11th Circuit: Assisted Living Facility Not a Home

Sherman chose the home care policy.

“On her application, Sherman expressly acknowledged that she was applying for home-care only coverage and that
she understood that the ‘coverage is designed to provide benefits for home health care services and does not provide coverage for confinement in any nursing home or assisted living facility,’” the court says. “Where the application required her to provide, in her own handwriting, the reason she was choosing a home care only policy, Sherman wrote
that the premiums associated with the policies that cover care in a facility are ‘too high’ for someone at her age.”

Sherman later moved into an ALF and has been receiving care there.

Sherman sued for breach of contract when Transamerica denied the claim.

“We are unpersuaded by Sherman’s claim that Florida law dictates that the definition of ‘home’ in the policy must include ALFs,” the court says. “As an initial matter, there is no dispute that the policy’s provisions plainly and unambiguously provide coverage only when the insured resides ‘at home,’ and not when residing at an ALF.”

The Transamerica policy “defines ‘home’ as ‘any place where [the insured] reside[s] other than a nursing facility, Alzheimer’s facility, hospital, hospice facility, assisted livingfacility, congregate care or any other similar residential care facility,’” the court says. “Thus, the policy unambiguously excludes ALFs from the definition of ‘home’ and does not cover expenses incurred while the insured resides in an ALF.”

OTHER CASES

Dunn said he has represented plaintiffs in other LTCI cases that he believes to be similar to the Sherman case.

Those cases hinged on the definitions of the terms “home care” and “home health care,” rather than “home,” and the clients in those cases succeeded at getting benefits paid, Dunn said.

In the other cases, Dunn said, the clients prevailed by showing that an ALF could function as a home health agency.