Connecticut Continental Casualty Long Term Care Insurance Class Action Settlement
The Settlement Class “includes all CNA policyholders with the Policies listed below that were issued in Connecticut and (1) who made a claim under a policy relating to a stay in a managed residential community (‘MRC’) in the State of Connecticut; (2) who were medically eligible for benefits; (3) but were not afforded coverage for the costs and expenses relating to the stay; (4) on the grounds that the facility (a) was not licensed by the state and/or (b) could not legally provide 24-hour-a-day, or continuous nursing services/care and/or (c) did not provide daily medical records, (5) who was not denied coverage for any other reason, and (6) who suffered ascertainable damages as a result of being denied coverage.”
If you are a Class I Member, and you submit a valid claim form, the settlement provides for:
Cash payment of 80% of the daily facility benefit for claims that were submitted in writing to CNA and/or denied by CNA in writing that fall within the Category One, Category Two or Category Three benefit categories discussed below. These benefits are applicable to each covered day of stays at an MRC (in the case of Category One and Category Two) or a private residence (in the case of Category Three) from December 27, 2007 through March 31, 2016.
o Category One: To be entitled to the Category One benefit, the Class I Member must have actually resided in an MRC and must have paid for and received “Qualified Care” (defined below) from an on-site ALSA. This benefit is paid only for days in which the Class I Member actually resided in an MRC while receiving Qualified Care from an on-site ALSA.
o Category Two: To be entitled to the Category Two benefit, the Class I Member must have actually resided in an MRC and must have paid for and received “Qualified Care” (defined below), but need not have received the care from an on-site ALSA. The Class I Member must, however, have: (i) paid for and received Qualified Care from a third party provider while residing in the MRC; (ii) provide documentation of payment for such Qualified Care (e.g., bank statements, cancelled checks, receipts), together with an affidavit or declaration, demonstrating that the provider’s daily or monthly cost was lower than the ALSA’s daily or monthly cost; and (iii) submit an affidavit confirming he or she would have engaged the ALSA if CNA had approved rather than denied the claim, but engaged the third party provider only because of the claim denial and because it was less expensive than the ALSA. This benefit shall be paid only for days in which the Class I Member actually resided in an MRC while receiving Qualified Care from a third party provider.
o Category Three: To be entitled to the Category Three benefit, the Class I Member must have resided in a private residence (e.g., your home) after the claim for a stay in an MRC was denied. To qualify for the Category Three benefit: (i) the Class I Member must have paid for and received Qualified Care (defined below) from a third party provider following the denial; (ii) the Class I Member or Class I Member representative must provide documentation of payment for such Qualified Care (e.g., bank statements, cancelled checks, receipts), together with an affidavit or declaration, demonstrating that the Class I Member would have stayed at the MRC and engaged the ALSA to provide care if CNA had approved rather than denied the claim, but instead moved to or remained at a private residence and engaged the third party provider only because of the claim denial and because it was less expensive than moving to or remaining at the MRC and paying the MRC and ALSA; and (iii) the service provider must not be another facility. This benefit shall be paid only for days in which the Class I Member actually resided at home while receiving Qualified Care.
For claims qualifying under Category One, Category Two or Category Three, cash reimbursement of 80% of the premiums you paid that would have been waived during the above stays if your claim(s) had originally been approved (“Waiver of Premium Benefit”).
Claims that would qualify under Category One, except that the Class I Member did not file a claim in writing and did not receive a claim denial in writing, can receive 50% of their policy’s daily facility benefit, and 50% of the Waiver of Premium Benefit, for every day they (a) resided in an MRC from December 27, 2007 through March 31, 2016 while paying for and receiving Qualified Care (defined below) or (b) resided in a private residence from December 27, 2007 through March 31, 2016 while paying for and receiving Qualified Care (defined below). To receive this benefit, the Class I Member or the Class I Member’s representative must submit a sworn statement that he or she was told by CNA on the telephone that MRCs were not covered under his or her policy and did not make a written claim for that reason; and the affidavit is corroborated by a telephone recording or some other form of contemporaneous evidence maintained by CNA.
“Qualified Care” means: (1) skilled nursing or intermediate nursing care – which is medical care above the level of assistance with the activities of daily living – at least three times a week; or (2) one of the following activities of daily living, with the frequency as indicated: Bathing (at least three times a week), dressing (at least five times a week), transferring (at least once a day), eating (at least once a day), incontinence care (at least once a day), medication (at least three times a week), mobility (at least once a day), or toileting (at least once a day); or (3) confinement in a locked or lockable memory care or dementia unit serving patients who are elopement risks with regular assistance. Care provided by friends or family members of any kind is not included.
The total of all payments to be made to all Class I Members pursuant to these benefits shall be capped at $2.75 million (“Payment Cap”). To the extent that the amount of approvable claims to all Class I Members exceeds the $2.75 million cap, the approvable claims submitted by the Class I Members shall be reduced proportionately by the percentage necessary to bring the total of all payments for approvable claims within the $2.75 million Payment Cap.
Settlement benefits will be offset by any other payments made to the Class I Member under his or her policy, such as, by way of example, for a previously approved home health care benefit. The days of settlement benefit payments shall be capped by any applicable benefit periods and maximums in the policy.
To determine your daily benefit amount, consult the declarations page of your policy and, if you purchased it, any inflation protection rider.
Proof of Purchase
Gardner, et. al. v. Continental Casualty Company,Case No. 3:13-cv-01918-JBA, District Court for the District of Connecticut
This settlement resolves allegations against the defendant regarding the denial of certain claims for stays in long term care facilities
Per the settlement CNA denied the long term care claims based on the fact that the claims were for stays at facilities that were were not licensed by the state and did not have the capacity to provide the level of care required by the policy terms
Allegedly, CNA declined claims based on the facilities not having a 24 hour nurse on staff, however there is evidence that in the past they approved claims for facilities with no such services
Based on this precedent the plaintiffs believe that their claims should not have been denied
The defendant denies the allegations and has agreed to settle to avoid the cost and uncertainty of a trial.
Gardner v. Continental Casualty Co. Settlement
c/o KCC, Settlement Administrator
P.O. Box 8060
San Rafael, CA 94912-8060