At the Law Offices of Steven M. Dunn, P.A., we have shifted our focus to meet the rising demand for representation in long term care insurance claims among the elderly living in Florida. We are committed to making sure you receive the benefits you are entitled to. Examples of long-term care insurance claims we have or are currently handling include:
- A lawsuit was brought on behalf of a client against Fortis Insurance Company, now known as John Hancock, for failing to honor long-term care coverage for care provided by an assisted-living facility. The denial was based on an arbitrary interpretation by the insurance company of what a “home health care agency” is, and by narrowly interpreting that phrase, denied coverage for the assisted living. The policy itself contained no definition for “home health care agency” and therefore set no limitations for a denial by the insurance company. The court held the policy was ambiguous and that it could be said that the assisted living facility met that definition. Therefore, the court ruled that the policy did cover the cost of the assisted Living Facility. See the following link to see the court order: Summary Judgment-Assisted Living Facility-”Home Health Care Agency”. This case was important because it allowed an individual with a “Home Care” policy to defray the cost of assisted living.
- A summary judgment was granted in a lawsuit brought against Blue Cross and Blue Shield of Florida for failing to honor long term care coverage for a man who was forced, because of his circumstances, to enter an assisted living facility. While there he was receiving care through a home health agency and he made a claim to have that care covered. The insurance company denied coverage based on a provision in the policy that denied benefits if the care was provided in an “institutional setting” and argued that an assisted living facility was an institution. The term “institutional setting” was not defined in the policy, but the insurance company construed that term to include assisted living. The court held that the term “institutional setting” was ambiguous, and found that the company had to cover the care. The insurance company unsuccessfully tried to use fuzzy policy language to deny benefits to someone who had paid premiums for years and desperately needed the care. Without that ruling, all of the premiums the insured person paid would have been wasted, and the policy rendered worthless. This case was important because it established the right of an individual to utilize his “Home Care” policy regardless of whether he resided in a house, apartment, condominium, or assisted living.
- A class action lawsuit was brought against Washington National Insurance Company for failing to apply an 8% inflation rider to all of the benefits under the policy. The federal court has ruled that the policy is ambiguous and the the complaint states a valid claim for breach of contract because of the insurer’s failure to apply the rider to all of the benefits. Since the ruling, after significant negotiations, the parties entered into a partial settlement agreement in which the insureds were placed back on claim immediately, will receive up to $200,000 for out of pocket expenses incurred for care, and a waiver of back premiums. Also, based on the court rulings, the insured effectively now have life time benefits available to them. The settlement requires the insurance company to establish a fund of $8,000,000 for reimbursement of the out of pocket expenditures made by the insureds for care. The settlement also requires the company to make a $100,000 charitable donation to the Southeast Branch of the National Alzheimer’s Association. The estimated total value of the case to the policy holders is estimated to be between $30-35 million. Click the link to view the final judgment approving the settlement: Class Action Final Judgment and Settlement Order.
- A lawsuit was brought challenging Continental Casualty Insurance Company’s requirement that in order for a person to receive needed home care benefits, they must first receive at least one skilled visit from a nurse, therapist or similar such provider regardless of whether the skilled visit was needed. The court appellate court issued a scathing opinion that is extremely important because it recognizes the strong public policy in Florida in favor of the elderly and the need for long term care insurance coverage to provide benefits without unreasonable barriers. View on our website or visit www.3dca.flcourts.org/Opinions/3D08-2226.p
- A Lawsuit was brought against Guarantee Trust Life Insurance Company seeking benefits for a man who, because of severe dementia, was forced to enter an assisted living facility. The insurance company denied the claim on the basis that the assisted living facility did not meet the definition of a covered home care provider. The insurance company did not challenge the insured’s need for the care. Instead, it asked the court to make a strained interpretation of the policy it drafted and sold to the insured. The court refused to do so and entered a judgment in favor of our client. In keeping with this company’s history of denial, appealed the court’s ruling. Click the link to view the judgment of the court. 10-18-10 Storfer Order Granting Summary
Past successes also include:
- A Long-Term Care Insurance company paid $975,000 after wrongfully denying a claim for long-term care benefits for a man residing in an assisted living facility.
- A Long-Term Care insurance company paid $250,000 after wrongfully denying a claim for long-term care benefits to a man residing in an assisted living facility.
- A Long-Term Care Insurance company paid $125,000 and agreed to pay $90 per day to a man for home health care he received while residing in an assisted living facility.
- A Long-Term Care Insurance company paid $268,000 and agreed to pay benefits for life to a woman who had a policy with an inflation rider that the company failed to properly apply.
