Oakland Long Term Care Insurance Claims Lawyer

Experienced Long Term Care Insurance Claims Attorneys In Oakland, CA

Oakland Long Term Care Insurance Claims AttorneyIf you are like many today, you may have invested in long-term care insurance to offset the future costs of a nursing home or home health care. Unfortunately, we have seen far too many who have trusted that those benefits would be there when they needed it only to get denied when they submitted a claim for benefits. Our Oakland long term care insurance claims lawyers can help.

At Pillsbury & Coleman, LLC, we are experienced Oakland long term care insurance claims lawyers who have dedicated our careers to holding large insurance companies accountable to their policyholders. For over four decades, we have gone up against some of the nation’s largest insurance companies to force them to pay the benefits that they were contractually obligated to pay. If you have been denied benefits from your long-term health insurer, let us go to work for you.

Few people are able to pay for the enormous costs of long-term care out of pocket. This was the whole point of long-term care insurance. While insurance companies have sold many of these policies over the years, now, with policyholders aging and needing benefits, insurance companies are finding ways to minimize their financial exposure. In many cases, these are purely in bad faith.

Insurance Is A Profitable Business

Insurance companies bank on taking in far more in premiums than they have to pay out in benefits. But in the case of long-term care, particularly, policyholders are aging as costs are skyrocketing. Although these companies have tried to keep up by charging ever more expensive premiums, they now see that their anticipated large profits are dwindling.

In the meantime, elderly adults, often on fixed incomes, may have struggled for years to afford their premiums so they could have these benefits when they needed them. As experienced Oakland long term care insurance claims lawyers, we see these individuals get denied the benefits they deserve by an industry that is more concerned with large profits than policyholders.

Long-Term Care Frequently Asked Questions

For over 30 years, our firm has specialized in advocating for policyholders in Oakland and the greater Bay Area who have faced wrongful denials of their long-term care insurance benefits. We understand the unique challenges faced by residents here, including the high cost of care and the specific nuances of California insurance regulations. We have successfully represented clients against major insurers, securing the benefits they rightfully deserve. We've handled cases involving long-term insurance claims, giving us a deep understanding of the local landscape.

We handle a wide range of denials, including those based on 'not meeting the activities of daily living (ADL) requirements,' 'lack of medical necessity,' 'pre-existing conditions,' and 'misinterpretation of policy language.' In Oakland, we often see cases where insurers dispute the level of care needed in assisted living facilities and skilled nursing homes, particularly given the high cost of such care. Additionally, we're familiar with the specific documentation requirements of California's Department of Insurance and how they impact local claims.

Insurers often employ tactics such as requesting excessive documentation, misinterpreting medical records, or claiming that the policyholder's condition doesn't meet the policy's definition of 'chronic illness.' We counter these tactics by conducting thorough investigations, gathering comprehensive medical evidence, and presenting compelling legal arguments that highlight the insurer's bad faith practices. We often engage independent medical experts to provide objective assessments.

We typically work on a contingency fee basis, meaning you don't pay us unless we successfully recover benefits for you. We understand the financial strain that comes with denied claims, and we strive to make our services accessible. We will fully explain our fee agreement during your initial consultation.

Common Reasons For Denials

Insurance companies are taking extra care to find ways they may deny claims in the interest of protecting their profits. Our Oakland long term care insurance claims lawyers frequently see insurance companies deny valid claims with the following excuses:

  • Unpaid premiums led to a coverage lapse
  • The facility or provider is not covered under the policy
  • The services that the providers offer are not covered under the policy
  • The policy requires hospitalization or nursing home confinement to pay benefits
  • The policy doesn’t cover “personal care”
  • The patient is able to perform some limited activities of daily living

And other standard excuses. If your insurance company is trying to limit your benefits or deny them altogether, we may be able to help.

Okay, here’s a rewrite focused on Oakland, California, and emphasizing E-E-A-T:

How Our Oakland-Focused California Long-Term Care Insurance Lawyer Can Best Serve You

Navigating the complexities of long-term care insurance in Oakland demands experienced advocates who possess a deep understanding of both the intricate policy language and the specific California laws designed to protect your rights. At Pillsbury & Coleman, we’ve dedicated years to advocating for Oakland residents, building a track record of success against even the largest long-term care insurance providers. Our firm’s experience in the Bay Area gives us a unique perspective on the challenges faced by local policyholders, including the high costs of care and the specific nuances of California’s regulatory environment. We are committed to ensuring Oakland residents receive the benefits they deserve.

Comprehensive, Oakland-Centric Legal Support at Every Stage:

Our attorneys provide comprehensive, tailored assistance throughout the entire long-term care insurance process, specifically addressing the needs of Oakland clients. This includes:

  • Expert, Oakland-Specific Claim Filing: We meticulously prepare and file your long-term care insurance claim, ensuring all documentation is accurate and effective, particularly considering the documentation requirements often utilized by insurers in the Bay Area.
  • Aggressive Claim Denial Disputes, Tailored for Oakland: If your claim has been unfairly denied, we leverage our deep understanding of California insurance law, and our specific experience with Oakland-based claims, to challenge and overturn those decisions. We understand the specific denials common in this area, such as those related to local care facilities.
  • Resolution of Lapsed Policy Issues, with Oakland Expertise: We navigate the complexities of lapsed policies, seeking solutions to reinstate or recover your rightful benefits, taking into account the common reasons for lapses we have seen in the Oakland area.
  • Strategic Appeals, Built for Oakland Success: We construct compelling appeals that address the specific reasons for denial, maximizing your chances of a favorable outcome in the context of Oakland-specific precedents and practices.
  • Tenacious Litigation, Focused on Oakland Residents: When necessary, we are prepared to take your case to court, providing unwavering representation to secure the benefits you deserve, within the Alameda County court system.”

Deep, Oakland-Informed Understanding of California Long-Term Care Insurance Law:

California, and specifically the Oakland region, presents unique legal complexities for long-term care insurance policyholders. The state’s insurance code includes provisions designed to protect vulnerable individuals, recognizing that these policies are often purchased during periods of good health but needed during times of increased vulnerability. However, these regulations are notoriously complex and require expert navigation. Pillsbury & Coleman possesses the specialized knowledge and extensive, Oakland-specific experience necessary to effectively navigate these legal intricacies and protect your rights. We regularly attend continuing legal education that concerns California insurance law, and are members of organizations that focus on California Elder law. Our deep expertise in this niche area of law, combined with our local knowledge, ensures that we can provide the strongest possible advocacy for Oakland residents.

Understanding Your Coverage

In the state of California, there are different types of long-term care insurance. While some specifically cover nursing home and residential care facilities, others may only cover home care scenarios. Each of these policies can limit who cares for you and what benefits they will pay for. Comprehensive policies will consider both residential care scenarios as well as home health care scenarios.

Each policy will be different in their coverage. It’s critical to understand what kind of coverage you have and what you can legally expect in the way of benefits and under what conditions you will be eligible.

At Pillsbury & Coleman, LLC, our team of Oakland long term care insurance claims lawyers have spent our careers holding large insurance companies accountable for paying the benefits that their policyholders are entitled to under the terms of their policies and California’s insurance laws. When you have trusted that your benefits will be there for you when you need them, you should not have to fight the insurance company every step of the way.

Getting The Legal Help You Need

Because of the increasing costs of long-term care and the aging of our society, we see insurance companies using more tactics than ever before to deny benefits to their policyholders. If you have run into problems getting benefits under your long-term care policy, contact the experienced Oakland long term care insurance claims lawyers at Pillsbury & Coleman, LLC to discuss how we can help.

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 live 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.