Justia Insurance Law Opinion Summaries

Plaintiff-appellant Nshan Simonyan had a dispute with his insurer, Nationwide Insurance Company of America ("Nationwide") over the company's handling of his defense arising out of a three-car accident in which Simonyan was a driver. Simonyan asked Nationwide to appoint, as "Cumis" counsel, a law firm that he had already hired to advance his affirmative claim against the driver who hit him. Nationwide refused. Simonyan appealed the dismissal of his case after the trial court sustained Nationwide’s demurrer to his second amended complaint without leave to amend. Simonyan argued his allegations were sufficient to state claims for breach of contract and breach of the implied covenant of good faith and fair dealing, and that the trial court abused its discretion in denying his motion to reconsider based on new allegations. Finding no reversible error, the Court of Appeal affirmed the trial court's judgment. View "Simonyan v. Nationwide Ins. Co. of America" on Justia Law

National Western Life Insurance Company (NWL) appealed after a jury found the company liable for negligence and elder abuse arising from an NWL annuity sold to plaintiff-appellant Barney Williams by Victor Pantaleoni. In 2016, Williams contacted Pantaleoni to revise a living trust after the death of Williams’ wife, but Pantaleoni sold him a $100,000 NWL annuity. When Williams returned the annuity to NWL during a 30-day “free look” period, Pantaleoni wrote a letter over Williams’ signature for NWL to reissue a new annuity. In 2017, when Williams cancelled the second annuity, NWL charged a $14,949.91 surrender penalty. The jury awarded Williams damages against NWL, including punitive damages totaling almost $3 million. In a prior opinion, the Court of Appeal reversed judgment, concluding that Pantaleoni was an independent agent who sold annuities for multiple insurance companies and had no authority to bind NWL. Williams petitioned the California Supreme Court for review, which transferred the matter back to the Court of Appeal to consider the agency relationship in light of Insurance Code sections 32, 101, 1662, 1704 and 1704.5, and O’Riordan v. Federal Kemper Life Assurance Company, 36 Cal.4th 281, 288 (2005). After the appellate court issued its opinion on transfer from the California Supreme Court, both Williams and NWL filed petitions for rehearing on various grounds. Upon consideration of those petitions, the Court of Appeal “remain[ed] confident” its prior opinion was correct and reissued that opinion with minor modifications. The Court affirmed the judgment finding NWL liable for negligence and financial elder abuse. However, punitive damages assessed against NWL were reversed. View "Williams v. National Western Life Insurance Co." on Justia Law

Plaintiff sued Aegis Security Insurance Company (Aegis) for breach of contract, insurance bad faith, and declaratory relief after Aegis denied her tender of a lawsuit brought against her by her neighbors. The underlying lawsuit alleged Plaintiff graded land and cut down trees on her neighbors’ property. The trial court granted Aegis’s motion for summary judgment, holding Aegis had no duty to defend because Plaintiff’s homeowner’s policy did not provide coverage for nonaccidental occurrences. The Second Appellate District affirmed the Superior Court’s judgment granting summary judgment to Defendant. The court held that the evidence established that Defendant did not have a duty to defend. The court reasoned that the policy at issue covers property damage resulting from an occurrence, which is defined as an accident. Here, the complaint in the underlying action alleges harm from Plaintiff’s intentional conduct and these events were not unforeseen or accidental. Thus, Plaintiff failed to carry her burden to show the neighbors’ claims may fall within the scope of the policy. View "Ghukasian v. Aegis Security Ins. Co." on Justia Law

Hospitals provided emergency medical services to members of the county’s health plan, which is licensed and regulated by the state Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act, Health & Saf. Code 1340. The county reimbursed the Hospitals for $28,500 of a claimed $144,000. The Hospitals sued, alleging breach of an implied-in-fact or implied-in-law contract. The trial court rejected the county’s argument that it is immune from the Hospitals’ suit under the Government Claims Act (Gov. Code 810).The court of appeal reversed. The county is immune from common law claims under the Government Claims Act and the Hospitals did not state a claim for breach of an implied-in-fact contract. The county does not contest its obligation to reimburse the Hospitals for the reasonable and customary value of the services; the issue is what remedies may be pursued against the county when the reasonableness of the reimbursement is disputed. The Knox-Keene Act provides alternative mechanisms to challenge the amount of emergency medical services reimbursements. A health care service plan has greater remedies against a private health care service plan than it does against a public entity health care service plan, a result driven by the Legislature broadly immunizing public entities from common law claims and electing not to abrogate that immunity in this context. View "County of Santa Clara v. Superior Court" on Justia Law

