Justia Insurance Law Opinion Summaries

Articles Posted in California Courts of Appeal
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In this case, the National Hockey League and associated parties (plaintiffs) sued their insurer, Factory Mutual Insurance Company (defendant), over losses incurred due to the COVID-19 pandemic under a commercial insurance policy. The plaintiffs claimed that their policy covered physical loss or damage to property due to COVID-19 and sought to overturn a lower court order that struck down most of their coverage theories.The Court of Appeal of the State of California, Sixth Appellate District, found that while the plaintiffs had adequately alleged physical loss or damage from the coronavirus, their insurance policy's contamination exclusion unambiguously excluded coverage for losses due to viral contamination. The court concluded that the policy excluded both the physical loss or damage caused by viral contamination and the associated business interruption losses.The plaintiffs had alleged that the virus physically damaged their property by changing the chemical composition of air and altering the molecular structure of physical surfaces. They also claimed that they had to close their hockey arenas, cancel games, limit fan access, and undertake various remedial measures to mitigate the virus's impact. However, under the terms of their insurance policy, the court found that these losses were not covered because they resulted from viral contamination, which was excluded from coverage under their policy. Thus, the court denied the plaintiffs' petition for review. View "San Jose Sharks, LLC v. Super. Ct." on Justia Law

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JRK Property Holdings, Inc. appealed from the order of dismissal entered after the trial court granted a motion for judgment on the pleadings filed by primary insurer Ironshore Specialty Insurance Company (Ironshore) and excess insurers RSUI Indemnity Company (RSUI), Evanston Insurance Company (Evanston), and others (collectively, Insurers). JRK sued Insurers for breach of contract and declaratory judgment after Insurers denied coverage for JRK’s lost business income that resulted from the  COVID-19 pandemic and associated government orders. The trial court entered an order of dismissal in favor of Insurers. JRK appealed.   The Second Appellate District reversed the trial court’s order of dismissal except as to RSUI and Evanston. The court remanded for the trial court to vacate its order granting the motion for judgment on the pleadings and to enter a new order granting the motion without leave to amend as to RSUI and Evanston and denying the motion as to all other defendants. The court explained that under MacKinnon v. Truck Ins. Exchange (2003), the historical background of the pollution exclusion shows its inclusion in insurance policies was intended to address only traditional sources of environmental pollution. The court rejected Insurers’ argument that inclusion of the term “virus” in the definition of a contaminant transforms an exclusion that applies to “pollution” into one that encompasses the spread of a virus due to the normal human activities of breathing and touching surfaces. The court further concluded that the RSUI pathogen exclusion applies because it bars coverage for “losses or damage” caused by the discharge or dispersal of “pathogenic” material. The Evanston pathogen exclusion specifically bars loss or damage caused by the spread of an organic pathogen, defined to include a virus. View "JRK Property Holdings, Inc. v. Colony Ins. Co." on Justia Law

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Endeavor Operating Company, LLC (Endeavor) is a “holding company” that owns “various subsidiaries in the entertainment, sports, and fashion business sectors.” Endeavor sued the insurers for (1) declaratory relief and (2) breach of contract related to COVID-19 closures. The insurers demurred to the complaint. The trial court issued a ruling (1) sustaining the demurrer without leave to amend and (2) denying Endeavor’s motion for a new trial. The court modified its initial ruling to find that the “actual” or “threatened presence” of COVID-19 or the SARS-CoV-2 virus “does not constitute a physical loss or damage required to trigger coverage for property insurance coverage” but reaffirmed its initial ruling that the contamination/pollution exclusion applied, which in the court’s view obviated its need to address the argument Endeavor raised for the first time in its new trial motion. Endeavor appealed.   The Second Appellate District affirmed. The court concluded that the insurance policy unambiguously requires “direct physical loss or damage to property” before Endeavor may recover under the business interruption clauses. The court held that Endeavor failed as a matter of law to plead “direct physical loss or damage to property.” The court explained that California courts are in accord that the phrase “direct physical loss or damage to property” means a “‘distinct, demonstrable, physical alteration’” of the insured property. This is the default definition to be applied where a policy does not provide a different definition of “direct physical loss or damage.” The policy here provides no different definition. View "Endeavor Operating Co., LLC v. HDI Global Ins. Co." on Justia Law

