Rejecting an invitation by appellant-plaintiff to disregard express policy language, the Eleventh Circuit Court of Appeals denied an appeal by an insured seeking home health care benefits for services received in an assisted living facility (ALF). Both the district court and the Eleventh Circuit rejected the plaintiff’s argument that state law and public policy required that the court “rewrite the policy” to provide coverage.
In 1997, the plaintiff in Sherman v. Transamerica Life Insurance Company purchased a “Home Care Only” policy. At that time, she had the option of purchasing a “facility-only” policy or an “integrated” policy, both of which would have provided ALF coverage, but she chose the less expensive home care-only policy. Years later, she moved into an ALF and applied for benefits for services received there. According to plaintiff, she was entitled to coverage because the ALF had become her “home.” The district court dismissed the complaint, holding that the policy plainly did not provide the coverage sought.
On appeal, the Eleventh Circuit affirmed finding that the plaintiff, having “knowingly purchased an insurance policy that covers only health care services provided in her home,” was not entitled to benefits for services rendered in an ALF. Florida’s insurance laws, said the court, do not “prohibit an insurance contract from covering health care services provided only at an insured’s home, as opposed to a facility” and public policy does not disfavor limited benefit policies that exclude ALF coverage. Additionally, the court noted that an “ALF is a highly-regulated environment with access to round-the-clock care services as necessary,” whereas “[i]n her home plaintiff’s living arrangements are not regulated by the Department of Elder Affairs, and she had only parttime access to a home health aide on a pre-arranged schedule.”