Appellant Dameron Hospital Association (Dameron) required patients or their family members sign Conditions of Admissions (COAs) when Dameron provides the patients’ medical care. The COAs at issue here contained language assigning to Dameron direct payment of uninsured and underinsured motorist (UM) benefits and medical payment (MP) benefits that would otherwise be payable to those patients under their automobile insurance policies. Dameron treated five of AAA Northern California, Nevada & Utah Insurance Exchange’s (CSAA) insureds for injuries following automobile accidents. Those patients had UM and/or MP coverage as part of their CSAA coverage, and Dameron sought to collect payment for those services from the patients’ UM and/or MP benefits at Dameron’s full rates. Instead of paying to Dameron the lesser of either all benefits due to the patients under their UM and MP coverage, or Dameron’s full charges, CSAA paid portions of those benefits directly to the patients which left balances owing on some of Dameron’s bills. Dameron sued CSAA to collect UM and MP benefits it contended CSAA owed Dameron under the assignments contained in the COAs. The trial court concluded that Dameron could not enforce any of the assignments contained in the COAs and entered summary judgment in CSAA’s favor. After its review, the Court of Appeal held Dameron could not collect payment for emergency services from the UM or MP benefits due to patients that were covered under health insurance policies. Additionally, the Court found: (1) the COA forms were contracts of adhesion; (2) it was not within the reasonable possible expectations of patients that a hospital would collect payments for emergency care directly out of their UM benefits; and (3) a trier of fact might find it is within the reasonable expectations of patients that a hospital would collect payments for emergency care directly out of their MP benefits. Accordingly, the Court concluded Dameron could not maintain causes of action to collect MP or UM benefits due to four of the five patients directly from CSAA. However, consistent with its opinion, the trial court could consider whether an enforceable assignment of MP benefits was made by one adult patient. View "Dameron Hospital Assn. v. AAA Northern Cal., Nevada etc." on Justia Law

United Talent Agency (UTA) purchased business insurance policies through two insurance companies. UTA filed suit against both companies after they denied property insurance coverage for economic losses related to the COVID-19 pandemic. The trial court sustained the insurers' demurrer claiming UTA failed to state facts sufficient to constitute a viable cause of action.The Second Appellate District affirmed, rejecting both of UTA's arguments on appeal. First, UTA claimed that the danger posed by the COVID-19 gave rise to the closure orders and other restrictions, which, in turn, caused UTA to suffer physical loss because these restrictions limited the company's use of and operations at its insured locations. The court explained that temporary loss of use of a property due to pandemic-related closure orders, does not alone constitute direct physical loss or damage.Second, UTA claims that the physical presence of COVID-19 virus constitutes physical damage. The court held that the mere presence of a virus or other contaminant, without evidence of required remediation, does not rise to the level of physical loss or damage. Thus, the court affirmed the trial court's order sustaining the insurance companies' demurrer. View "United Talent Agency v. Vigilant Insurance Co." on Justia Law

Plaintiff, a Hollywood restaurant, maintained a business interruption insurance policy through Defendant.  In response to COVID-19, the Governor, Mayor of Los Angeles, and several public health agencies ordered Plaintiff to close its restaurant, resulting in the loss of all its business. Plaintiff filed a claim with Defendant insurance company, which was denied based on the grounds that the policy only covered “direct physical loss of or damage to” the property, and expressly excluded coverage for losses resulting from a government order and losses caused by or resulting from a virus. Plaintiff appealed after Defendant's demurrer was sustained without leave to amend.   The California Court of Appeal affirmed the dismissal and held that Plaintiffs cannot establish a breach of contract.  At issue is whether the clause’s requirement can be construed to cover the pandemic-related closure. The court held that under California law a business interruption policy that covers physical loss and damages does not provide coverage for losses incurred by reason of the COVID-19 pandemic. Moreover, the court explained that the fact that loss and damage requirements are sometimes found in exclusionary provisions does not change the plain meaning of the terms. The court noted that even if Plaintiff could bring itself within the coverage clause, the virus exclusion would bar coverage. View "Musso & Frank Grill v. Mitsui Sumitomo Ins. USA" on Justia Law

