FI L ED

U.S. COURT OF APPEAL S

EL EVENTH CI RCUI T MAY 25, 2012

J OHN L EY

CL ERK [DO N OT PUBLISH]

IN THE UN ITED STATES COURT OF APPEALS

FOR THE ELE VENTH CIRCUIT

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No. 1 1- 15 61 0

Non -Arg um en t Ca le nd ar

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D.C. Dock et No. 6 :1 1- cv -0 08 07 -GKS-GJ K

EDITH SHERMAN,

ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll Pl ai nt iff - App el la nt

,

vers us

TRANSAMERIC A LIFE

INSURANCE COM PANY,

ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll ll Defen da nt - App el le e.

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App eal fro m

th e Uni te d S ta te s Di st ric t Co ur t
for th e Mi dd le Dis tri ct of F lo rid a

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(Ma y 25 , 20 12 )

Befo re CARNES, M ARCUS an d WILSON, Circu it Ju dg es

.

PER CURI AM:Pl ai nt iff Edi th Sh erm an ap pe al s fro m th e di st ric t co ur t’s or de r di sm is si ng he r

co m pl ai nt in fav or of Defen da nt Tran sa m eri ca Life In su ran ce Co m p a n y. I n th e

co m pl ai nt

, Sh erm an al le ge d th at Tran sa m eri ca br each ed he r lo ng te rm care in su ran ce

po li cy (th e “ Po li cy ”) be cau se ev en th ou gh sh e se le ct ed lo ng te rm care co ve rag e at he r

ho m e in st ead of a faci li ty, th e as si st ed li vi ng faci li ty (“ ALF”) she m ov ed in to is he r

ho m e an d he r care sh ou ld th eref or e be co ve red un de r th e Po li cy. B a s e d o n th e

un am bi gu ou s la ng ua ge of th e P o l i cy , th e di st ric t co ur t di sa gr eed

. On ap pe al

,

Sh erm an arg ue s th at th e di st ric t co ur t erre d b ecau se th e Po li cy vi ol at es Flo rid a la w

by ex cl ud in g ALFs fro m th e d e f i n i t i on of “ ho m e” an d by fai li ng to reco gn iz e th e

br oa d pu bl ic po li cy un de r Fl or id a la w in fav or of “ ho m e he al th care ” be in g pr ov id ed

by ALFs, an d be cau se sh e is on ly se ek in g cov erag e fo r he r “ ho m e care ,” no t for th e

ren t an d o th er n on -car e ch arg es of t he ALF. After t ho ro ug h re vi ew, we affi rm

.

W e rev ie w t h e d i s t ric t co ur t’s or de r gr an ti ng a m ot io n to di sm is s de no vo

.

Red la nd Co . v. Ban k o f Am . Cor p., 5 68 F.3d 12 32 , 12 34 (11 th Cir . 20 09 ).

The rel ev an t fact s are th es e. In ap pl y in g fo r th e Po li cy , Sh erm an ha d th e op ti on

of ch oo si ng fro m on e of t h r e e types of po li ci es : (1 ) “ In te gr at ed Faci li ty an d Hom e

Care In su ran ce ” ; ( 2 ) “ Faci 1i ty Onl y In su ran ce”; an d (3 ) “ Hom e Care Onl y

In su ran ce.” The “ in te gr at ed ” po li cy pr o v i d e s co ve rag e whe th er th e in su red is

rece iv in g care in a nu rs in g h o me, a ss is te d li vi ng faci li ty (“ ALF’ ‘), o r at ho m e. The

2“ faci li ty on ly” p o l i cy pr ov id es co ve rag e in ei th er a nu rs in g ho m e or ALF, an d th e

“ ho m e-ca re on ly” po li cy pr ov id es co ve rag e on ly in t h e i n s u r ed ’s own ho m e.

Sh erm an ch os e to pu rch as e th e ho m e-ca re on ly po li cy

. On he r ap pl ic at io n, Sh erm an

ex pr es sl y ack no wled ge d th at sh e was ap pl y in g fo r ho m e-ca re on ly co ve rag e an d th at

sh e un de rs to od th at th e “ co ve rag e is de si gn ed to pr ov id e b e n e f i t s fo r ho m e he al th

care se rv ic es an d do es no t pr ov id e co ve rag e fo r co nf in em en t in an y nu rs in g ho m e or

as si st ed li vi ng faci li ty.” W he re th e ap pl ic at io n req ui red he r t o p r o v i de , i n he r own

ha nd writ in g, th e reas on sh e was ch oo si ng a ho m e care on ly p ol ic y , S h e r man w ro te

th at th e pr em iu m s a s s o c i at ed wit h th e po li ci es th at co ve r care in a faci li ty are “ to o

hi gh ” fo r so m eo ne at h er ag e.

