Gunson v. James

364 F. Supp. 2d 455, 2005 U.S. Dist. LEXIS 4375, 2005 WL 658762
CourtDistrict Court, D. New Jersey
DecidedJanuary 12, 2005
DocketCivil Action 04-3341 (FLW)
StatusPublished
Cited by3 cases

This text of 364 F. Supp. 2d 455 (Gunson v. James) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Gunson v. James, 364 F. Supp. 2d 455, 2005 U.S. Dist. LEXIS 4375, 2005 WL 658762 (D.N.J. 2005).

Opinion

OPINION

WOLFSON, District Judge.

This matter has come before the Court upon: 1) the three motions for summary judgment filed by James R. Gunson, Plaintiff pro se (“Plaintiff’ or “Gunson”); 2) the motion to dismiss, or in the alternative, for summary judgment, filed by Defendants Long Term Care Partners, LLC (“LTCP”), John Hancock Life Insurance Co. (“John Hancock”), and Metropolitan Life Insurance Co. (“MetLife”) (Collectively “Private Defendants”); 3) the motion to dismiss, or in the alternative, for summary judgment, filed by Kay Coles James, Director of the United States Office of Personnel Management (“Director James” or “Defendant James”); 4) and Plaintiffs motion to appoint counsel. Plaintiff, a federal annuitant, alleges that Defendants imper-missibly denied him long term care insurance coverage in violation of the Americans with Disabilities Act (“ADA”), 42 U.S.C. § 12101 et seq., and the Rehabilitation Act, 29 U.S.C. § 794 et seq. This Court has jurisdiction pursuant to 28 U.S.C. § 1331. For’the reasons set forth below, Private Defendants’ motion for summary judgment is granted, Defendant James’s motion for summary judgment is granted, Plaintiffs motions for summary judgment are denied, and Plaintiffs motion to appoint counsel is denied.

I. BACKGROUND AND PROCEDURAL HISTORY

A) The Federal Long Term Care Insurance Program

The United States Office of Personnel Management- (“OPM”) established the *458 Federal Long Term Care Insurance Program (“FLTCIP”) pursuant to the Long Term Care Security Act (“LTCSA”), 5 U.S.C. § 9001 et seq. The LTCSA directed the OPM to contract with qualified carriers and establish a program whereby federal employees and annuitants, current and retired members of the uniformed services, and their qualified relatives “may obtain long-term care insurance coverage.” 5 U.S.C. §§ 9001(1X6), 9002(a), 9003.

Congress’s intent was to provide families with “affordable options for dealing with the catastrophic expenses of nursing home care, home care, assisted living, and other forms of long-term care services.” S.Rep. No. 106-34, 2000 WL 970179 at 29. Long term care refers to “a wide range of health and support services for persons who have lost the capacity for self-care. Long-term care services include home and community-based services as well as those provided in nursing homes and other institutions.” S.Rep. No. 106-34, 2000 WL 970179 at 17.

Long term care is not health insurance, nor is it acute care. Long term care is chronic care that an individual may need for the rest of his or her entire life. Health insurance may cover some of the skilled medical services an individual may need when unable to care for himself after an illness or injury. However, such coverage is usually for a limited period and only as long as the individual shows medical improvement. Health insurance plans typically do not cover ongoing chronic care such as extended stay in an assisted living facility or a continuing need for a home health aide to help the individual in day to day living tasks.

The LTSCA directs the OPM to enter into “Master Contracts” with qualified insurance carriers, following competitive bidding. 5 U.S.C. § 9003(a)-(b). Congress mandated that each master contract contain the following: (a) a detailed statement of the benefits offered, including any máxi-mums, limitations, exclusions, and other definition of benefits; (b) the premiums charged; (c) the terms of the enrollment period; and (d) such other terms and conditions agreed to by OPM and the carrier. 5 U.S.C. § 9003(b). Further, the LTSCA also established that each otherwise eligible individual would be responsible for payment of 100 percent of the premiums for such coverage. 5 U.S.C. § 9004(a). Thus, the federal government would not be contributing to this benefit.

Congress recognized that “the costs of issuing policies on a guaranteed basis [would] increase premiums substantially for all enrollees.” H.R.Rep. No. 106-610(1), 2000 WL 564093 at 11. Therefore, the LTSCA also states that: “Nothing in this chapter shall be considered to require that long-term care insurance be guaranteed to an eligible individual.” 5 U.S.C. § 9002(e)(3). 1 Instead of guaranteed insurance, the LTSCA establishes minimal underwriting standards for master contracts, and delegates-the establishment of further underwriting requirements to the qualified carriers and OPM. 5 U.S.C. § 9002(e). Once the qualified carrier has negotiated these -underwriting guidelines with OPM, the carrier uses the guidelines to determine the applicants’ insurability. This determination is “subject to review only to the extent and in the manner provided in the applicable master contract.” 5 U.S.C. § 9003(c)(2).

B) Federal Long-Term Care Insurance from LTCP

LTCP is a joint venture between John Hancock and MetLife formed for the ex- *459 elusive purpose of providing and administering the long term care insurance offered to “eligible individuals” under the LTCSA. Private Defs.’ Statement of Material Facts at ¶¶ 1-2. LTCP acts pursuant to a bid package and a “best and final offer” that now functions as the Master Contract between John Hancock and Met-Life on the one hand and OPM on the other. Under this Master Contract, all eligible individuals are permitted to apply for long term care insurance from LTCP, the exclusive provider of long term care insurance under the FLTCIP. Id. at ¶¶ 3-4. Each applicant is ultimately approved for either full or alternative coverage or services, as determined by LTCP, based upon standard industry underwriting guidelines established by MetLife and John Hancock and approved by OPM. Id. at ¶¶ 5-6.

Specifically, all applicants are offered at least one of three options. If the applicant is considered fully qualified, he or she is eligible to purchase full long term care insurance from LTCP.

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Bluebook (online)
364 F. Supp. 2d 455, 2005 U.S. Dist. LEXIS 4375, 2005 WL 658762, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gunson-v-james-njd-2005.