Justia Insurance Law Opinion Summaries

A hospital must provide “necessary stabilizing treatment” for any person in an “emergency medical condition,” 42 U.S.C. 1395dd(b), Health & Saf. Code 1317(a). California’s Knox-Keene Act (section 1340) requires that the patient's health insurance plan reimburse the hospital for providing “emergency services and care.” If the hospital and plan do not have an existing contract, the plan must pay the “reasonable and customary value." If a plan without a contract pays reimbursement that the hospital believes is below the “reasonable and customary value,” the hospital may sue the plan in quantum meruit for the shortfall.The court of appeal held that a hospital may not additionally sue for the tort of intentionally paying an amount that is less than what a jury might later determine is the “reasonable and customary value” of the services, and thereby obtain punitive damages, nor may the hospital sue for injunctive relief under California’s unfair competition law to enjoin the plan from paying too little in possible future claims. In the quantum meruit claim, a trial court properly instructs the jury that the “reasonable value” of emergency medical services is “the price that a hypothetical willing buyer would pay a hypothetical willing seller for the services, [when] neither [is] under compulsion to buy or sell, and both hav[e] full knowledge of all pertinent facts.” Rejecting challenges to several evidentiary rulings, the court affirmed the jury’s verdict finding that the plan paid the suing hospital the reasonable and customary value of its emergency medical services. View "Long Beach Memorial Medical Center v. Kaiser Foundation Health Plan, Inc." on Justia Law

Letgolts and Plattner (plaintiffs) remodeled their home in 2008. The contractor, Pinchevskiy, did some demolition and then walked away, causing extensive damage to the home. The plaintiffs retained attorney Marks, who sued Pinchevskiy, the plaintiffs’ home insurer, and their insurance agent who allegedly inaccurately advised the plaintiffs that their existing homeowners' policy would cover possible property damage by Pinchevskiy. The complaint detailed property damage but did not mention personal injury. Marks withdrew from the case in 2012. The plaintiffs retained Pierce, who secured a default judgment against Pinchevskiy in 2015; his insurer, National, filed for liquidation before Pierce could collect on the judgment. Pinchevskiy was bankrupt.The plaintiffs sued Pierce for negligent delay in seeking recovery from National. Pierce’s lawyers argued the plaintiffs could never have prevailed against National because Pinchevskiy’s policy did not cover construction defects. The court entered judgment for Pierce. The court of appeal affirmed, rejecting the plaintiffs’ attempt to assert a personal injury claim based on Plattner’s alleged 2008 fall from temporary stairs installed by Pinchevskiy. National’s policy did cover personal injuries but the tardy, uncorroborated claim was at odds with the detailed lists of problems given to the insurer years before. Pursuing insurance money from National was a lost cause from the start, so whether Pierce committed malpractice did not matter, View "Letgolts v. David H. Pierce & Associates PC" on Justia Law

This appeal arose from an application by State Farm General Insurance Company (SFG) to increase its homeowners’ insurance rates, under the prior approval system implemented by Proposition 103. Nonprofit Consumer Watchdog (CW) intervened in the proceeding, and challenged SFG’s proposed rates. The Commissioner relied on regulation section 2644.20, addressing projected yield, to use the combined annual statement of SFG’s parent company, State Farm Mutual Automobile Insurance Company (State Farm Mutual) and its property-casualty affiliates. The Commissioner ordered SFG to decrease its rate retroactively and issue refunds (Rate Order). SFG filed a petition for writ of mandate. The superior court determined Insurance Code section 1861.05(a) required the rate to mathematically reflect the applicant insurer’s income, and the Commissioner’s interpretation and application of regulation Insurance Code section 2644.20 to use the income of SFG’s affiliates conflicted with the statute. The court entered judgment for SFG, issued a peremptory writ of mandate requiring the Rate Order be set aside, and remanded remaining issues to the Commissioner, including the propriety of the retroactive rate and refund. The Commissioner and CW (Appellants) appealed the judgment and writ of mandate, contending the Commissioner properly interpreted the statute and regulation and had authority to set an earlier effective date and require refunds. SFG cross-appealed the order directing remand to the Commissioner, which it argued was unnecessary in light of the impropriety of the retroactive rate and refund as well as a subsequent rate change for SFG. The Court of Appeal concluded the superior court correctly determined section 1861.05(a) required use of the applicant insurer’s income, and the Commissioner erred in interpreting and applying Regulation 2644.20 here. Furthermore, the Court concluded the retroactive rate and refund were impermissible, and remand was not warranted under the circumstances. The superior court was directed to modify the writ of mandate to require the Rate Order be vacated in its entirety, and affirmed the judgment and writ of mandate in all other respects. View "State Farm General Insurance Company v. Lara" on Justia Law

