A 3-judge panel at the 11th Circuit Court of Appeals has rejected an appeal filed by a Florida woman who wants a long-term care insurance (LTCI) to provide home health care benefits.
The woman, Edith Sherman, says she is getting care in her personal residence, which happens to be in an assisted living facility (ALF).
The insurer, Transamerica Life Insurance Company, contends that the facility is a kind of long-term care (LTC) facility, not a place that would count as a home according to the terms of the policy it issued to Sherman.
A federal district court agreed with the insurer, and the 11th Circuit upheld the district court ruling in an opinion that is posted on the appellate court website but not considered officially published. The opinion was attributed to the court, not to one of the judges who considered the case.
Representatives for Transamerica Life, a unit of AEGON N.V., The Hague, Netherlands, were not available to comment on the ruling.
Steven Dunn, a Bay Harbor Island, Fla., lawyer who helped represent Sherman, said he and his client are disappointed by ruling.
“It’s not consistent with Florida law and how seniors transition through life as they age,” Dunn said in an interview. “An assisted living facility is someone’s home as a matter of Florida law.”
Because Sherman’s policy is not paying benefits, her family is having to pay for her care, Dunn said.
When Sherman applied for coverage, the court says, she could choose from a menu of three options:
- “Integrated Facility and Home Care Insurance.”
- “Faci1ity Only Insurance.”
- “Home Care Only Insurance.”
The first option was supposed to provide coverage wherever the insured was living, the facility-only provided coverage in either a nursing home or an ALF, and the home care policy provided coverage only in the insured’s own home, the court says.
Sherman chose the home care policy.