So m et im e aft er pu r c h a s i ng th e Po li cy , Sh erm an m ov ed in to The Heri ta ge at

Lak e Fo res t, an ALF, whe re sh e ha s be en rece iv in g care

. Sh erm an so ug ht

rei m bu rs em en t fr om

Tran sa m eri ca fo r th e “ th e co st of th e ‘H om e Care ”’ sh e ha s

rece iv ed whi le li vi ng at th e faci li ty. Tran sa m eri c a d e n i e d he r cl ai m , e xp la in in g

th at th e Po li cy ex cl ud es th e co ve rag e sh e se ek s. Sh erm an su ed

, a l le gi ng br each of

co nt ract

. The di st ric t co ur t di sm is se d th e co m pl ai nt

, an d th is ti m el y ap pe al fo ll ows

.

We are un pe rs ua de d by Sh erm an ’s cl ai m th at Fl or id a la w di ct at es th at th e

de fin it io n of” Hom e” in t he Po li cy m us t in cl ud e ALFs. As an ini ti al m at te r, th ere is

no di sp ut e th at th e Po li cy ’s pr ov is io ns pl ai nl y an d un am bi gu ou sl y pr ov id e co ve rag e

3on ly whe n th e in su red res id es “ at Hom e,” an d no t whe n res id in g a t a n A LF

. The

Po li cy ex pr es sl y pr ov id e s t h a t bo th “ ho m e care se rv ic es ” an d “ ho m e he al th care

se rv ic es ” (th e on ly two se rv ic es at is su e he re) m us t be pr ov id ed in th e in su r e d ’s

“ Hom e” to be co ve red

. The P o l ic y th en de fin es “ Hom e” as “ an y pl ace whe re [th e

in su red ] res id e[s ] ot he r th an a nu rs in g faci li ty, Alzh ei m er’s faci li ty, Hos pi ta l, ho sp ic e

faci li ty, as si st ed li vi ng faci li ty, co ng r e g a t e care or an y ot he r si m il ar res id en ti al care

faci li ty.” Thu s, th e Po li cy un am bi gu ou sl y ex cl ud es ALFs fro m th e de fin it io n of

“ Hom e” an d do es no t co ve r ex pe ns es in cu rred whi le th e in su red res id es in an ALF. 1

W e reco gn iz e, as Sh erm an arg ue s, th at un de r Fl or id a la w, ap pl ic ab le st at ut or y

regu la ti on s su rro un di ng in su ran ce co nt ract s in effe ct at th e ti m e th e co nt ract is fo rm ed

are de em ed by la w to b e in co rp or at ed in to th e co nt ract

. Aut o- Owner s In s. Co

. v.

DeJ oh n, 64 0 So

. 2d 15 8, 16 1 (Fl a. 5t h DCA 19 94 ); se e al so Fl a. St at .§ 62 7.4 18 (1 )

(2 00 3) ( p r o v i d i ng th at an y in su ran ce po li cy th at is ot he rwis e va li d bu t co nt ai ns a

pr ov is io n no t in co m

pl ia nc e wit h th e req ui rem en ts of th e In su ran ce Co de m us t be

ha rm on iz ed wit h th e Co de ). Howev er, as th e di st ric t co ur t fo un d, no ne of th e st at ut es

or reg ul at io ns Sh erm an ci te s co nf li ct s wit h th e t e r ms o f t he Po li cy

. Nor

, m or e

Not only does the policy

expressly exclude the cove rag e Sherma n seeks, but plaintiff 1 expressly acknow ledg ed in her

Application, by

her initials, the intention to purchase “Home Ca re Only cover ag e” tha t “does not provide c overa g e for confine ment in any

. . . assisted living

fac ility .” I n addition, plaintiff expressly explained in her own ha

ndwriting , that she did not purcha se a policy

ty pe that included f

acilities cove rag e bec ause she deter mined that the premiums for that policy

ty pe we re “ too high.”

4sp eci fic al ly, do th ey pr oh ib it an in su ran ce co nt ract fro m co ve rin g he al th care se rv ic es

pr ov id ed on ly at an in su red ’s ho m e, as op po se d to a faci li ty. In de ed

, Sh erm an ad m it s

in he r br ie f th at “ th e ci te d st at ut es m ay no t di rect ly pr oh ib it an in su rer fro m ex cl ud in g

an ALF fro m th e de fin it io n o f h o me.” Gray Br. at 4. Thu s, fo r ex am pl e, whi le

Fl or id a Adm in is tra t i v e Co de § 58 A-2 .00 2( 7) in cl ud es ALFs in th e de fin it io n of

“ ho m e,” as it is us ed in Ch ap te r 40 0, Part IV (“ Hos pi ces ”), th is ru le do es no t pr oh ib it

in su ran ce po li ci es fro m li m it in g co ve rag e to ci rcu m st an ces whe re th e in su red res id es

ou ts id e o f su ch a faci li ty.

