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The Ninth Circuit affirmed the district court's dismissal of plaintiffs' claim that their insurer, Blue Shield, violated the Medical Loss Ratio (MLR) provision of the Patient Protection and Affordable Care Act (ACA). The MLR is the ratio between what an insurer pays out in claims for medical services and the revenue it takes in. The panel held that there was no basis in the language, history, intent or spirit of the ACA to narrow the MLR by excluding payments for services rendered by out-of-network physicians. In this case, the MLR was properly calculated under federal law by including the settlement reimbursements for medical services by nonnetwork providers. Therefore, the district court correctly recognized the services were covered by the plan and the payments were made. View "Morris v. California Physicians' Service" on Justia Law

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At the summary judgment stage, the district court found that an employee of Greenwald Neurosurgical, P.C. caused over $100,000 in losses to the P.C., while he was acting in the ordinary course of the P.C.’s business. The district court then issued a judgment to the P.C. for the policy amount of $100,000 pursuant to a Dishonesty Bond issued by Western Surety Company. Western appealed the district court’s determinations that the employee caused the loss while acting in the ordinary course of business and that the P.C. actually suffered the loss. The P.C. cross-appealed the district court’s findings that it was the only entity insured under the bond and argued it was awarded too little by way of attorney’s fees. The Idaho Supreme Court determined: (1) the district court correctly concluded that only the P.C. was an insured and the only entity that could recover under the bond; (2) whether the employee was acting the “ordinary course of [the P.C.’s] business” was a jury question; (3) a genuine issue of fact existed regarding the amount of losses the P.C. sustained; and (4) the district court erred in awarding attorney’s fees to the P.C. The Supreme Court therefore vacated summary judgment, and remanded for further proceedings. View "Greenwald v. Western Surety" on Justia Law

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The parties agreed that the anti-stacking provision barred the insureds from recovering any money from Country Preferred for a car accident. The insureds contend that as a result, Country Preferred committed fraud and was unjustly enriched by collecting three separate premiums for underinsured motorist (UIM) coverage, when the anti-stacking provision rendered the UIM coverage in the insureds' second and third policies worthless or "illusory" under Missouri courts. The Eighth Circuit affirmed the district court's dismissal of the fraudulent misrepresentation and unjust enrichment counterclaims, holding that the anti-stacking provisions did not render UIM coverage in multiple policies illusory because the premium paid for coverage under each policy corresponded with an increase in coverage. In this case, payment for UIM coverage under the insureds' second and third insurance policies buys coverage for non-named, non-family passengers and drivers of the insureds' second and third vehicles. View "Country Preferred Insurance Co. v. Lee" on Justia Law

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The Georgia Supreme Court granted certiorari in this case to review whether the Court of Appeals erred in reversing the grant of summary judgment to the insurer on the insured’s failure-to-settle claim. The Court also asked the parties to address whether an insurer’s duty to settle arises only when the injured party presents a valid offer to settle within the insured’s policy limits or whether, even absent such an offer, a duty arises when the insurer knows or reasonably should know that settlement within the insured’s policy limits is possible. As to this threshold issue, the Court concluded an insurer’s duty to settle arises only when the injured party presents a valid offer to settle within the insured’s policy limits. Applying the applicable rules of contract construction to correspondence from two injured parties in the instant case, the Court concluded the injured parties presented to the insurer a valid offer to settle within the insured’s policy limits but that the offer did not include any deadline for accepting the offer. Based on the undisputed evidence, as a matter of law, the insurer did not act unreasonably in failing to accept the offer before it was withdrawn by the injured parties. As the insurer was entitled to summary judgment, the Court reversed the decision of the Court of Appeals. View "First Acceptance Insurance Company of Georgia, Inc. v. Hughes" on Justia Law

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The Supreme Court granted this petition for a writ of prohibition brought by insurers (collectively, Petitioners) seeking to have the Court prohibit enforcement of a ruling by the circuit court that denied Petitioners’ motion for summary judgment against Respondent, holding that the circuit court erred as a matter of law in denying Petitioners’ motion for summary judgment. David Ralph Allen died from injuries he sustained in a motorcycle collision with a car. The car was owned by an auto dealership, and Petitioners provided an insurance policy for the dealership. The garage operations and auto hazard provision of the policy provided a limit of $300,000 in liability coverage. The commercial umbrella provision provided up to $5 million in liability coverage. Respondent, administratrix of Allen’s estate, asserted a declaratory judgment action against Petitioners to determine the amount of insurance coverage available. Petitioners asserted that the umbrella coverage part of the policy did not cover Respondent’s claims against the driver. The circuit court denied Petitioners’ motion for summary judgment on the coverage issue. The Supreme Court disagreed, holding that the circuit court erred in denying summary judgment for Petitioners on the umbrella coverage issue. View "State ex rel. Universal Underwriters Insurance Co. v. Honorable Patrick Wilson" on Justia Law

