requirements for eligibility under long-term care insurance policies. Insurance companies are not permitted to contract around the statutorily required coverage. (Mission National Ins. Co. v. Coachella Valley Water Dist. (1989) 210 Cal.App.3d 484, 497 [The coverage provided by the Insurance Code sets the floor for coverage, but “[t]he insurance company, in drafting the insurance contract, had the right to enlarge coverage beyond the statutory language”].) Insurers can only contract to provide more or broader coverage, not less.

Insurance Code section 10232.8 sets forth various mandated provisions for long-term care insurance policies, including those that are intended to be “federally qualified” policies whereby premium payments are tax deductible and benefits, up to certain maximums, are tax free. Section 10232.8(e) provides mandatory definitions of key terms and phrases found in such long-term care policies, by importing definitions found in guidance published by the Internal Revenue Service. Section 10232.8(e) states:

Until the time that these definitions may be superseded by federal law or regulation, the terms “substantial assistance,” “hands-on assistance,” “standby assistance,” “severe cognitive impairment,” and “substantial supervision” shall be defined according to the safe-harbor definitions contained in Internal Revenue Service Notice 97-31, issued May 6, 1997.

But some carriers try to skirt these mandatory definitions. “Severe cognitive impairment” is defined under the IRS Notice 97-31 as “loss or deterioration in intellectual capacity that is (a) comparable to (and includes) Alzheimer’s disease and similar forms of irreversible dementia, and (b) measured by clinical evidence and standardized tests that reliably measure impairment in the individual’s (i) short-term or long-term memory, (ii) orientation as to people, places, or time, and (iii) deductive or abstract reasoning.” However, some insurance companies have issued long-term care policies in California requiring the presence of “severe cognitive impairment” for benefit eligibility while purporting only to define the phrase “cognitive impairment” rather than the complete term “severe cognitive impairment.” This would, in effect, serve to heighten the level of impairment necessary to trigger coverage by allowing the insurer to come up with its own definition of “severe.” That is unlawful in California.

Use of Deceptively Worded Claim Forms To Deny Claims

The covenant of good faith and fair dealing requires insurers to thoroughly inquire into all possible bases to pay a claim before it is denied. (Egan v. Mutual of Omaha Ins. Co. (1979) 24 Cal.3d 809, 818-819.) The burden is on the insurer to seek out information relevant to a claim. (Frommoethelydo v. Fire Ins. Exchange (1986) 42 Cal.3d 208, 220; Egan, supra, 24 Cal.3d at 818-819; Mariscal v. Old Republic Life Ins. Co. (1996) 42 Cal.App.4th 1617, 1620; Hughes v. Blue Cross of Northern California (1989) 215 Cal.App.3d 832, 846.) This requires the insurer to communicate with the insured and her physicians in a “manner calculated to elicit an informed response.” (Hughes, supra, 215 Cal.App.3d at 846.)

Despite this, some long-term care insurers have adopted deceptively worded claim forms in order to increase claim denials. One insurer has been found to send a “Cognitive Impairment Questionnaire” to assisted living facilities and treating physicians to complete. If the physician or facility does not check the box for “severe” cognitive impairment, and instead checks the box for “mild” or “moderate” cognitive impairment, then the claim is automatically denied without further investigation. That is wrong.

Abusive Tactics Designed To Take Advantage Of Vulnerable Insureds

It is shocking to see the number of hurdles that vulnerable insureds must overcome in order to “perfect” a claim submitted to some long-term care insurers. Some carriers insist on monthly forms, signed by both the care provider and the insured or the insured’s guardian, in addition to a care provider’s certification of care, with a monthly invoice. Unless the forms are completed with 100% precision, the claim is automatically denied without further investigation. In one instance, a carrier denied benefits based on an obvious typo on the claim form.

In another instance, a carrier terminated benefits three years in a row, claiming that its 86-year-old insured, who had Alzheimer’s Disease and resided in an assisted living facility, no longer had “severe” cognitive impairment entitling her to benefits. Her son repeatedly called the insurance company to talk with someone in charge. But he could only talk to a carousel of call-center personnel, none of whom could speak meaningfully about the company’s determination. He could never speak with anyone with substantive authority over his mother’s claim, because the company’s procedures do not allow claim representatives to speak with policyholders. Sharp tactics like this will inevitably lead to the imposition of punitive damages.