Sh erm an al so arg ue s th at Fl or id a pu bl ic po li cy d i s f av or s li m it ed be ne fit

lo ng -te rm care po li ci es th at ex c l u d e ALF co ve rag e, an d th at th e Po li cy crea te s

di si nc en ti ve s fo r m ov in g in to an ALF. Howev er, th e fact th at Fl or id a Adm in is tra ti ve

Co de § 69 O-1 57 .30 1- .30 4 pr es cri be s th e m ax im um rat es an in su rer m ay

ch arg e fo r

a “ ho m e he al th care on ly” po li cy , as op po se d to m ax im um rat es fo r “ faci li ty on ly”or

“ co m pr eh en si v e ” po li ci es , be li es he r arg um en t. If a ho m e he al th care on ly po li cy

were i ll eg al un de r Fl or id a la w, th ere wo ul d b e n o re as on to pre sc rib e rat es sep arat e

fro m th os e fo r in st it ut io n on ly or co m pr eh en si ve pl an s. Thu s, as an ot he r di st ric t

co ur t ha s he ld in a cas e ve ry si m il ar to th is on e, Fl or id a la w “ go e s n o f u r t h e r th an

es ta bl is hi ng th at as si st ed li vi ng faci li ti es are wel c o me in Fl or id a, an d th at th e st at e

wil l es ta bl is h a s e t of gu id el in es to en su re th at th os e faci li ti es are ad eq ua te an d

5de si rab le to th ei r res id en ts

. Not hi ng in th at se ct io n de cl ares th at th e po li cy is su ed by

th e Defen da nt is il le ga l, o r t h at Fl or id a la w req ui res th at in su rers pa y fo r th ei r

po li cy ho ld ers ’ de ci si on to rel oc at e to an a s s i s t e d li vi ng faci li ty.” Sawy er v.

Tran sa m eri ca Li fe In s. Co ., 20 10 W L 13 72 44 7, at *9 (S.D. Fla . 20 10 ). 2

In de ed

, “ Fl or id a’s pu bl ic polic y is tha t co ntr ac ts, inc lud in g in su ran ce co nt ract s,

m us t be en fo rced as writ te n.” Id

. at *1 0; se e al so Exc el si or In s. Co

. v. Po m on a Park

Bar & Pack ag e St or e, 36 9 So

. 2d 9 3 8

, 9 4 2 (Fl a. 19 79 ) (Un le ss th ere is a ge nu in e

am bi gu it y , th e ru le s of co nt ra c t c o ns tru ct io n do “ no t al lo w co ur ts to re-wri te

co nt ract s, ad d m ean in g th at is no t pr es en t, or ot he rwis e reac h res ul ts co nt rary to th e

in te n t i on s of th e pa rti es .”) Des pi te th e av ai la bi li ty of po li ci es th at co ve r care

as so ci at ed wit h li vi ng in a faci li ty, Sh erm an kn owi ng ly pur ch as ed an in su ran ce po li cy

th at co ve rs on ly he al th care se rv ic es pr ov id ed in he r ho m e. Sh erm an ha s fai le d to ci te

As for Sher

man’s cla im that she is not seeking cover ag e for room and boa

rd, but only 2

for the “ home ca

re” she re ceive s at the AL F, we are unpersua ded. B eca use she is not rec eiving

this “home ca

re” at her home, as re quired by

the Policy , she ca

nnot rec eive c overa g e under the Policy . Moreove r, AL F c are is not merely “home c are ” that is provided in a f acility . Rather, the

law make s a sig nificant distinction betwee n service s provided in an AL F a nd service s provided at

home. An AL F is a hig hly -re g ulated envir onment with acc ess to round-the- clock c are service s, as

nece ssary . See, e.g ., Fla. A dmin. Code Ch. 58A-5 (discussing inter alia A L F lice nsing a nd inspection requir ements, re sidential car e standa rds, staff ing sta ndards, f ood service standards, and phy sical plant standar ds, and eme rg ency manag ement). I

n her home , plaintiff’s living

arr ang ements ar e not re g ulated by the Depa rtment of Elder

Affa irs, and she ha d only part-time

acc ess to a home he alth aide on a pre- arr ang ed sche dule.

6to an y la w th at wou ld jus ti fy al te rin g th e ex pr es s la ng ua ge of th e Po li cy to crea te

co ve rag e whe re n on e ex is ts . Accor di ng ly, we affi rm

.

AFFIRMED.

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