State Farm General Insurance Company (SFG) appealed an order awarding attorney fees to intervenor Consumer Watchdog (CW), in a dispute over documents SFG designated as confidential in a rate hearing under Proposition 103. After the administrative law judge (ALJ) denied SFG’s motion to seal, SFG sought writ relief from the superior court, which CW and the Insurance Commissioner successfully opposed. CW then moved for fees under section 1861.10, which provided for reasonable advocacy fees to a consumer representative that makes a substantial contribution to the adoption of an order. The court awarded CW’s requested fees, and SFG appealed, contending the fee motion was untimely, and the fee award was inconsistent with the statutory requirements and an abuse of discretion. Rejecting these arguments, the Court of Appeal affirmed. View "State Farm General Insurance Company v. Lara" on Justia Law

Peggy Baltar’s home was destroyed by wildfire in 2014. She had a new house built on the same property. Her insurer, CSAA Insurance Exchange (CSAA), paid the full amount charged by her contractor for construction of the new house. Altar sued for breach of contract and breach of the implied covenant of good faith and fair dealing. According to Baltar, CSAA breached the policy by, among other things, failing to provide her with a complete and accurate estimate for replacing the original house, which would have provided her with a budget for the construction of the new house. Without such a budget, she claimed she was forced to build a cheaper house than the one destroyed by the fire. She claimed this, and other asserted breaches of the policy, amounted to bad faith and entitled her to punitive damages. The trial court granted CSAA’s motion for summary judgment and entered judgment in favor of the company. Baltar appealed, but finding no reversible error, the Court of Appeal affirmed. View "Janney v. CSAA Insurance Exchange" on Justia Law

The Travelers Indemnity Company of Connecticut (Travelers) appealed an order sustaining demurrers filed by Navigators Specialty Insurance Company (Navigators) and Mt. Hawley Insurance Company (Mt. Hawley) to the third amended complaint. Travelers sought to recover from other insurance carriers some or all of the amounts it paid to defend TF McGuckin, Inc. in an underlying construction defect litigation. Travelers contended the trial court incorrectly concluded that the causes of action for equitable contribution and equitable indemnity failed to state a claim. Travelers also argued that, in the event the Court of Appeal contends the trial court properly sustained the demurrers, the appellate court should order that Travelers be given leave to amend its complaint to plead a claim for equitable subrogation. The Court of Appeal concluded the trial court erred in sustaining the demurrers to both the equitable contribution and equitable indemnity causes of action. Accordingly, judgment was reversed and the matter remanded for further proceedings. View "The Travelers Indemnity Co. v. Navigators Specialty Ins. Co." on Justia Law

Following a preliminary hearing, petitioner Dr. Sanjoy Banerjee was charged in an information with two counts of presenting a false or fraudulent health care claim to an insurer (a form of insurance fraud, counts 1-2), and three counts of perjury (counts 3-5). The superior court denied Banerjee’s motion to dismiss the information as unsupported by reasonable or probable cause. Banerjee petitioned for a writ of prohibition to direct the superior court to vacate its order denying his Penal Code section 995 motion and to issue an order setting aside the information. The Court of Appeal issued an order to show cause and an order staying further proceedings on the information, pending the Court's resolution of the merits of Banerjee’s petition. The State filed a return, and Banerjee filed a traverse. The State argued the evidence supported a strong suspicion that Banerjee committed two counts of insurance fraud and three counts of perjury, based on his violations of Labor Code section 139.3(a) between 2014 and 2016. During that period, Banerjee billed a workers’ compensation insurer for services he rendered to patients through his professional corporation and through two other legal entities he owned and controlled. The insurance fraud charges are based on Banerjee’s 2014-2016 billings to the insurer through the two other entities. The perjury charges were based on three instances in which Banerjee signed doctor’s reports, certifying under penalty of perjury that he had not violated “section 139.3.” Banerjee argued: (1) the evidence showed he did not violate the statute's referral prohibition; (2) even if he did not comply with section 139.3(e), the “physician’s office” exception to the referral prohibition applied to all of his referrals to his two other legal entities; and (3) the patient disclosure requirement of section 139.3(e), the referral prohibition of section 139.3(a), and the physician’s office exception to the referral prohibition were unconstitutionally vague. The Court of Appeal concluded: (1) Banerjee did not violate section 139.3(a) by referring his patients to his two other legal entities; and (2) the evidence supported a strong suspicion that Banerjee specifically intended to present false and fraudulent claims for health care benefits, in violation of Penal Code section 550(a)(6), by billing the workers’ compensation insurer substantially higher amounts through his two other legal entities than he previously and customarily billed the insurer for the same services he formerly rendered through his professional corporation and his former group practice. Thus, the Court granted the writ as to the perjury charges but denied it as to the insurance fraud charges. View "Banerjee v. Super. Ct." on Justia Law

