Justia Insurance Law Opinion Summaries
Medical Mutual Insurance Co. of North Carolina v. Gnik
A former patients of Pediatric Partners for Attention and Learning, Inc. and its founder, Dr. Joni Johnson, sued them in state court after discovering that the clinic’s in-house psychologist, Sharonda Avery, was not a licensed psychologist. The clinic and Dr. Johnson asked their professional liability insurance carrier, Medical Mutual Insurance Company of North Carolina, to defend and indemnify them in those lawsuits. Medical Mutual responded by filing a declaratory judgment action in federal court, arguing that it could rescind the policy covering Pediatric Partners and Dr. Johnson due to Dr. Johnson’s material misstatements in her insurance applications. The United States Court of Appeals for the Fourth Circuit ruled that Medical Mutual has no duty to indemnify or defend Dr. Johnson or Pediatric Partners under Virginia law due to material misstatements made by Dr. Johnson in her policy applications. The court affirmed the district court's decision that Dr. Johnson's misrepresentation that none of her employees had been subject to disciplinary investigative proceedings was a material misstatement, and therefore, Medical Mutual could rescind its professional liability policy covering Pediatric Partners and Dr. Johnson. View "Medical Mutual Insurance Co. of North Carolina v. Gnik" on Justia Law
Schiff v. Liberty Mutual Fire Insurance Co.
The case involves a dispute between Dr. Stan Schiff and Liberty Mutual Insurance Companies. Dr. Schiff, on behalf of himself and a class of similarly situated providers, claimed that Liberty Mutual's practice of reducing provider bills to an 80th percentile cap based on a computer-generated calculation violated Washington's Consumer Protection Act (CPA). Liberty Mutual argued that the statutory requirement to conduct a reasonable investigation into medical expenses is satisfied by determining the 80th percentile of charges for a treatment in the geographic area, and this practice is not an unfair practice under the CPA.The Supreme Court of the State of Washington ruled that Liberty Mutual's practice of using the FAIR Health database to determine the 80th percentile of charges for a treatment in the geographic area is not unfair or unreasonable and does not violate the CPA or the personal injury protection (PIP) requirements to establish standards under which reasonable charges for medical procedures are determined. The court reasoned that comparing charges for the same treatment in the same geographic area is relevant to the determination of reasonableness. The court reversed the Court of Appeals' decision and remanded the case to the trial court to enter a summary judgment order in favor of Liberty Mutual. View "Schiff v. Liberty Mutual Fire Insurance Co." on Justia Law
Consolidated Rest. Operations, Inc. v Westport Insurance Corp.
The case involves Consolidated Restaurant Operations (CRO), a company that owns and operates dozens of restaurants, and Westport Insurance Corporation (Westport). CRO had an "all-risk" commercial property insurance policy with Westport, which covered "all risks of direct physical loss or damage to insured property." When the COVID-19 pandemic hit, causing CRO to suspend or substantially curtail its operations due to the presence of the virus in its restaurants and government restrictions on nonessential businesses, CRO sought coverage for the ensuing loss of revenue. Westport denied coverage, stating that the coronavirus did not cause "direct physical loss or damage" to CRO's properties. CRO filed a lawsuit seeking a declaration of Westport's obligations under the policy and damages for breach of contract.The Supreme Court of New York dismissed the complaint, declaring that the policy did not cover CRO's alleged losses. The Appellate Division affirmed this decision, interpreting "direct physical loss or damage" to require a tangible alteration of the property, which CRO had not demonstrated.The case was then brought to the New York Court of Appeals. The court held that "direct physical loss or damage" requires a material alteration or a complete and persistent dispossession of insured property. The presence of the virus in the restaurants and the resulting cessation of in-person dining services did not meet this requirement. The court thus affirmed the lower courts’ dismissal of the complaint. View "Consolidated Rest. Operations, Inc. v Westport Insurance Corp." on Justia Law
COMBS V. SPICER
In this case heard before the Supreme Court of Kentucky, the primary issue was whether the Breathitt Circuit Court correctly dismissed Teresa Spicer's lawsuit against James Combs for intentional infliction of emotional distress (IIED). Spicer's suit arose from damages linked to Combs' actions, following a fatal ATV accident which resulted in the death of Tiara Combs, James Combs’ wife and Spicer's daughter. Prior to the lawsuit, Combs and Spicer, as co-administrators of Tiara's estate, had signed a release settlement with Progressive Casualty Insurance Company, effectively absolving both Combs and Progressive of any further liability relating to the accident.After learning that Combs was intoxicated at the time of the accident, a fact he allegedly hid from her, Spicer sought to sue Combs personally for IIED. Combs moved to dismiss Spicer's complaint on the grounds that the previous release signed by Spicer barred her claim, and that her complaint did not meet the standard for an IIED claim. The circuit court dismissed the action, holding that the release was intentionally broad and included all potential claims, including IIED.On appeal, the Court of Appeals reversed the dismissal, ruling that the release did not prevent Spicer from asserting a personal cause of action against Combs. The Supreme Court of Kentucky affirmed the Court of Appeals' decision. The court ruled that the language of the release only covered claims possessed by the estate and not Spicer's individual claims. Furthermore, the Court held that Spicer's complaint was sufficient to proceed under a motion to dismiss for failure to state a claim, leaving it to the circuit court to resolve whether Spicer can sufficiently establish her claim at a later time. View "COMBS V. SPICER" on Justia Law