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Appellant, a former employee of the City of La Habra Heights (City), pled no contest to a felony that arose out of the performance of her official duties. Under the terms of Appellant’s plea agreement, the conviction was later reduced to a misdemeanor under Penal Code section 17 and then dismissed under Penal Code section 1203.4. After Respondent California Public Employees’ Retirement System (CalPERS) determined that Appellant forfeited a portion of her retirement benefits as a result of her felony conviction, she filed a petition for writ of administrative mandate. The trial court denied her petition.   The Second Appellate District affirmed. The court concluded the trial court did not err in denying the petition because, consistent with the language and purpose of section 7522.72, Appellant’s retirement benefits were subject to forfeiture upon her no-contest plea to a job-related felony, notwithstanding the subsequent reduction to a misdemeanor and dismissal of the charge. Further, the court explained that Appellant asserts that section 7522.72 is unconstitutional, but she fails to present any cognizable argument or legal authority to support her claim. View "Estrada v. Public Employees' Retirement System" on Justia Law

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The insurer, in this case, had notice of the hospital’s lien for treatment provided to the patient and, pursuant to a settlement agreement with the patient, gave him a check for the lien amount made payable to both him and the hospital. The hospital, Long Beach Memorial Medical Center, claims this action did not comply with the Hospital Lien Act (HLA) and sued the insurer who wrote the check, Allstate Insurance Company, for violating the HLA. The trial court granted Allstate’s motion for summary judgment, ruling Allstate’s two-payee check, which was never cashed, satisfied its obligation under the HLA.   The Second Appellate District reversed. The court concluded that merely delivering to the patient (or, in this case, his attorney) a check for the lien amount, made payable to both the patient and the hospital, is not a payment in satisfaction of the hospital’s lien under the HLA. The court explained Allstate maintains that it made this payment to the Medical Center concurrent with payment to the patient and that, therefore, the Medical Center cannot establish Allstate made a settlement payment to the patient without paying the Medical Center the amount of its lien. The court explained that Allstate declined to specify which check made payable to the Medical Center as copayee—the February 2020 check or the March 2021 check— Allstate claims satisfied its payment obligation to the Medical Center. However, neither check was a payment to the Medical Center. Moreover, Allstate does not invoke the exception to the general rule here. View "Long Beach Memorial Medical Center v. Allstate Ins. Co." on Justia Law

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Plaintiff and appellant Rhonda S. is the conservator, appointed pursuant to section 5350 of the Lanterman-Petris Short Act (LPS), of her adult son David S. Plaintiff sued Defendants and respondents Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals for a declaration of their obligations, under LPS and the terms of David’s health plan, to transport and accept for “assessment and evaluation” (each as defined in LPS) conservatees like David upon their conservators’ demand. The trial court sustained Kaiser’s demurrer.
The Second Appellate District affirmed. The court explained that it rejects Plaintiff’s implication that an LPS conservatee is per se suffering from an “Emergency Medical Condition” at all times following the judicial determination of grave disability. The purposes of LPS conservatorship include providing treatment to the conservatee. (Section 5350.1.) To assume a conservatee’s condition remains static following the conservatorship order is to assume treatment is always ineffectual. We are offered no basis for such an assumption. For a mental health condition to be an “Emergency Medical Condition” under the plan, “acute symptoms of sufficient severity” must result in an “immediate” specified danger or mental health disorder-induced disability. Second, even if conservatees were in a state of perpetual “Emergency Medical Condition” within the meaning of the plan, Plaintiff’s requested declaration would eliminate the coverage requirement that a “reasonable person would have believed that the medical condition was an Emergency Medical Condition which required ambulance services.” View "Rhonda S. v. Kaiser Foundation Health Plan" on Justia Law

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Allstate Insurance Company and several of its affiliates (collectively, Allstate) brought qui tam actions on behalf of the State of California alleging insurance fraud under the California Insurance Frauds Prevention Act (IFPA) (and the Unfair Competition Law (UCL) against three medical corporations, a medical management company and its parent company, four physicians, and Sattar Mir, an individual. The trial court found the complaints failed to state causes of action under the IFPA and the UCL because they were not pled with requisite specificity, the business models alleged were lawful, and one of the actions was time-barred.   The Second Appellate District reversed the orders sustaining the demurrers and judgments of dismissal. The court explained that the trial court found the complaints failed to state causes of action under the IFPA and the UCL because they were not pled with requisite specificity, the business models alleged were lawful, and one of the actions was time-barred. The court concluded that the operative complaints adequately plead causes of action under both statutes. View "P. ex rel. Allstate Ins. Co. v. Discovery Radiology etc." on Justia Law

