San Mateo Long Term Care Insurance Claims Attorney

Navigating Long-Term Care Insurance Claims in San Mateo: Expert Legal Guidance from Pillsbury & Coleman, LLP

San Mateo Long Term Care Insurance Claims LawyerLong-term care in San Mateo is one of the fastest-growing forms of benefits that help Americans when they need it. These plans are bought individually and the Employee Retirement Income Security Act generally provides more compensation for policyholders than for employees (ERISA). The policyholder has the right to sue the insurer if the insurer unjustifiably and without a reasonable basis refuses a long-term care claim. Our San Mateo long term care insurance claims attorney has answers to hard questions you may have.

Insurance companies are always trying to maximize their profits and they tend to reject your long-term care claim. The San Mateo long term care lawyers at Pillsbury & Coleman, LLP, are prepared to handle your case if you were rejected a San Mateo Long Term care claim.

We understand that navigating the claims process can be particularly daunting for family members, especially adult children, who may be unfamiliar with the policy’s details. Our experienced attorneys provide compassionate and comprehensive support, guiding families through every step of the process.

Trustworthy Representation for Long-Term Care Needs:

Long-term care insurance is designed to provide crucial coverage for services and expenses not typically covered by standard health insurance, particularly when individuals face chronic medical conditions, disabilities, or cognitive impairments such as dementia. As defined in §10231.2 of the California Insurance Code, long-term care insurance covers “diagnostic, preventative, therapeutic, rehabilitative, maintenance, or personal care services that are provided in a setting other than an acute care unit of a hospital.”

Our commitment at Pillsbury & Coleman, LLP is to provide trustworthy and effective legal representation, advocating for our clients’ rights and ensuring they receive the benefits they deserve. If you are facing challenges with your long-term care insurance claim in San Mateo, contact us for a consultation.

How Long-Term Care Insurance Works In San Mateo

Long-term care insurance is a policy under which you pay on time and the insurance provider pays for long-term care costs if you need it. The costs of a nursing home assisted living, or in-home treatment is usually covered by these insurance plans.

Unfortunately, several insurance providers incorrectly refuse long-term care coverage, leaving your loved ones with no idea what to do or how to pay for it. They bombard policyholders with perplexing and time-consuming paperwork. When a policyholder has a problem with a claim, they are never able to talk to the same benefits administrator about it. Policyholders, who are often in their 80s and 90s, may fail to send in documentation or just give up.

If you receive a rejection, don’t give in to the insurance company’s pressure to embrace it and walk away. You have the right to fight for the insurance proceeds that you or a loved one paid for when the policy was bought and consult with your case with one of our attorneys.

Understanding Your Long-Term Care Insurance: A Guide to Receiving Benefits in San Mateo

Imagine you or a loved one needs help with everyday tasks like bathing, dressing, or eating. This is where long-term care insurance can be a lifeline. But how do you actually get those benefits you’ve been paying for? It’s not always as straightforward as you might think.

How Can I Know My Policy Inside and Out

The first step is to become an expert on your own insurance policy. Think of it like a rulebook for getting the support you need. Carefully read through the terms and conditions. Key questions to ask include:

  • What qualifies me for benefits? Look for specific triggers, such as needing assistance with a certain number of daily activities or having a diagnosed medical condition.
  • Who can be my caregiver? Can a family member provide care, or does it have to be a licensed professional? This is crucial for planning your care.
  • Where can I receive care? Does the policy cover care at home, or only in a facility? Knowing this helps you understand your options.

How Do I Avoiding Common Pitfalls in Long Term Care Claims

Many people get denied benefits because they don’t fully understand their policy. Insurance companies can be very particular about the details. If you’re unsure about anything, don’t hesitate to seek expert advice.

Long-Term Care Frequently Asked Questions

In San Mateo, as in the rest of California, long-term care insurance aims to provide financial support for individuals who require assistance with "activities of daily living" (ADLs). These typically include eating, bathing, dressing, continence, and transferring. This assistance may be needed due to injuries, illnesses, the effects of aging, or cognitive impairments like Alzheimer's. Policies help cover costs for care in facilities or at home, depending on the policy type. Understanding the specifics of your policy is vital in San Mateo, where care costs can be significant.

No. California offers three main types:

  • Nursing Facility and Residential Care Facility Only" policies, covering care in nursing homes and assisted living facilities, but not home care.
  • Home Care Only" policies, which cover various home-based services like home health care and adult day care, but not facility care.
  • Comprehensive Long-Term Care" policies, which cover both facility and home care, including essential benefits like nursing home care, assisted living, and home health services.

It is important to know that even within these categories, benefit amounts and payment structures (indemnity vs. reimbursement) can vary greatly. Therefore, careful review of any policy being considered for use in San Mateo county is highly advised.

The California Department of Insurance regulates long-term care insurers operating in San Mateo and throughout the state. While California law provides regulatory frameworks, our experience at Pillsbury & Coleman has shown that navigating claim disputes can still be challenging. We've observed that direct legal advocacy is often more effective than relying solely on departmental complaints. This is especially true in a location like San Mateo, where the cost of living and therefore the cost of care is very high.

If you're facing difficulties with a long-term care claim in San Mateo, take these steps:

  • Obtain a complete copy of your policy from the insurer.
  • Gather all relevant medical records.
  • Communicate with your treating physician to ensure a clear "Plan of Care" is documented, reflecting your required level of care.
  • Maintain detailed records of all communication with the insurance company, including notes, logs, and correspondence.
  • Consult with an experienced attorney, like those at Pillsbury & Coleman, who have a proven track record of handling long-term care claim disputes in California, as this can greatly increase your chances of a positive outcome.

Fighting for Your Rights in San Mateo

If you’ve already filed a claim and been denied, don’t give up! This is where having an experienced attorney can make a huge difference. At Pillsbury & Coleman, LLP, our San Mateo long-term care insurance claims attorneys have a deep understanding of insurance law and a proven track record of success. We know how to navigate the complex legal landscape and fight for the benefits you deserve.

Focusing on What Matters Most

We understand that dealing with long-term care needs can be incredibly stressful, both emotionally and financially. You might be facing physical and mental challenges, and the last thing you need is a battle with an insurance company.

That’s why we’re here to help. Our compassionate attorneys will take on the burden of dealing with the insurance provider, allowing you to focus on your health and your loved ones. We’ll ensure you receive the care you need, so you can concentrate on what truly matters: your well-being.

Why Choose Pillsbury & Coleman, LLP?

  • Local Expertise: We specialize in serving San Mateo residents, and understanding the specific challenges they face.
  • Proven Success: We have a history of successfully fighting insurance companies and securing benefits for our clients.
  • Personalized Attention: We provide compassionate and personalized legal support, guiding you through every step of the process.

Remember, you paid for your long-term care insurance for a reason. Don’t let an insurance company deny you the benefits you deserve. Contact Pillsbury & Coleman, LLP, for a consultation, and let us help you navigate this challenging time.

Contact our San Mateo Long-Term Care Insurance Claims Attorney

Our San Mateo Long Term Care Attorneys at Pillsbury & Coleman, LLP, has handled a wide variety of long term care cases for clients. We also represented clients whose life and health insurance benefits were wrongfully refused, in addition to offering legal counsel when insurance providers behaved in bad faith and denied long term disability or care policies. Residents of San Mateo should depend on our team’s decades of experience while looking for a long-term disability attorney in California.

If you believe you have been wrongfully denied disability, life, or long-term health care coverage, contact our lawyers today for a free consultation. We will assist you in evaluating the legal options available to you after analyzing your case.

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.