San Jose Long Term Care Insurance Claims Lawyer
Skilled Long Term Care Insurance Claims Attorneys Serving San Jose, CA
If you are like many people, you may have invested in a long-term care policy for the day when you might require the assistance of that vital care. Although long-term care insurance can be a valuable resource for many people, the insurance is only as good as the benefits you get when you need it. If you have counted on your long-term care insurance to be there for you and have been wrongly denied, we can help. At Pillsbury & Coleman, LLC, our skilled San Jose long-term care insurance claims lawyers have spent four decades advocating for individual’s rights when they are unfairly denied benefits.
The Increasing Expense Of Long-Term Care
It is estimated that nearly 70 million Americans will be over the age of 65 by 2030, and many will need assistance paying for their care. Long-term care gets more expensive each year, with the average annual cost of care as of 2020 coming in at $137,240 here in California. Consequently, more older adults are counting on long-term insurance to supplement their costs at this critical time.
Those who purchase these policies do so trusting that they will be able to take advantage of benefits when the time comes for their needed care. Unfortunately, for many, they find out the reality of an industry that is more concerned with profits than their policyholders. If you have made a claim for long-term care benefits and have been denied, you are not alone.
What Does Your Policy Cover?
In the state of California, there are three types of long-term care insurance that are offered. It’s important to keep in mind what type of coverage you have and what benefits this entitles you to.
- Nursing facility and residential care facility coverage covers skilled, intermediate, or custodial care in an institutional setting such as a nursing home, assisted care facility, or other residential care facilities. These policies do not cover home care.
- Home care coverage covers home health care, adult daycare, personal care, homemaker service, hospice services, and respite care. Care in a facility is not covered.
- Comprehensive long-term care must include nursing home benefits, residential care facilities, home health care, adult day care, personal care, homemaker services, hospice, and respite care.
We can help you understand your policy and what you can expect in the way of benefits.
Navigating Long-Term Care Insurance Claims: Expert Legal Support in San Jose and Nationwide
At Pillsbury & Coleman, LLP, serving San Jose and clients across California and the nation, our attorneys bring decades of specialized experience in successfully challenging major long-term care insurance companies. We understand that deciphering the complexities of your long-term care insurance policy can be daunting, with its intricate wording and varied provisions. Our San Jose-based Long-Term Care Insurance Claims Lawyers are dedicated to providing clear, expert guidance, ensuring you fully understand your rights and benefits.
Understanding the Challenges Faced by Families
Often, it’s the adult children, unfamiliar with the original policy details, who are tasked with navigating the claims process for their elderly parents. This adds significant stress during an already challenging time. We recognize this burden and are committed to simplifying the process, providing compassionate and knowledgeable support.
California’s Long-Term Care Insurance Regulations: A Foundation of Protection
In California, long-term care insurance is governed by Sections 10231 through 10237.6 of the Insurance Code. These regulations are designed to protect individuals requiring long-term care services due to chronic medical conditions, disabilities, or disorders like dementia. (§10231.2 defines long-term care insurance as 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.”).
Protecting Your Rights Against Unfair Denials
Unexpected illnesses or injuries can necessitate long-term care, and insurance is meant to alleviate the financial strain. Unfortunately, many insurance companies prioritize profits over policyholders, often denying legitimate claims. At Pillsbury & Coleman, LLP, we have a proven track record of successfully recovering compensation for California residents. Our attorneys, based in San Jose, have over four decades of experience fighting for policyholders, both in and out of the courtroom.
We will remain forever grateful to each and every one you
“You truly make a difference in people’s lives because you do not just win cases, you do not just get judgments collected, you actually put lives back together and help heal wounds. More importantly, I believe for all the long hours you put, your significant others should see what a difference you m...
Mehran Imanabadi
The “go-to” firm for bad faith insurance coverage issues
“As part of an in-house legal team, I look for smart, capable and no-nonsense outside counsel to guide me on critical issues. Pillsbury & Coleman’s attorneys proved to be all of the above. They crafted a creative and insightful strategy for my case that convinced me they were the go-to firm for bad f...
Bill Friedman, In-house Counsel, CISCO
Always there for me no matter what!
“I can’t thank you enough for what you have done for me. I am so grateful that I had you helping me with this most difficult time of my life. You were always there for me no matter what and I deeply appreciate it.”
Peter Englert
I can’t thank all of you enough!
“You have to hear this a lot. You folks are life changers in people’s lives. I can’t thank you enough and as a client, I believe you deserve every dime you got. I am writing this and thinking of my first calls of desperation to the four or five firms I found on Google. My favorite was the last attor...
