Justia Insurance Law Opinion Summaries

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

National Western Life Insurance Company (NWL) appealed after it was held liable for negligence and elder abuse arising from an NWL annuity sold to 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 the Court of Appeal's prior opinion reversing the judgment, the Court concluded Pantaleoni was an independent agent who sold annuities for multiple insurance companies and had no authority to bind NWL. The Court determined that Pantaleoni was an agent for Williams, not NWL. The California Supreme Court vacated that decision and remanded, asking the appeals court to reconsider its finding that Pantaleoni did not have an agency relationship with National Western Life Insurance Company 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). Upon remand, the Court of Appeal affirmed the judgment finding NWL liable for negligence and financial elder abuse. However, punitive damages assessed against NWL were reversed. The Court found no abuse of discretion in the trial court’s calculation of the attorney fee award, but remanded the case for the court to reconsider the award in light of the reversal of punitive damages. View "Williams v. Nat. W. Life Ins. Co." on Justia Law

Appellant Dameron Hospital Association (Dameron) required patients or their family members to sign Conditions of Admissions (COAs) when Dameron provided the patients’ medical care. The COAs at issue in this case contained language that assigned 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 California State Automobile Association Inter-Insurance Bureau'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 judgment in CSAA’s favor following CSAA’s successful motion for summary judgment. 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. Further, the Court held: (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 was 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 this 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. etc." on Justia Law

Westmoreland owned a Cobb, California dwelling that was insured for fire loss, with a coverage limit of $372,000. The “open policy” provided up to 125 percent of the limit for “Extended Replacement Cost” coverage ($465,000) for repairing, rebuilding, or replacing the dwelling after a fire. In 2015, the Cobb house was destroyed when the Valley Fire swept through Lake County. The estimated cost to rebuild or replace that dwelling at the Cobb location was $422,676. The Insurer paid Westmoreland $372,000, the actual cash value of the lost dwelling. Westmoreland built a replacement home at a different location for no more than $372,000, then demanded an additional $50,676–the difference between the actual cash value amount and the estimated cost to rebuild at the Cobb location.Insurance Code 2051.5(c) provided that, where a “total loss” of an insured structure occurs, the insurer cannot limit or deny payment of the replacement costs if the insured “decides to rebuild or replace the property at a location other than the insured premises,” and in such cases, “the measure of indemnity shall be based upon the replacement cost of the insured property and shall not be based upon the cost to repair, rebuild, or replace” at the other selected location.The court of appeal directed the dismissal of Westmoreland’s suit. Neither section 2051.5 nor the insurance contract requires the Insurer to indemnify Westmoreland for replacement costs that they did not actually incur. View "Westmoreland v. Fire Insurance Exchange" on Justia Law

A congregation of the hierarchical Church of God purchased an insurance policy from GuideOne Specialty Mutual Insurance Company (GuideOne) covering the risk of fire damage to a church building that was held by the congregation, as agent of the greater church, in trust for the benefit of the larger church body. After the local congregation voted to sever its relationship with the Church of God, a regional oversight authority took over as the agent/trustee holding the property on behalf of the greater church, after which the previously affiliated local congregation moved out, and the new agent added the property to its own insurance policy, with Church Mutual Insurance Company (Church Mutual), covering the same risk. Fire destroyed the building while both policies were in effect. Church Mutual paid the claim. GuideOne denied coverage on the ground that the former local congregation no longer had an insurable interest in the property. The issue this case presented for the Court of Appeal was whether Church Mutual was entitled to contribution from GuideOne. The trial court concluded the answer was no. While the appellate court disagreed with certain aspects of the trial court’s statement of decision, it concluded the trial court reached the correct result. The Court of Appeal also concluded the trial court correctly determined Church Mutual was not entitled to prevail against GuideOne on a separate subrogation cause of action. View "Church Mutual Ins. Co. v. GuideOne Specialty Mutual Ins. Co." on Justia Law