In 2000, governmental entities filed a class action against lead paint manufacturers. Following remand, the plaintiffs filed an amended complaint alleging representative public nuisance on behalf of the People, claiming that the presence of lead in paint and coatings in and around California homes and buildings has created a massive public health crisis. The trial court found ConAgra, NL, and Sherwin-Williams jointly and severally liable and ordered the establishment of a fund for the abatement of lead paint in pre-1978 homes in the 10 jurisdictions represented in the case. Following another remand, after the California Supreme Court denied review and the U.S. Supreme Court denied certiorari, the trial court recalculated the amount to be paid into the abatement fund as $401,122,482.Underwriters at Lloyd’s London and other insurers sought a determination that they had no coverage obligation to ConAgra. The trial court determined that ConAgra, as successor to paint manufacturer W.P. Fuller, was not entitled to indemnity from its insurers for its payment to the abatement fund due to Insurance Code section 533, which provides that insurers are not liable for losses caused by a willful act of the insured. The court of appeal affirmed. Fuller had actual knowledge of the harms associated with lead paint when it promoted lead paint for interior residential use, which establishes the willful act required to trigger section 533 prohibition against insurance coverage. View "Certain Underwriters at Lloyd's London. v. Conagra Grocery Products Co." on Justia Law

Relator Gilbert Ellinger brought a qui tam suit on behalf of the People of the State of California against Zurich American Insurance Company (Zurich), ESIS, Inc. (ESIS), and Stephanie Ann Magill, under Insurance Code section 1871.7, a provision of the Insurance Frauds Prevention Act (IFPA). In January 2016, Ellinger injured his back while working, and he immediately informed his supervisor. The following month, Ellinger reported to his employer’s human resources manager that he had sustained a work-related injury and had told his supervisor about it. The human resources manager created a “time line memorandum” summarizing the conversations she had with Ellinger about the injury. She placed the memorandum in Ellinger’s personnel file. Ellinger filed a workers’ compensation claim. Magill worked as a senior claims examiner for ESIS and was the adjuster assigned to investigate Ellinger’s claim. ESIS denied Ellinger’s claim on an unspecified date. Magill later testified that she denied the claim because of a written statement from Ellinger’s supervisor in which the supervisor claimed that Ellinger had not reported the injury to him. When the human resources manager was deposed in November 2016, she produced the time line memorandum, which Ellinger’s counsel in the workers’ compensation action did not know about until then. Nearly eight months after that disclosure, in July 2017, ESIS reversed its denial of the claim and stipulated that Ellinger was injured while working, as he had alleged. Contrary to Magill’s testimony, her email messages showed that the human resources manager had emailed Magill the time line memorandum in March and April 2016, and Magill thanked the manager for sending it. Ellinger alleged that Magill’s concealment of or failure to disclose the time line memorandum violated Penal Code section 550 (b)(1) to (3). On the basis of those alleged violations, Ellinger alleged that defendants were liable under section 1871.7. Against each defendant, Ellington sought a civil penalty and an assessment of no greater than three times the amount of his workers’ compensation claim. The trial court sustained defendants’ demurrers without leave to amend, concluding defendants could not be held liable under section 1871.7 for any failures of Magill in the claims handling or review process. Finding no reversible error in sustaining the demurrers, the Court of Appeal affirmed. View "California ex rel. Ellinger v. Magill" on Justia Law

Robinson submitted an “uninsured driver” claim to State Farm for injuries sustained in an accident involving her car and an unidentified vehicle. Coverage was available only if the two cars came into contact. (Ins. Code 11580.2(b)(1).) In arbitration, State Farm propounded requests for admissions that there was either no contact between the two cars or that no damage resulted from any contact. Robinson failed to respond by the due date. After finding that Robinson had not “substantially complied” with Code of Civil Procedure sections 2033.220 or 2015.5, the court deemed the requests admitted and awarded sanctions. Robinson unsuccessfully moved to withdraw or amend the deemed admissions, citing inadvertence. The arbitrator entered an award in favor of State Farm, relying on the established admissions.The trial court confirmed the award. The court of appeal affirmed. In typical arbitration proceedings, discovery disputes are resolved by the arbitrator but in uninsured-motorist arbitration proceedings, discovery disputes are resolved by a trial court. Trial court discovery orders in these proceedings are not reviewable on appeal from a judgment confirming the arbitration award. A party’s recourse to challenge an allegedly improper discovery ruling in an uninsured-motorist arbitration proceeding is through a timely petition for a writ of mandamus. View "State Farm Mutual Automobile Insurance Co. v. Robinson" on Justia Law