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Long Term Care Insurance Battle Goes to Court

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The case of a Pebble Beach resident against the Chicago based CNA Financial group is now going to federal court. A lawsuit that was filed on behalf of 91 year old Janice O’Brien claimed that she required home care and that the insurance company that she had paid for years denied her claim. Despite appeals from her attorney, a judge decided on Tuesday that the case should be moved to U.S District Court in San Jose because it may involve more than $75,000 and the financial group is located out of state.

Although the original intent was to have some type of mediation with the financial group, those actions failed. As a result, they are now in a discovery phase for a trial that will occur next summer. Efforts to reach CNA Financial group were not successful, although a spokeswoman said earlier in the year that the company disagreed with the resident’s assertions and that they were willing to defend themselves against a lawsuit.

The suit claimed that the insurance company ignored the advice of three doctors, including one of its own, when processing the claims for the resident’s medical bills. The woman had paid for insurance since 1996. After a hospital stay in 2011, the doctors had determined that she should not live alone. Doctors also provided evidence that she required supervision due to conditions such as cognitive impairment, hypertension, and hyponatremia. The woman’s family had hired caregivers but all of her claims for these options were denied by the insurance company. The claims still have not been reimbursed.

The woman’s attorney says that the next step will be to get testimony from the insurance company employees who were responsible for rejecting the claims. Although the mediation process was not successful, the attorney believes that both sides of the case made a good effort to try to resolve the issue, but that everyone was not able to agree to the same value of the case itself. Meanwhile, the family has been disappointed with the entirety of the proceedings. They feel that the insurance company has not been willing to work with them within the situation. They also still feel that the claims should have been paid when they were filed. According to the attorney, the family was determined to take the case to trial for justice if the insurance company was not willing to reach a settlement that would be fair to the circumstances.

Ultimately, this is a strong example of what can happen when insurance companies fail to meet the promises and pay the claims that their clients have been investing in for years. Given the amount of attention that this case is getting, it has promoted a large amount of awareness regarding filing claims for long term care options and the probability of getting those claims reimbursed and handled appropriately. Keeping updated with claims can be a very important aspect to insuring that care is provided and reimbursed.