On February 22, a criminal complaint was filed against the defendant for unlawful driving or taking of a vehicle. On February 26, the defendant was in custody and present in court for a pretrial hearing. The court continued the matter to March 20. The Surety posted a bond of $25,000 for the defendant’s release from custody. At the March 20 pretrial hearing, the defendant was not present. The court told defense counsel “I’ll give you a week to bring him back in. … Bench warrant of 35,000 held … it’s not likely to waste your family and friends money and then FTA on a 10851.” On March 28, the defendant again failed to appear. The court ordered bail forfeited. A notice of forfeiture was mailed to the parties on March 29.On October 2, the Surety moved to vacate, forfeit, and exonerate bail or to extend time, arguing that the court lost jurisdiction over the bond because it failed to declare a forfeiture (Penal Code 13051) when the defendant did not appear on March 20. The court of appeal affirmed the denial of the motion. The trial court had a rational basis for believing there may have been an excuse for the defendant’s failure to appear sufficient to warrant continuing the case without declaring a forfeiture and retained jurisdiction to later declare the bail forfeited. View "People v. Bankers Insurance Co." on Justia Law

Three appeals arose from an insurance coverage dispute following a wildfire that burned in Siskiyou County, California. In September 2014, the Boles Fire damaged and destroyed numerous homes in the town of Weed, including the homes owned by plaintiffs Gary Andrighetto, James Dalin, and Matthew Vulk. Plaintiffs and others filed suit against their insurance company, defendant State Farm General Insurance Company, alleging various claims, including breach of contract and negligence. Central to the parties’ dispute was whether State Farm intentionally or negligently underinsured plaintiffs’ homes. Plaintiffs argued their homes were insufficiently insured due to State Farm’s alleged failure to calculate reasonable or adequate policy limits on their behalf for the full replacement cost of their homes. After the trial court granted State Farm’s motion for summary judgment against Andrighetto, Dalin and Vulk stipulated to entry of judgment in favor of State Farm. Each plaintiff timely appealed, and the Court of Appeal consolidated the appeals for argument and disposition. Thereafter, the Court requested that the parties discuss in their briefing whether the judgments in the Dalin and Vulk matters needed to be reversed pursuant to Magana Cathcart McCarthy v. CB Richard Ellis, Inc., 174 Cal.App.4th 106 (2009). After review, the Court affirmed the trial court in the Andrighetto matter; the Court reversed in the Dalin and Vulk matters, and remanded those for further proceedings. View "Vulk v. State Farm General Ins. Co." on Justia Law

In the underlying action, the insureds were sued by victims of a fire that occurred at the insureds' property. The insurer, Aspen, and managing underwriter, D&H, defended the action, which ultimately settled without any out-of-pocket payment from the insureds. The insureds then filed this action against Aspen and D&H, seeking a declaration that a conflict of interest existed in the underlying case between them and Aspen and D&H, so they were entitled to so-called "Cumis" counsel under Civil Code section 2860. The trial court sustained a demurrer without leave to amend and entered judgment for Aspen and D&H.The Court of Appeal concluded that the demurrer was the incorrect procedural vehicle to resolve the insureds' declaratory judgment claim against Aspen and D&H. However, the insureds' family suffered no prejudice because the second amended complaint (SAC) did not allege a conflict of interest entitling them to independent counsel pursuant to section 2860 as a matter of law. Accordingly, the court modified the judgment to declare the rights adverse to the insureds and affirmed the trial court's judgment. View "Nede Management, Inc. v. Aspen American Insurance Co." on Justia Law