Sacramento Long Term Care Insurance Claims Lawyer

Skilled Long Term Care Insurance Claims Attorneys Serving Sacramento, CA

Sacramento Long Term Care Insurance Claims AttorneyWhen you or a loved one is facing the daunting decision to get long term care, having long term care insurance coverage is a wonderful resource to help meet the extensive expenses you are facing. Unfortunately, long-term care insurance companies have the right to deny coverage and often do so even with valid claims. This when you need the help of an experienced Sacramento long term care insurance claims lawyer.

You have diligently paid your premiums over the years for this very time in your life, and it can be overwhelming when the insurance company doesn’t meet its obligations. At Pillsbury & Coleman, LLP, our team of Sacramento long term care insurance claims lawyers are here to help you get the benefits you deserve under the terms of your policy.

When Do You Need Long Term Care Coverage?

As we witness the aging of America, we are also seeing the increased need for long term care. For most long-term care insurance, it will cover certain types of care when you need help with two of the six Activities of Daily Living (ADL), or have experienced cognitive impairment. These include:

  • Personal hygiene
  • Dressing
  • Eating
  • Toileting
  • Transferring
  • Ambulating

Consequently, a long-term care policy can help pay for:

Unfortunately, although long-term insurance is a valuable resource, it is only as good as your ability to get benefits when you need it. When your insurance company fights you each step of the way, you need the help of an experienced Sacramento long-term care insurance claims lawyer to hold them accountable.

The For-Profit Nature Of The Insurance Industry

In the vast world of insurance coverage, long-term care is extremely expensive. In California, the average cost of one year of long-term care has been estimated at $137,240 per year, as of 2020, and increases annually. And it is not only the elderly who need that care. Over 35 percent of individuals requiring long-term care are between the ages of 18 and 64.

Insurance companies, however, are for-profit businesses, and, as any for-profit enterprise, they strive to keep costs low. But what happens when there is a conflict between their profits and their contractual obligation to pay claims? This is what many people face each day when they have been unfairly denied coverage for a life situation that they counted on being covered for.

Why Was Your Claim Denied?

Long-term insurance companies have a litany of reasons they use to deny coverage. They may:

  • Allege you missed a payment
  • Claim the facility is not an eligible care provider
  • Claim that you had no prior hospitalization
  • Claim that they do not provide for some services, such as “personal care”
  • Claim that you are able to perform some limited activities of daily living
  • Claim there are conflicting medical opinions
  • Claim that your condition has improved and you no longer qualify
  • Claim that your medical condition is excluded

When your insurance company denies or resists paying benefits, our skilled team of Sacramento long term care insurance claims lawyers will aggressively advocate for you. Even if you have been denied benefits, you have the right to appeal that denial. Whether you have been denied benefits or are just embarking on a claim, we can help.

Expertise and Experience in Long-Term Care Claims

At Pillsbury & Coleman, LLP, our attorneys possess a deep understanding of the intricacies of long-term care insurance policies and the tactics employed by insurance companies. With years of dedicated practice in this specialized area, we have successfully assisted countless clients in Sacramento and throughout California in securing the benefits they deserve.

Our firm’s expertise is grounded in:

  • Extensive Knowledge of Insurance Law: We possess a thorough understanding of California insurance regulations and the legal precedents that govern long-term care claims.
  • Decades of Combined Experience: Our team has a long track record of successfully handling complex long-term care insurance disputes.
  • Familiarity with Major Insurers: We have worked extensively with all major long-term care insurers operating in California, giving us unique insight into their claims processes and strategies.
  • Understanding the For-Profit Insurance Industry: We acknowledge the fact that insurance companies are for profit buisnesses, and use that knowledge to best serve our clients. We understand that the high costs of long term care, create a high motivation for insurance companies to deny claims.

Getting The Help You Deserve

Pillsbury & Coleman, LLP, is committed to providing compassionate and effective legal representation. We understand the emotional and financial stress associated with long-term care claims, and we strive to alleviate these burdens by:

  • Providing personalized attention and responsive communication.
  • Maintaining the highest ethical standards and professional integrity.
  • Prioritizing our clients’ best interests at all times.
  • Providing clear and honest legal advice.

At Pillsbury & Coleman, LLP, we have helped countless individuals in the Sacramento area and throughout California get the benefits that they paid for and deserve.

The last thing you should have to do when considering long-term care is to fight with the insurance company that you trusted to be there when you needed it. Our Sacramento long term care insurance claims lawyers have worked with all major insurers in the state and understand the tactics of the industry. Contact us today to see how we can help you get the long-term care benefits that you deserve under your policy terms.

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. Unum Provident.