Mt. Hawley Insurance Company v. City of Richmond Heights
The City of Richmond Heights, Missouri filed a claim with Mt. Hawley Insurance Company under a commercial property policy for losses of tax revenue due to government-mandated COVID-19 closures. Mt. Hawley denied the claim and sued for a declaratory judgment that it was not obligated to cover the losses. Richmond Heights counterclaimed with five counts: (1) breach of contract, (2) vexatious refusal to pay, (3) fraudulent inducement and misrepresentation, (4) negligent misrepresentation, and (5) breach of fiduciary duty. The United States District Court for the Eastern District of Missouri dismissed the counterclaims, denied amendments to two of them, and granted declaratory judgment to Mt. Hawley. On appeal, the United States Court of Appeals for the Eighth Circuit affirmed the decision of the lower court.The appellate court held that the insurance policy required "direct physical loss of or damage to property" for coverage which was not met by the COVID-19 shutdowns. The court also rejected the city's argument that the Additional Covered Property Endorsement in the policy removed the "physical damage or loss" requirement for losses of sales tax revenues. Furthermore, the court found that the city's claims of fraud, misrepresentation and breach of fiduciary duty were not distinct from its breach of contract claim and thus were properly dismissed by the district court. Lastly, the court affirmed the district court's denial of the city's motion to amend its breach of contract and vexatious refusal claims, concluding that the proposed amendments would not have survived a motion to dismiss. View "Mt. Hawley Insurance Company v. City of Richmond Heights" on Justia Law
State of Alaska v. Lane
In the case of Brett Lane v. the State of Alaska, Department of Family & Community Services, Office of Children’s Services, the Supreme Court of the State of Alaska affirmed the lower court's decision denying the Office of Children's Services's (OCS) post-trial motion for a new trial on liability. The court concluded that the weight of the evidence supported the jury's verdict on Lane's theories of retaliation. However, the court found an error in the jury instruction relating to noneconomic damages caused by a dangerous client, Wilson. As a result, the court vacated the damages judgment and remanded for a new trial solely on noneconomic damages. The court also remanded the matter back to the lower court for an evidentiary hearing on OCS's claim that the jury award duplicated workers’ compensation benefits that Lane received. The court held that OCS should be given the opportunity to prove that the jury award created an impermissible duplication of damages. View "State of Alaska v. Lane" on Justia Law
Mid American Construction LLC v. Sandlin
Marshall Sandlin, a laborer at Mid American Construction LLC, suffered an injury to his left foot during work. After an initial medical examination conducted by a physician chosen by Mid American's insurance carrier, Grinnell Mutual, Sandlin underwent another independent medical examination (IME) by a physician of his choosing. Sandlin sought reimbursement for the full cost of this second examination, as he believed the first examination's evaluation was too low.The Supreme Court of Iowa had to decide whether an amendment to Iowa Code section 85.39(2) in 2017 limited an employee's reimbursement for an IME to only the cost of the impairment rating or included the full cost of the examination. The court held that the employee is eligible for reimbursement of the reasonable cost of the full examination to determine the impairment rating, not merely the cost of the impairment rating itself. The court interpreted the term "examination" as used in the statute to include review of medical records, physical examination, testing, and written report.However, the court found that the commissioner's analysis of the physician's fee as reasonable was incomplete. While the commissioner considered the physician's written opinion about the reasonableness of his fee, the commissioner failed to analyze the typical fee charged for such an examination in the local area where the examination was conducted, as required by the 2017 amendment to the statute. Consequently, the court remanded the case for further fact-finding on the issue of the reasonableness of the fee based on the typical fee charged in the local area.Thus, the Supreme Court of Iowa affirmed in part and vacated in part the decision of the Court of Appeals and affirmed in part, reversed in part, and remanded the judgment of the District Court. View "Mid American Construction LLC v. Sandlin" on Justia Law
Jumlist v. Prime Insurance Co.
