Long Term Care Issues- Are Assisted Living Facilities Covered Under Home Care Policies?

In my 5 plus years of handling Long Term Care Insurance claims, I have seen several issues cropping up on a regular basis. The first issue I dealt with of course, was my father's case in which John Hancock Insurance Company refused to cover the cost of care my father received in an Assisted Living Facility (ALF). Since that time, we have been successful in many cases against several insurance companies on the same issue-whether a "home care" policy, should cover the cost of care in an Assisted Living Facility.

We have had this issue with Washington National Insurance Company, Bankers Life Insurance Company, Senior Health Insurance Company of Pennsylvania (SHIP), Guarantee Trust Life Insurance Company, Genworth, Transamerica, and others.

We believe there is no good reason under the law for a long term care insurer to deny such a claim. Under Florida law, an ALF is a person's home and when a person enters an ALF because he or she requires assistance with activities of daily living, so long as the care the person receives is documented and delivered pursuant to a plan of care, then the care should be covered.

It seems as though the push back from the insurance companies is rooted in the desire to see that a percentage of its insureds never receive long term care benefits; and if they can successfully assert that ALFS are not covered, then they have succeeded in taking premium dollars from their insureds and avoid paying them benefits when they need them, the goal of which is to line their own pockets.

We are determined to fight this fight. Recently, in Storfer v. Guarantee Trust Life Insurance Company (GTLI), the Federal Court for the Southern District of Florida ruled in favor of the insured who by necessity entered an assisted living facility. Needless to say GTLI Company denied the claim and actually argued that by interpreting the policy in such a way as to deny the claim, it was actually doing its insureds a favor! That argument was rejected by the court. True to its philosophy of denying needed benefits to its insured, GTLI has appealed the decision. Click the following link to view the court decision: http://longtermcarelawoffice.com/wp-content/uploads/10-18-10-Storfer-Order-Granting-Summary2.pdf

If you have a long term care insurance policy, are living or in an ALF, or are contemplating moving into one, we can help you. Contact us at 305-868-1400.