Gardner & Rosenberg secured a settlement of its client’s lawsuit against a national insurance company arising from its denial of coverage to a policyholder under a long-term care policy.  Read the Complaint…

 

[REDACTED FOR PRIVACY]

COMMONWEALTH OF MASSACHUSETTS

BARNSTABLE COUNTY SUPERIOR COURT

_______________________________

____________________,                            )             CASE NO: _________

Plaintiff,                                                                   )

v.                                                                                )

CONTINENTAL CASUALTY COMPANY         )

Defendant                                                                )

_______________________________ )

COMPLAINT

Plaintiff _____________ submits this Complaint against Defendant Continental Casualty Company (“CCC”) for breach of its insurance policy and for bad faith claims handling.

THE PARTIES

1. ___________ is an individual who resides in _______________.
2. CCC is an insurance company registered to do business in Massachusetts, and, on information and belief, with a principal place of business in Chicago, Illinois.

JURISDICTION AND VENUE

3. This Court has personal jurisdiction over CCC because it transacts business in the Commonwealth, and because the acts and conduct that are the subject matter of this action arose from CCC’s transaction of business in the Commonwealth.
4. Venue is proper in this county because ___________ lives in this county.

FACTUAL ALLEGATIONS

5. ____________ is an insured under a Long Term Care Insurance Contract bearing policy number ____________ issued by CCC (the “Policy”).
6. On or about October 7, 2013, _____________ made a claim for benefits under the Policy for her stay at __________ (the “Facility”) because of a medical condition.
7. Not until on or about December 30, 2013, did CCC acknowledge receiving and reviewing the claim. On or about that date, CCC admitted that the Facility meets the Policy requirements.
8. CCC denied the claim, however, and based its denial entirely on an erroneous assertion that ____________ did not qualify as “Chronically Ill” under the Policy.
9. On information and belief, CCC made this determination despite the fact that the nursing service with whom it contracts to make recommendations concerning whether a policyholder is Chronically Ill, in fact determined that ________ was Chronically Ill.
10. __________ attempted, repeatedly, to contact CCC concerning its claims decision.
11. On or about January 20, 2014, ___________ formally requested that CCC reconsider its denial.
12. On or about March 18, 2014, CCC wrote that it had reviewed ____________ correspondence, and said that it would be requesting documents from the Facility.
13. On or about July 10, 2014, ___________ again formally appealed CCC’s denial.
14. On or about October 28, 2014, CCC wrote to __________ again denying the claim (the “Final Denial”). In the Final Denial, CCC admitted that it had originally denied the claim because it had determined that ________was not Chronically Ill as defined by the Policy.
15. In the Final Denial, however, CCC finally admitted that its original bases for denial — that ________ was not Chronically Ill — was wrong. In the Final Denial, CCC admitted that __________ in fact had been Chronically Ill as defined by the Policy.
16. So, in an attempt to find some other basis on which to deny coverage, it its Final Denial, CCC raised, for the first time, a new justification that, although _______ was Chronically Ill, and although the Facility qualified under the Policy, CCC did not have to provide coverage because ________ was receiving Qualified Long Term Care from her husband rather than from by the Facility’s staff.
17. CCC wrote that although the Facility was charging __________ for room and Board (approximately $6,000 per month), the care services she required were being provided by her husband.
18. The Policy, however, does not require that Qualified Long Term Care be provided by the Facility.
19. Additionally, the Facility did, in fact, provide various services that constitute Qualified Long Term Care under the Policy.
20. Moreover, under the Policy, CCC agrees that it will pay for room and board irrespective of who provides the care services. The Policy, by its terms, includes room and board as a component of Qualified Long Term Care for which it will pay:

Each day You require Home and Community-Based Care, We will pay benefits as follows:

B. For Qualified Long Term Care received in an Alternate Care Facility, including room and board, the lessor of:

(1) The Maximum Daily Facility Benefit shown in the Schedule, or

(2) The expenses incurred for such care. (emphasis added)

21.  Had CCC explained this basis for denial when the claim was submitted, __________ would, of course, have had the Facility provide her the services provided by her husband

22.  The Facility charges only around $350 per month for the services provided by _________’s husband

23.  Accordingly, CCC’s position is that because _________ had her husband, rather than the Facility, provide services that cost approximately $350 per month, CCC will not pay the room and board of approximately $6,000 per month.

24.  Indeed, after CCC informed _______ of its position, her husband ceased providing the services, and CCC began providing coverage.

CLAIMS FOR RELIEF

COUNT I – Breach of Contract

25. ___________ incorporates all other allegations in this Complaint.
26. CCC issued a binding Policy of insurance to _____________.
27. ______________ performed all of her obligations under the Policy.
28. CCC’s denial of ____________ claim under the Policy constitutes a breach of the Policy that has caused __________ damage.

COUNT II – Declaratory Judgment

29. __________ incorporates all other allegations in this Complaint.
30. A dispute exists between _______ and CCC as to whether coverage exists under the Policy.
31. The Court should enter an order that there is in fact coverage for the claim under the Policy.

COUNT III  — Unfair Claims Handling

M.G.L. Chapter 93A (to be added in Amended Complaint)

Illinois Section 154

32. ___________ incorporates all other allegations in this Complaint.
33. CCC’s wrongful conduct occurred in trade or commerce and primarily and substantially in the Commonwealth.
34. CCC’s conduct violated Massachusetts General Laws Chapter 176D (and therefore Chapter 93A) and Illinois Section 154.
35. CCC’s conduct was vexatious and unreasonable.
36. CCC misrepresented pertinent facts and insurance Policy provisions relating to the coverage by shifting its bases for denial of coverage.
37. CCC failed to acknowledge and act reasonably promptly upon communications with respect the claim.
38. CCC failed to adopt and implement reasonable standards for the prompt investigation of the claim.
39. CCC refused to pay the claim without conducting a reasonable investigation based upon all available information.
40. CCC failed to affirm or deny coverage of the claim within a reasonable time.
41. CCC failed to effectuate a prompt, fair and equitable settlement of the claim.
42. CCC failed to provide promptly a reasonable explanation of the basis in the Policy in relation to the facts or applicable law for denial of the claim.
43. CCC compelled __________ to institute this litigation in order to recover the amounts due under the Policy.
44. CCC’s wrongful acts caused ___________ damage.
45. _____________ has sent a demand letter pursuant to Chapter 93A, and will amend this Complaint to reflect CCC’s response, if any.

WHEREFORE, ___________ requests judgment against CCC in an amount to be determined at trial, together with enhanced and triple damages and attorney fees, and that the Court grant such other relief as is just and proper.

Jury Demand: ____________ demands a trial by jury on all issues so triable.

Dated: April 20, 2015

________________________

By her attorneys

_____________________

Josh Gardner (BBO No. 657347)

Nick Rosenberg (BBO No. 657887)

Gardner & Rosenberg P.C.

33 Mount Vernon Street

Boston, MA 02108

Phone: 857-225-2743

Email: josh@gardnerrosenberg.com