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Petitioners Infinity Select Insurance Company and Infinity Property and Casualty Corporation (collectively, Infinity) are named Defendants in a pending action (the instant lawsuit). The instant lawsuit stems from an earlier 2013 case (the prior action) in which plaintiffs sued Infinity’s insured for negligence and wrongful death in connection with a three-vehicle collision (the collision). In August 2022, the court issued its ruling. The primary effect of the ruling was to reform the Infinity policy to provide greater bodily injury policy limits of $750,000. Per its terms, the ruling “establishes the policy limits for the jury’s consideration in the upcoming jury trial on the remaining causes of action” including plaintiffs’ cause of action against Infinity for bad faith breach of the implied covenant of good faith and fair dealing due to Infinity’s rejection of plaintiffs’ Code of Civil Procedure section 998 demand of $750,000. Infinity filed a petition for a writ of mandate challenging the subject ruling.   The Fifth Appellate District concluded that the trial court erred in reforming the Infinity policy. The court held that the motor carrier of property—not the insurer—bears ultimate responsibility for meeting the requirements necessary to obtain a motor carrier permit. Moreover, even where an insurer intends to issue and certify a policy under section 34631.5, it is not obligated to issue the policy in the full amount of $750,000. Additionally, the court wrote evidence of insurance is not the only means of complying with the MCPPA financial responsibility requirements and infinity was under no duty to determine whether the insured had otherwise complied with MCPPA requirements. View "Infinity Select Ins. Co. v. Super. Ct." on Justia Law

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Plaintiff Gene Moran, who was a patient at Huntington Beach Hospital (the Hospital) three times in 2013, sued defendants Prime Healthcare Management, Inc., Prime Healthcare Huntington Beach, LLC, Prime Healthcare Services, Inc., and Prime Healthcare Foundation, Inc. (collectively defendants) under various theories in 2013. In a prior opinion, the Court of Appeal found that while most of Moran’s claims lacked merit, he had sufficiently alleged facts supporting standing to claim the amount that self-pay patients were charged was unconscionable, and reversed the trial court’s dismissal of the case. Moran’s sixth amended complaint included both the allegations regarding unconscionability and a new theory of the case: defendants had violated the Unfair Competition Law (UCL), and the Consumer Legal Remedies Act (CLRA) by failing to disclose Evaluation and Management (EMS) fees charged in the emergency room through signage or other methods. The complaint sought relief under both the old and new theories for violations of the UCL, CLRA, and for declaratory relief. Defendants moved to strike the allegations regarding EMS fees, arguing their disclosure obligations were defined by statute. The trial court agreed and struck the allegations from the sixth amended complaint. Finding no reversible error in that decision, the Court of Appeal affirmed. View "Moran v. Prime Healthcare Management, Inc." on Justia Law

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Plaintiff is a thoracic surgeon. After the stock market crash now known as the “Great Recession” of 2008, Plaintiff’s sister recommended Gregory Acosta and Diamond Bar Executive Benefit Programs & Insurance Services, Inc. (the Acosta entities) as a potential financial planning service. In 2008, the Acosta entities and Securities America had contracts with Pacific Life Insurance Company (Pacific Life) that authorized them to act as a broker (or “producer”) for Pacific Life. Plaintiff later sued Acosta, the Acosta entities, Kestra, Securities America, and Pacific Life. Plaintiff asserted claims for fraud, negligent misrepresentation, breach of fiduciary duty, negligence, financial elder abuse, and violation of California’s Unfair Competition Law (UCL). He alleged his damages were $495,254.78. Plaintiff argued that the trial court inappropriately entered summary judgment for Pacific Life on his negligence and UCL claims because Pacific Life remains liable to Plaintiff.   The Second Appellate District affirmed the trial court’s decision granting summary judgment for Pacific Life. The court explained that the law and the undisputed evidence, in this case, indicate that it is the broker who typically conducts this suitability analysis. Variable life insurance policies are a “variable product,” and a different Insurance Commissioner regulation requires “brokers and agents selling variable products [to] comply with suitability standards.” The court further explained that section 2534.2(c) does not obligate an insurance company to conduct its own independent suitability analysis, regardless of whether the broker has also conducted one. Moreover, Pacific Life’s conduct—whether labeled “direct” or “vicarious” in the eyes of the law—falls completely within the terms of the release. View "Fischl v. Pacific Life Ins. Co." on Justia Law