Berry v. Time Insurance Co.

798 F.Supp.2d 1015 (2011)

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Nature of the Case

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Facts

P purchased a Nursing Home Insurance Policy (the policy) from D. P fell in September of 2008. P has required home health care assistance to remain in her home. D informed her that, with no exceptions, alternate care could only be covered by the policy if it were provided by a licensed home healthcare provider. After this discussion, P discovered South Dakota does not license home healthcare providers. P believed D would not provide alternate care coverage and obtained independently funded home healthcare, services, and equipment so she could remain in her home. Eighteen months later, P's son, Dr. Spencer Berry, M.D., contacted D and, for the first time, P was informed of a list of steps that were required before she could receive alternative care benefits. Dr. Berry called D to request coverage of P's treatment plan, which had been in effect prior to the evaluation, and he provided D with information on P's healthcare providers. D refused to cover this care because the home healthcare provider did not meet minimum licensing criteria. The policy does not state that a home health provider must be licensed or certified. D offered to pay for some equipment and approved some home health care expenses. P rejected this offer because she desires full coverage of the expenses associated with her chosen home healthcare provider. The policy states that alternative care plans are to be negotiated between the parties, but the parties were unable to reach a final agreement. P sued for breach of contract.