San Francisco Long Term Care Insurance Claims Attorney

Dedicated Long Term Care Lawyers for Insurance Claim Clients in San Francisco

In San Francisco, navigating long-term care insurance claims can be particularly challenging. At Pillsbury & Coleman, LLP, our experienced attorneys have a proven track record of successfully litigating against major long-term insurance companies, securing favorable outcomes for our clients in the Bay Area. We understand that deciphering the complex language and provisions of your long-term care insurance policy can be overwhelming. Our San Francisco-based Long-Term Care Insurance Claims Lawyers are dedicated to clearly explaining your rights and the benefits you are entitled to.

This challenge is often compounded by the fact that adult children, who may not have been involved in the initial policy purchase, frequently find themselves responsible for managing the claims process on behalf of their elderly parents.

In San Francisco, as throughout California, long-term care insurance is regulated under Sections 10231 through 10237.6 of the Insurance Code. These policies are designed to cover a range of services and expenses not typically covered by standard health insurance, addressing chronic medical conditions, disabilities, or disorders such as dementia. (See, §10231.2, which defines 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.”). We are well versed in these regulations, and how they apply to San Francisco residents.

Rising Costs of Long-Term Care

With nearly 70 million Americans projected to be over 65 by 2030, the cost of long-term care continues to soar. The annual average cost is projected to come out to $146,000 in California for a private room in 2022. Cities like San Jose and Santa Maria lead the way coming in at $187,000 a year. Consequently, the older population is relying on this care to supplement their costs during this critical time. Unfortunately, it seems like the industry is more focused on profits than on fulfilling policyholder needs.

Understanding Your Policy

In California, long-term care insurance typically falls into three categories, each having very specific coverage and benefits:

• Nursing Facility and Residential Care Facility Coverage: Includes care within institutional settings such as nursing homes or assisted care facilities. Home care is not covered.
• Home Care Coverage: Encompasses services like home health care, adult day care, personal care, and more, excluding care in a facility.
• Comprehensive Long-Term Care: Covers a wide array of services including nursing home benefits, home health care, hospice, and more.

How Our San Francisco Long-Term Care Insurance Lawyers Advocate for You

In the heart of San Francisco, navigating the complexities of long-term care insurance demands experienced advocates who grasp the intricacies of these policies and the specific legal protections available to you. Pillsbury & Coleman is committed to vigorously defending your rights against even the largest long-term care insurance providers in the Bay Area.

Comprehensive, San Francisco-Focused Legal Support at Every Stage:

Our attorneys deliver specialized assistance throughout the entire claims process, tailored to the needs of San Francisco residents:

• • Precise Claim Filing: We meticulously prepare and file your long-term care insurance claim, ensuring all essential documentation is accurately and effectively presented, considering the nuances of San Francisco’s local care facilities.
  • Aggressive Claim Denial Disputes: If your legitimate claim has been unfairly denied, we utilize our deep understanding of California insurance law, with a specific focus on its application within San Francisco, to challenge and overturn those decisions.
  • Expert Resolution of Lapsed Policy Issues: We adeptly navigate the complexities of lapsed policies, seeking effective solutions to reinstate or recover your rightful benefits within the context of San Francisco’s regulatory environment.
  • Strategic, Locally Informed Appeals: We construct compelling appeals that directly address the specific reasons for denial, maximizing your chances of a favorable outcome, while understanding the local San Francisco landscape of long term care.
  • Tenacious Litigation in San Francisco Courts: When necessary, we are fully prepared to take your case to court within San Francisco, providing unwavering, locally experienced representation to secure the benefits you deserve.

San Francisco-Specific Expertise in Long-Term Care Insurance Law

California’s Insurance Code, particularly as it applies within San Francisco, includes specific provisions designed to protect long-term care policyholders. We recognize that San Francisco residents purchase these policies with the expectation of security during vulnerable times. However, the regulations governing these policies are notoriously complex. At Pillsbury & Coleman, our attorneys possess the specialized knowledge and extensive experience needed to navigate these legal intricacies effectively, safeguarding your rights within the San Francisco context. Our deep expertise in this niche area of law ensures we provide the strongest possible advocacy for our San Francisco clients.

Holding San Francisco Insurers Accountable for Bad Faith Practices

When long-term care insurance companies operating in San Francisco 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 within the San Francisco legal system, leveraging our legal expertise to secure settlements that often exceed contractual benefits. We operate on a contingency fee basis, meaning San Francisco clients only pay if we successfully recover their benefits.

Prioritizing San Francisco Residents, Not Insurance Company Profits

We understand that San Francisco residents place trust in their insurance companies. Unfortunately, many insurers prioritize profits over policyholders, leading to unjust claim denials. At Pillsbury & Coleman, we are committed to reversing this trend for our San Francisco clients. We have built a reputation that insurers recognize, as we are prepared to take cases to trial within the San Francisco courts. We prioritize the needs of our San Francisco clients above all else, providing personalized attention and treating each individual with respect, not just as a file number. We are dedicated to fighting for your peace of mind and financial security in San Francisco.

Our San Francisco Long Term Care Insurance Claims Attorney Can Help!

Remember, your long-term care insurance should be there for you when you need it the most. We will hold the insurance industry accountable to their promises and ensure you receive the benefits that are rightfully yours.

Long-Term Care Frequently Asked Questions

San Francisco 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.