Potovsky

I. Background

The Potovskys’ policy covered “actual expenses incurred” for qualified long

term care should one of them become “chronically ill”—which the policy defined

as requiring “[s]ubstantial [s]upervision to protect [themselves] from threats to

health and safety due to severe [c]ognitive [i]mpairment.”1 The policy did not

cover long-term care provided by spouses or children, and only those who had

been receiving qualifying care for ninety days or more were eligible to submit a

claim for reimbursement.

Mrs. Potovsky began to experience mental decline in her eighties. She

struggled with many everyday tasks, and suffered falls, burns, and other accidents.

Her primary care physician and her neurologist diagnosed her with dementia after

she performed poorly on multiple memory tests.

Mr. Potovsky contacted Lincoln to begin filing a claim under the policy in

September 2022, because he intended to hire a caregiver for Mrs. Potovsky. Out of

caution, Mr. Potovsky first asked Lincoln for a determination of Mrs. Potovsky’s

1 These facts are from the Second Amended Complaint and incorporated documentation. See Webb v. Trader Joe’s Co., 999 F.3d 1196, 1201 (9th Cir. 2021).…