No doubt, many carriers are grappling with an onslaught of long-term care insurance claims. Some have beefed-up their claims departments in order to appropriately manage claims and deliver on the promises that they made when selling their policies. Others have shipped off all claims handling responsibilities to poorly-trained and understaffed third-party administrators who are either unfamiliar with the covenant of good faith and fair dealing or, worse yet, disregard it.

Serving California with Local Expertise in Long-Term Care Insurance Claims

Pillsbury & Coleman is committed to providing comprehensive legal support to individuals across California facing challenges with their long-term care insurance claims. We understand that navigating these complex issues requires localized knowledge and a deep understanding of the unique circumstances faced by residents in different regions. Our team has extensive experience serving clients throughout the state, ensuring personalized and effective representation.

For dedicated assistance in your specific area, please visit our location-specific pages:

• Long-Term Care Insurance Claims Lawyer in San Francisco: Serving the unique needs of San Francisco residents with expert legal counsel.
• Long-Term Care Insurance Claims Attorney in Sacramento: Providing experienced advocacy for clients in the Sacramento region.
• Long-Term Care Insurance Claims Lawyer in San Mateo: Offering specialized legal support to San Mateo County residents.
• Long-Term Care Insurance Claims Attorney in San Jose: Representing clients in San Jose with a focus on achieving favorable outcomes.
• Long-Term Care Insurance Claims Attorney in Oakland: Delivering dedicated legal assistance to those in the Oakland area.

Regardless of your location within California, Pillsbury & Coleman is dedicated to helping you secure the benefits you deserve. Contact us today for a consultation.

Schedule A Consultation Today With A California Long-Term Care Insurance Claims Lawyer

Our lawyers are ready to help you get the insurance benefits that you are entitled to receive under your policy. To meet with one of our experienced attorneys about your case, please call our office at (415) 433-8000 or send us an email.

Philip L. Pillsbury

For more than 30 years, Mr. Pillsbury has focused his practice on representing policyholders in insurance bad faith and insurance coverage matters. Awards, settlements, and verdicts totaling over $500 million. Focused his practice on representing policyholders in insurance bad faith and insurance coverage matters ranging from commercial general liability, construction defect, builder’s risk and property/business interruption to errors and omissions and maritime insurance.

Long-Term Care Success

Chang v. Massachusetts Mutual Life Insurance Company, San Francisco County Superior Court, Case No. CGC-16-554087

In this case, our client was confined to a psychiatric facility due to schizophrenia. The cost of specialized facility care for a loved one is staggering and can overwhelm families. Fortunately, our client had purchased long-term care insurance from MassMutual and dutifully paid premiums for 14 years before her condition progressed to the point where she could no longer independently and needed round-the-clock care for her own safety. MassMutual promised to pay a monthly benefit to cover the cost facility confinement.

After receiving her claim for benefits, however, MassMutual, through its third- party administrator, LifeCare Assurance Company, sued Ms. Chang in federal court, claiming that 14 years earlier, she had not completed her policy application correctly, and therefore, that her policy should be rescinded.

We investigated MassMutual’s conduct and determined that it smacked of bad faith and “postclaims underwriting” to try to avoid paying approximately $4 million in policy benefits. Postclaims underwriting refers to the practice of an insurer improperly avoiding liability by seeking to rescind coverage based on misrepresentations in the application in spite of the fact that a reasonable investigation during the underwriting process would have resulted in non-issuance of the policy at the outset. It is fundamentally recognized within the industry that in absence of conducting a reasonable investigation at the time of underwriting, carriers cannot seek to rescind coverage based on the results of a more thorough investigation conducted after submission of a claim. Indeed, California law specifically precludes an insurer from seeking to rescind coverage based on misrepresentation where information obtained by
the insurer prior to issuance of coverage suggests an insured’s application responses “could not reasonably be relied upon.” (DiPasqua v. Cal. Western States Life Ins. Co. (1951) 106 Cal.App.2d 281, 284.) In such an instance, carriers have a “duty of further inquiry” before issuing coverage. (Id.) They cannot sit back, issue coverage, only to raise application misstatements after a claim gets submitted. The practice of postclaims underwriting is unfair, biased, unreasonable, and not consistent with the requirement that the insurer must consider the interests of the insured as equal to its own. In Hailey v. California Physicians’ Service (2007) 188 Cal.App.4 th 452, 465, the court explained this unlawful practice as follows:

Underwriting is a label commonly applied to the process, fundamental to the concept of insurance, of deciding which risks to insure and which to reject in order to spread losses
over risks in an economically feasible way. In essence, postclaims underwriting occurs when an insurer waits until a claim has been filed to obtain information and make underwriting decisions which should have been made when the application for insurance was made, not after the policy was issued. In other words, the insurer does not assess an insured’s eligibility for insurance, according to the risk he presents, until after insurance has been purchased and a claim has been made. Although the insurer may ask an applicant for some underwriting information before it issues the policy, it will not follow up on that information until after a significant claim arises. Only after a claim has arisen will the insurer examine the application and request additional information to see whether the applicant could have been excluded from coverage.
* * *

The insurer controls when the underwriting occurs… If the insured is not an acceptable risk, the application should be denied up front, not after the policy is issued.

We obtained a dismissal of MassMutual’s federal court lawsuit. We further brought a bad faith action against MassMutual in state court in San Francisco in order to secure Ms. Chang’s future benefits and other damages. The San Francisco Superior Court agreed with our analysis, ruling that MassMutual could not seek to rescind coverage, had to pay benefits, and that we had gathered sufficient evidence to support an award of punitive damages against MassMutual: “There is a triable dispute as to whether MassMutual acted maliciously or oppressively within the meaning of Civil Code Section 3294. When viewing the facts most favorably to the Plaintiff, MassMutual issued a policy which it had significant doubts about, decided not to conduct an
investigation, and only long after the contestability period had expired, it chose to conduct the very investigation it could have before, after it had received a claim by Ms. Chang.” (Click here for Court Order.). We successfully obtained a settlement for Ms. Chang for a confidential sum on the first day of trial.

Turley v. Prudential Insurance Company, San Francisco County Superior Court,
Case No. CGC-20-587222

In this matter, we represented an 86-year-old who was repeatedly denied long- term care benefits by Prudential Insurance Company and its third-party administrator, CHCS Services. Mrs. Turley began residing in an assisted living facility after she was diagnosed with Alzheimer’s and had a documented history of wandering, getting lost, forgetting to eat, and forgetting to take medications. She and her late husband had purchased long-term care insurance policies from Prudential. Prudential promised to pay monthly benefits to cover the cost of assisted living if they became sick and needed such care. But after Mrs. Turley’s children submitted a claim for benefits on their mother’s behalf, they encountered one hassle after another. Although Mrs. Turley had Alzheimer’s, Prudential and its administrator, CHCS, kept terminating the claim every year, supposedly on the grounds that Mrs. Turley’s Alzheimer’s was not sufficiently
severe. Alzheimer’s is a progressive disease. People do not recover from Alzheimer’s. Nonetheless, Prudential’s repeated terminations of benefits forced Mrs. Turley’s children in an endless loop of appeals, convincing Prudential to reinstate benefits, then receiving a denial the next year. Finally, Prudential refused to reinstate benefits. Pillsbury & Coleman filed a lawsuit against Prudential for insurance bad faith in order to put an end to its conduct. In the course of our lawsuit, Pillsbury & Coleman discovered overwhelming evidence regarding the practices of Prudential and CHCS. We successfully obtained a settlement for a confidential amount shortly before trial.

Maramonte v. Unum Group, Unum Life Insurance Company of America, San Francisco County Superior Court, Case No. CGC-23-604671

This was an insurance bad faith action arising from Unum’s denial of long-term care benefits. Our client was 86 years old and had been diagnosed with a host of serious and debilitating conditions, including major neurocognitive disorder (dementia), colon cancer, major depression, and severe malnutrition. Mrs. Maramonte had purchased a long-term care policy from Unum. Such policies provide monthly benefits when insureds become sick and need assistance or supervision with activities of daily living. Mrs. Maramonte needed such assistance. She had cognitive impairment, would repeatedly become disoriented, and was a high fall risk. After Unum denied benefits, Mrs. Maramonte’s family contacted our firm, and after reviewing the matter, we determined that the denial was not only wrong but also was in bad faith. We filed a lawsuit for insurance bad faith, and within 6 months obtained a settlement for Mrs. Maramonte. We have a known track record of success against every major insurance company in the United States. And we have particular success against Unum — we won the largest disability insurance bad faith verdict in California history in the landmark case of Chapman v. UnumProvident.