In the United States Court of Appeals for the Eleventh Circuit, the Court reviewed a case involving the estates of two patients who passed away after undergoing liposuction procedures at CJL Healthcare, LLC in Georgia. After the patients' deaths, their estates filed lawsuits against the clinic and its doctor. The clinic's insurer, Prime Insurance Co., defended the clinic under a reservation of rights but ultimately withdrew its defense after the costs of defending the lawsuits exhausted the insurance coverage.The estates of the patients and the clinic then filed a lawsuit against the insurers, Prime Insurance Co., Prime Holdings Insurance Services, and Evolution Insurance Brokers, claiming they had breached their duties, contract, and acted negligently. They also claimed the insurers had unlawfully sold surplus lines insurance. The district court dismissed the case, and the plaintiffs appealed.The Court of Appeals affirmed the district court's decision. The Court held that the policy unambiguously provided a $50,000 limit for a single professional liability claim and a $100,000 aggregate limit for all claims. The Court further held that the insurers' duty to defend the clinic ended when the policy limits were exhausted by payment of damages and claim expenses. The Court also affirmed the district court's finding that the Georgia Surplus Lines Insurance Act did not provide a private cause of action for the unauthorized sale of surplus lines insurance. View "Jumlist v. Prime Insurance Co." on Justia Law
Pinther v. American National Property and Casualty Insurance Company
In the Supreme Court of Wyoming, an appeal by Ronald Pinther, a former insurance agent, was dismissed. Pinther had worked for American National Property and Casualty Insurance Company (ANPAC) and American National Insurance Company (ANICO). He filed a lawsuit against ANPAC, ANICO, and another agent, Philip Maggard, claiming breach of contract, breach of good faith and fair dealing, fraudulent inducement, promissory estoppel, civil conspiracy, and age discrimination. The district court granted summary judgment in favor of ANPAC and Mr. Maggard. On appeal, the Supreme Court held that the district court had not erred in its decision. The court found that Mr. Pinther's breach of contract claim against ANPAC was governed by the Post-Termination Compensation Schedule outlined in the agent agreement. The court further held that Mr. Pinther's claim of a breach of an implied duty of good faith and fair dealing could not be maintained given the at-will nature of the agency contract. The court also dismissed Mr. Pinther's fraudulent inducement claim against ANPAC, noting that the recruiting brochure did not govern his agreement with ANPAC. The court further held that Mr. Pinther's claim for tortious interference with a contract against Mr. Maggard could not be maintained as the actions of Mr. Maggard, as an agent of ANPAC, were imputed to ANPAC. Lastly, the court held that Mr. Pinther's civil conspiracy claims against ANPAC and Mr. Maggard failed as the underlying tort claims did not survive summary judgment. View "Pinther v. American National Property and Casualty Insurance Company" on Justia Law
Orthopedic Institute v. Sanford Health Plan, Inc.
In this case, a group of healthcare providers (Providers) sued the insurer Sanford Health Plan, Inc. (SHP) for excluding them from participating in some of its health benefit plans. The Providers argued that according to South Dakota’s “Any Willing Provider” law (SDCL 58-17J-2), they had the right to participate as panel providers in all of SHP's plans. The law stipulates that a health insurer cannot block patient choice by excluding a willing and qualified healthcare provider from its panel of providers if the provider is within the geographic coverage area of the health benefit plan. The circuit court determined that the law did not permit SHP to exclude a qualified and willing healthcare provider from participating in every health benefit plan it offered, granting summary judgment in favor of the Providers.The Supreme Court of the State of South Dakota affirmed the circuit court's decision. It interpreted the law as plan-specific, meaning an insurer may not exclude any willing and fully qualified provider from any of its plans or from any tier within a plan. It also clarified that an insurer may still exclude providers from plans if they do not meet the statutory requirements for participation as a panel provider. The court concluded that, according to the law, SHP could not exclude the Providers from participating in its TRUE Plan or Tier 1 of the PLUS Plan, thus affirming the circuit court's granting of summary judgment in favor of the Providers. View "Orthopedic Institute v. Sanford Health Plan, Inc." on Justia Law