Coverage Under Long-Term Care Insurance Policies
If you are reading this page, you already know that long-term care insurance is supposed to provide insurance benefits to pay for assistance with “activities of daily living” (ADL) or, if due to cognitive impairment, a person requires assistance for his or her own safety. Additionally, if you are reading this now, you likely have firsthand experience with an insurance company — your own or that of a loved one — that has disregarded or minimized evidence that supports the claim in order to deny it.
The ADL’s for which your insurance company is supposed to pay benefits generally include eating, bathing, dressing, walking, moving from a bed to a chair and being continent. If you or a loved one has experienced an injury, illness or the progression of a physical or mental impairment that makes it unreasonably difficult — or even impossible — to perform these ADL’s, the insurance company is obligated under California law to honor your claim. Where a policyholder is suffering from Alzheimer’s disease or another mental illness or brain disorder such that he or she requires assistance or supervision, your long-term care insurer should be paying benefits.
A policyholder qualifies for long-term benefits under most policies if he or she requires “standby” assistance. In other words, if, for example, the policyholder needs a caregiver to stand or sit next to him for his own safety when performing certain activities — such as walking, getting up from a chair, using the shower — the insurance company is obligated to pay benefits. Under most policies, the policyholder need not establish that he actually needs a caregiver to for “hands on” assistance. It is enough that the policyholder needs someone standing next to him watchfully and on guard or providing assistance if necessary.
Your long-term care policy may also entitle you to benefits for treatment in a nursing facility or residential care facility, home care, adult day care or other types of care. If your insurance company is refusing the pay benefits for such treatment despite evidence that such treatment is necessary, the insurance company is reneging on its obligations under the policy.
A long-term care insurance policy may be titled a “custodial care” or a “personal care” policy. Whatever it is called, the insurance company selling the policy has a duty of good faith and fair dealing — and, as with any other insurance policy governed by California law, is prohibited by California law from unreasonably denying or delaying the payment of claims.
Your Insurance Company Is Bound By A Duty Of Good Faith And Fair Dealing In Deciding Long-Term Insurance Claims
As with any other type of claim arising under California law, your insurance company has a duty under California law to thoroughly and fairly investigate your long-term care claim. As the California Supreme Court stated in the landmark case of Egan v. Mutual of Omaha Insurance Co. (1979) 24 Cal.3d 809, an insurance company must “fully inquire into possible bases that might support the insured’s claim.” Your insurance company acts in bad faith if it fails not only to investigate the reasons supporting your claim but also if it fails to thoroughly investigate “the foundation for its denial.”
California law is clear that cannot properly ignore evidence that supports the insured’s claim. As the California appellate court stated in Mariscal v. Old Republic Life Ins. Co. (1996) 42 Cal. App.4th 1617:
“An insurance company may not ignore evidence which supports coverage. If it does so, it acts unreasonably towards its insured and breaches the covenant of good faith and fair dealing.”
Contact The Law Offices Of Bennett M. Cohen
At the Law Offices of Bennett M. Cohen, we represent individuals throughout the Bay Area in long-term care insurance claims. We have successfully confronted and overcome insurance company tactics for our clients and are committed to doing so for you. If you choose our firm, you will have an aggressive, tireless team representing your interests. (See the results and client testimonials.)
At our firm, the first consultation is free. Please contact us to schedule a meeting with our San Francisco long-term care claim lawyer (LTC claim lawyer) to discuss your case.