- A Long-Term Care Insurance company paid $130,000 and a minimum of $100,000 in future benefits to a 98 year old woman whose benefits were cut-off when the company failed to properly apply an inflation rider.
- A Long-Term Care Insurance Company paid a 95 year old woman $100,000 and at least $100,000 in future benefits whose benefits were cut-off when the company failed to properly apply an inflation rider.
- A Long-Term Care Insurance Company paid $126,500 to a woman who moved into an assisted living facility after the company initially refused to cover the cost of care she received from the facility. Additionally, the company agreed to pay 70% of the cost of the assisted living facility for the rest of her life.
- A Long-Term Care Insurance Company paid a woman $100,000 after refusing to honor the restoration of benefits clause in her insurance policy. The restoration clause was interpreted by the company to require the insured to be “treatment free” for 180 consecutive days in order for the policy benefits to fully restore. The company took the position that if an insured took a a pill or attended a regularly scheduled doctor appointment constituted “treatment”. Therefore, under that interpretation, given the ages of the insureds, virtually no policy can restore.
- A Long-Term Care Insurance Company paid a woman $86,650 for wrongfully converting her policy to a non-forfeiture option where she should have been receiving benefits while residing in an assisted living facility. If the company had properly paid benefits, she would have been entitled to a waiver of her premium payments. Therefore, she should not have been asked to convert her policy to a non-forfeiture status.
- A Long-Term Care Insurance Company agreed to restore policy benefits to an 86 year old woman who needed full time care and was paying out of pocket in excess of $700 per week. The reinstatement has a potential value of $200,000.
- A Long-Term Care Insurance Company agreed to reinstate a woman’s policy after lapsing it for non-payment of premiums. Based on a Florida Statute that provides for reinstatement if the non-payment was due to a medical condition that prevented the insured form dealing with her affairs, we were able to establish that the non-payment was due to a cognitive problem that affected our client’s memory. The reinstatement has a value in excess $150,000.
- A Long-Term Care Insurance Company agreed to cover the cost of care for a woman living in an assisted living facility. The settlement is valued in excess of $200,000. The company had to pay attorney fees as well under a Florida Statute that provides for fee when an insured person is successful in a claim for insurance benefits that are wrongfully denied.
- A Long-Term Care Insurance Company agreed to pay benefits of $100,000 for a man residing in assisted living facility where benefits were initially denied. Attorney fees and costs were paid by the company as well.
- A Long-Term Care Insurance Company agreed to pay benefits valued at approximately $200,000 for a woman residing in an assisted living facility where benefits were initially denied. Attorney fees and costs were paid by the insurance company as well.
- A Long-Term Care Insurance Company agreed to pay benefits valued in excess of $240,000 for a woman residing in an assisted living facility where benefits were initially denied. Attorney fees and costs were paid by the insurance company as well.
- A Long-Term Care Insurance Company agreed to pay benefits valued in excess of $225,000 for a man residing in an assisted living facility where benefits were initially denied. Attorney fees and costs were paid by the insurance company as well.
- A Long-Term Care Insurance Company agreed to pay benefits valued in excess of $260,000 for a woman residing in an assisted living facility where benefits were initially denied. Attorney fees and costs were paid by the insurance company as well.
- A Long-Term Care Insurance Company agreed to restore policy benefits after an initial denial. The company claimed the client’s policy did not qualify for restoration of benefits because she allegedly received medical treatment (injections of insulin) during the restoration period. Ultimately, after suit was filed, the company agreed to restore the policy. Our client is now receiving benefits. The settlement is worth approximately $230,000. Attorney fees and costs were paid by the insurance company as well.
- A Long-Term Care Insurance Company agreed to pay benefits valued in excess of $200,000 for a man residing in an assisted living facility where benefits were initially denied. Attorney fees and costs were paid by the insurance company as well.
- A Long-Term Care Insurance Company agreed, after an initial denial, to pay past and future benefits valued in excess of $250,000 for an 85 year old woman who needed full time care. Attorney fees and costs were paid by the insurance company as well.
- A Long-Term Care Insurance Company agreed, after an initial denial, to pay past and future benefits valued in excess of $250,000 for an 84 year old woman who needed full time care. The denial was based on an alleged lapse of the policy because our client did not meet the requirements for a waiver of premium and according to the company the premiums went unpaid. Her particular policy required that she receive a certain amount of days of care per week in order for the waiver of premium provision to apply. However, because the policy failed to define when a week began for the purposes of the provision, the denial could not hold up. Attorney fees and costs were paid by the insurance company as well.