Stuart Pressman
How Our San Jose Long-Term Care Insurance Lawyers Can Assist You:
Our firm offers comprehensive legal support at every stage of the claims process, ensuring your rights are protected:
- Expert Claim Filing: We meticulously prepare and file your claim, ensuring all documentation is accurate and compelling.
- Aggressive Claim Denial Disputes: We leverage our deep understanding of insurance law to challenge and overturn unfair denials.
- Lapsed Policy Resolution: We navigate the complexities of lapsed policies to recover or reinstate your benefits.
- Strategic Appeals: We craft persuasive appeals, addressing specific denial reasons to maximize your chances of success.
- Tenacious Litigation: When necessary, we are prepared to take your case to court, providing unwavering representation.
Deep Expertise in Long-Term Care Insurance Law
California’s insurance code includes specific provisions to protect long-term care policyholders, recognizing their vulnerability. Pillsbury & Coleman possesses the specialized knowledge and extensive experience to navigate these intricate regulations. Our expertise ensures we provide the strongest possible advocacy.
Holding Insurers Accountable for Bad Faith Practices
When insurance companies breach their duty of good faith by wrongfully denying claims, we take decisive action. Our firm specializes in holding insurers accountable, securing settlements that often exceed contractual benefits. We operate on a contingency fee basis, ensuring you only pay if we win.
Client-Centered Approach: Prioritizing Your Needs
We understand that trust is essential. Unfortunately, insurance companies often prioritize profits over policyholders. At Pillsbury & Coleman, we are committed to reversing this trend. We prioritize your needs, providing personalized attention and unwavering support. We are recognized by insurers for our willingness to take cases to trial, ensuring your peace of mind and financial security.
Long-Term Care Frequently Asked Questions
What kind of support can long-term care insurance offer to San Jose residents?
In San Jose, like the rest of California, long-term care insurance is designed to provide financial assistance for individuals who require help with daily activities. These activities include eating, bathing, dressing, continence, and moving around. This need can arise from injuries, illnesses, aging, or cognitive conditions such as Alzheimer's. Policies help to manage costs for care provided either at home or in specialized facilities, depending on the specifics of the plan. Given the high cost of care in San Jose, understanding your policy details is crucial.
Do all long-term care plans in San Jose provide the same benefits?
No, California provides three main types of long-term care insurance:
- Plans that cover care exclusively in nursing homes and assisted living facilities, excluding home care.
- Plans that cover only home-based services, such as home health care and adult day care, excluding facility care.
- Comprehensive plans that cover both facility and home care, including essential benefits like nursing home care, assisted living, and home health services.
Even within these categories, benefit amounts and payment structures (indemnity vs. reimbursement) can vary significantly. Therefore, it's strongly recommended that any policy intended for use in San Jose county be thoroughly reviewed.
Who oversees long-term care insurance providers serving San Jose?
The California Department of Insurance regulates long-term care insurers operating in San Jose and throughout the state. While California law establishes regulatory frameworks, Pillsbury & Coleman's experience indicates that resolving claim disputes can still be complex. We've found that direct legal advocacy is often more effective than relying solely on departmental complaints. This is especially true in a high-cost area like San Jose.
If my long-term care claim is challenged in San Jose, what actions should I take?
If you encounter difficulties with a long-term care claim in San Jose, consider these steps:
- Obtain a complete copy of your insurance policy from the provider.
- Compile all relevant medical records.
- Collaborate with your treating physician to ensure a detailed "Plan of Care" is documented, reflecting your required care level.
- Maintain meticulous records of all communications with the insurance company, including notes, logs, and correspondence.
- Seek advice from an experienced attorney, such as those at Pillsbury & Coleman, who possess a proven track record in handling long-term care claim disputes in California, as this can significantly improve your chances of a successful outcome.
Understanding Your Policy’s Benefit Schedule
The policy’s Benefit Schedule details the daily benefit amount, elimination period, maximum benefit duration, and any inflation adjustments. Policies from the late 1990s often feature unlimited lifetime benefits with 5% annual COLA increases. These benefits are crucial for vulnerable individuals, especially the elderly, and essential for their families to avoid financial hardship. The costs of long-term care, particularly in California, are substantial.
Getting The Assistance Of A Long-Term Care Insurance Claims Lawyer In San Jose
If you are having difficulty getting benefits under your long-term care policy, call the experienced San Jose long term care insurance claims lawyers at Pillsbury & Coleman, LLC. We have dedicated our practice to holding the insurance industry accountable to their policyholders. Contact us today to discuss your claim and see 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 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.
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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.