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The Ninth Circuit affirmed the district court's denial of plaintiffs' motion to remand to state court. The panel joined the Fourth Circuit in holding that receipt of an initial pleading by a statutorily designated agent does not begin the thirty-day removal clock under 28 U.S.C. 1446(b)(1), and that it was instead actual receipt by State Farm that started the removal clock. The panel applied this rule and held that State Farm timely removed the case where removal was calculated from when the forwarded copy of the complaint reached State Farm's designated recipient. View "Anderson v. State Farm Mutual Automobile Insurance Co." on Justia Law

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The Supreme Court affirmed the judgment of the district court entering judgment against a commercial general liability (CGL) insurer on a homeowners’ insurer’s lawsuit seeking reimbursement for the amount it paid to settle a death claim, holding that the district court correctly interpreted the CGL insurance contract, and substantial evidence supported the court’s factual findings on potential liability and the reasonableness of the settlement. A dentist and his wife formed a limited liability company (LLC) that held title to investment properties, including a farmhouse. An accidental shooting at the farmhouse resulted in a death, and a death claim followed. The dentist had purchased homeowners liability insurance and CGL insurance from separate insurers. The CGL insurer denied coverage. The homeowners’ insurer settled the death claim for $900,000. Thereafter, the homeowners’ insurer filed this action seeking subrogation from the CGL insurer. The district court entered judgment against the CGL insurer for $450,000. The Supreme Court affirmed, holding that the LLC, as owner of the farmhouse, had potential liability under a premises liability theory for a dangerous condition and that the CGL insurer, as coinsurer of the farmhouse property, was obligated to indemnify the homeowners’ insurer for half of the $900,000 settlement. View "Metropolitan Property & Casualty Insurance Co. v. Auto-Owners Mutual Insurance Co." on Justia Law

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Dorothy Smith sued her homeowner's insurance carrier, Mississippi Farm Bureau Casualty Insurance Company (“Farm Bureau”), after Farm Bureau denied her claim based on the earth-movement exclusion in the policy. Smith filed suit against her home builder, Larry Brown, d/b/a Brown’s Construction Company, and Farm Bureau after learning that her home’s foundation was defective. Smith filed a claim for the repair of the foundation. Farm Bureau filed a motion for summary judgment, which was denied by the trial court. Farm Bureau then filed a petition for interlocutory appeal by permission, which the Mississippi Supreme Court granted. The Supreme Court found the trial court erred in denying Farm Bureau’s motion for summary judgment: the earth-movement exclusion was unambiguous and excluded coverage for the property damage suffered by Smith. View "Mississippi Farm Bureau Casualty Insurance Company v. Smith" on Justia Law

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Tony Kourianos worked as a coal miner for more than 27 years before filing a claim for benefits under the Black Lung Benefits Act (“BLBA”). His claim was reviewed through a three-tiered administrative process. Ultimately, the Benefits Review Board (“BRB”) found that he was entitled to benefits. The BRB also found that Kourianos’s last employer, Hidden Splendor Resources, Inc., was the “responsible operator” liable for paying those benefits. Hidden Splendor’s insurer, Rockwood Casualty Insurance Company, petitioned the Tent Circuit Court of Appeal for review of the BRB’s decision: (1) challenging the administrative law judge’s (“ALJ”) decision prohibiting Hidden Splendor from withdrawing its responsible operator stipulation; and (2) contending the BRB incorrectly found that Kourianos was totally disabled and entitled to benefits. Finding no abuse of discretion in the BRB decision, the Tenth Circuit denied Rockwood's petition. View "Rockwood Casualty Insurance v. Director, OWCP" on Justia Law

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After plaintiff's insured (a general contractor) secured a default judgment against defendant's insured (a subcontractor), when a homeowner obtained an arbitration award against the general contractor, plaintiff indemnified the general contractor for the arbitration award. Defendant refused to indemnify the subcontractor for the amount of the default judgment and plaintiff then filed suit to recover from defendant under Insurance Code section 11580 the amount of the default judgment against the subcontractor. The Court of Appeal affirmed the trial court's grant of summary judgment for plaintiff, holding that the default judgment was not void. The court also held that it was doubtful that the default judgment was secured in an action based upon property damage, and none of the authorities defendant cited required a contrary conclusion. The court rejected defendant's claims supporting its contention that plaintiff did not prove the default judgment was covered under any of defendant's policies. Finally, the court denied defendant's claim regarding the "per occurrence limits," and NMH's attorney fees and costs claims. View "The Insurance Company of the State of Pennsylvania v. American Safety Indemnity Co." on Justia Law