Plaintiff State Farm Mutual Automobile Insurance Company (State Farm) filed an Insurance Fraud Protection Act (IFPA) action alleging defendants Sonny Rubin, M.D., Sonny Rubin, M.D., Inc., and Newport Institute of Minimally Invasive Surgery (collectively, defendants) fraudulently billed insurers for various services performed in connection with epidural steroid injections. A month prior, however, another insurer, Allstate, filed a separate IFPA lawsuit against the same defendants, alleging they were perpetrating a similar fraud on Allstate. The trial court sustained defendants’ demurrer to State Farm’s complaint under the IFPA’s first-to-file rule, finding it alleged the same fraud as Allstate’s complaint. State Farm appealed, arguing its complaint alleged a distinct fraud. After review, the Court of Appeal agreed the demurrer was incorrectly sustained, but for another reason. The Court found the trial court and both parties only focused on whether the two complaints alleged the same fraudulent scheme, but in this matter of first impression, the Court found the IFPA’s first-to-file rule required an additional inquiry. "Courts must also review the specific insurer-victims underlying each complaint’s request for penalties. If each complaint seeks penalties for false insurance claims relating to different groups of insurer-victims, the first-to-file rule does not apply. A subsequent complaint is only barred under the first-to-file rule if the prior complaint alleges the same fraud and seeks penalties arising from the false claims, submitted to the same insurer-victims." Judgment was reversed and the matter remanded for further proceedings. View "California ex rel. State Farm Mutual Automobile Ins. Co. v. Rubin" on Justia Law

Hodroj, a passenger, was injured in a single-car collision. The driver was insured by CSAA. Hodroj’s attorney wrote to CSAA offering that Hodroj would settle his claim for bodily injuries in exchange for payment of the driver’s insurance policy limits if CSAA provided a sworn declaration confirming the policy limits and delivered a check within 21 days of acceptance. CSAA could condition its acceptance on Hodroj signing a written release of all bodily injury claims. CSAA responded: “We accept ... [and] are tendering ... $100,000[.]” Enclosed were a sworn declaration attesting to the policy limits, and a written release to be signed by Hodroj. A $100,000 check was sent separately, providing that it should not be presented until the release was signed. Hodroj reneged on the settlement because the release included a release of claims for property damage. Hodroj sued the driver. CSAA sued Hodroj for breach of contract.The court of appeal affirmed judgment in favor of CSAA. An objective observer would conclude that the parties intended to settle Hodroj’s bodily injury claim for the policy limits. That the proposed document contained terms materially different from what had been agreed did not change the binding effect of the agreement. Hodroj was not obliged to sign a release that was inconsistent with what he agreed to but a proposal that does not accurately reflect the agreement does not unwind the entire deal. Hodroj breached the contract by filing suit. View "CSAA Insurance Exchange v. Hodroj" on Justia Law

This appeal presented an issue of first impression for the Court of Appeals: does a commercial property insurance policy provide coverage for a business’s lost income due to the COVID-19 pandemic? After review of the specific insurance policy that California Mutual Insurance Company (California Mutual) issued to The Inns by the Sea (Inns) for its five lodging facilities, the Court determined Inns could not recover from California Mutual for its lost business income resulting from the COVID-19 pandemic. Further, Inns did not identify any manner in which it could amend its complaint to state a claim for coverage. Accordingly, the Court affirmed the trial court’s order sustaining California Mutual’s demurrer without leave to amend. View "The Inns by the Sea v. Cal. Mutual Ins. Co." on Justia Law

The primary issue in this case was whether imposing sales tax on in-state lessors of business equipment to a title insurer violated Article XIII, section 28(f) of the California Constitution. The California Department of Tax and Fee Administration (Department) contended it did not because the lessor, not the title insurer/lessee, was the taxpayer. In the Department’s view, whether the lessee reimburses the lessor for its sales tax obligation was strictly a matter of contract and did not implicate the constitutional limit on taxing insurers. Conversely, First American Title Insurance Company (First American) pointed out that in equipment leases not involving an insurer, the state assesses a use tax, not a sales tax. But where, as here, the lessee is constitutionally exempt from paying use tax, Regulation 1660(c)(1) solved that problem by providing that the sales tax applied instead. First American argued that as a result, Regulation 1660(c)(1) imposed a de facto use tax on title insurers in violation of Article XIII, section 28(f). The trial court agreed with First American and ordered the Department to “remove, strike out and otherwise give no force or effect to that portion of Regulation 1660(c)” providing that when the lessee is not subject to use tax, the sales tax applies. The Court of Appeal reversed: “Article XIII, section 28(f) does not prohibit a sales tax whose legal incidence is on a lessor, even though the economic burden of the tax is ultimately borne by the title insurer/lessee.” View "First American Title Insurance Co. v. Cal. Dept. of Tax and Fee Admin." on Justia Law