Long-Term Care Insurance Company Not Required to Pay for Care at Facility Without 24-Hour Nursing Staff

A U.S. District court holds that a long-term care insurance company did not breach its contract when it refused to pay for care at a facility that did not have a nurse on staff 24 hours a day. Painter v. John Alden Life Insurance Co. (U.S. Dist. Ct., E.D. Ky., No. 21-40-DLB-EBA, May 27, 2022).

Louella Painter purchased a long-term care insurance policy from John Alden Life Insurance Co. in 1998. The policy provided a lifetime daily benefit of $100 for care in a long-term care facility, defining it as a place with 24-hour nursing care. In 2020, Ms. Painter entered The Seasons at Alexandria, a long-term care facility that includes personal care as well as skilled nursing beds. Ms. Painter, who was in a personal care bed at the facility, submitted claims for benefits. The insurance company denied the claim because the Seasons did not provide 24-hour nursing care.

Ms. Painter sued the insurance company for breach of contract. She submitted evidence that there was one nurse down the hall from the personal care section of the Seasons working an eight-hour shift per day. Ms. Painter asked for a declaratory judgment.

The U.S. District Court, Eastern District of Kentucky, grants the insurance company summary judgment. The court holds that the Seasons did not meet the definition of a long-term care facility under the insurance policy because it did not employ a nurse who provided 24-hour care.

For the full text of this decision, go to: https://cases.justia.com/federal/district-courts/kentucky/kyedce/2:2021cv00040/95205/37/0.pdf?ts=1653731343

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