Justia Insurance Law Opinion Summaries

Plaintiff is a former federal employee and participant in a health-insurance plan (“Plan”) that is governed by the Federal Employees Health Benefits Act (“FEHBA”). The Plan stems from a contract between the federal Office of Personnel Management (“OPM”) and Blue Cross Blue Shield Association and certain of its affiliates (together, “Blue Cross”). Blue Cross administers the Plan under OPM’s supervision. Plaintiff suffered from cancer, and she asked Blue Cross whether the Plan would cover the proton therapy that her physicians recommended. Blue Cross told her the Plan did not cover that treatment. So Plaintiff chose to receive a different type of radiation treatment, one that the Plan did cover. The second-choice treatment eliminated cancer, but it also caused devastating side effects. Plaintiff then sued OPM and Blue Cross, claiming that the Plan actually does cover proton therapy. As against OPM, she seeks the “benefits” that she wanted but did not receive, as well as an injunction directing OPM to compel Blue Cross to reform its internal processes by, among other things, covering proton therapy in the Plan going forward. As against Blue Cross, she seeks monetary damages under Texas common law. The district court dismissed Plaintiff’s suit.   The Fifth Circuit affirmed. The court held that neither the advance process nor the proton-therapy guideline poses an immediate threat of injury, so injunctive relief is therefore unavailable. Further, the court found that FEHBA preempts Plaintiff’s common-law claims against Blue Cross. Accordingly, the court held that no relief is available under the relevant statutory and regulatory regime. View "Gonzalez v. Blue Cross Blue Shield" on Justia Law

Almost two decades prior to this decision, the Mississippi Supreme Court handed down Farmland Mutual Insurance Co. v. Scruggs, 886 So. 2d 714 (Miss. 2004). In that opinion, the Court held that Farmland Mutual Insurance Co., the liability insurer for Mitchell Scruggs, Eddie Scruggs, Scruggs Farms & Supplies LLC, and Scruggs Farm Joint Venture (collectively, Scruggs), had no duty to defend Scruggs in a federal lawsuit by Monsanto Company. The reason no coverage applied was because Monsanto had alleged that Scruggs committed the intentional act of conversion by saving and using unlicensed seeds. Eight years later, a district court judge overturned a jury’s verdict that Scruggs had willfully violated Monsanto’s patents. Consequently, Scruggs was not liable for treble damages and attorney’s fees. Scruggs returned to state court in 2013. Citing Rule 60(b) of the Mississippi Rules of Civil Procedure, Scruggs asked the Lee County Circuit Court to reopen and vacate the final judgment entered in 2004 in favor of Farmland on the coverage issue. Scruggs asserted the Mississippi Supreme Court’s opinion had been erroneously decided based on facts that came to light in the federal case. The state court rejected the motion as untimely under Rule 60(b). Scruggs appealed. While Scruggs asserted the motion was timely, the Mississippi Supreme Court found the motion’s timing is irrelevant: Rule 60(b) was not a procedural vehicle for a trial court to overturn a mandate issued from the Mississippi Supreme Court. Because the trial court lacked jurisdiction to grant Scruggs’s request, the Supreme Court affirmed the circuit court’s denial of the motion. View "Scruggs, et al. v. Farmland Mutual Insurance Co." on Justia Law

Plaintiffs, current and former employees of RingCentral, participated in RingCentral’s employee welfare benefits plan. The plan participated in the “Tech Benefits Program” administered by Sequoia Benefits and Insurance Services, LLC, a management and insurance brokerage company. The Tech Benefits Program was a MEWA that pooled assets from employer-sponsored plans into a trust fund for the purpose of obtaining insurance benefits for employees at large-group rates. Plaintiffs filed this putative class action on behalf of the RingCentral plan and other Tech Benefits Program participants, asserting that Sequoia owed fiduciary duties to the plan under ERISA because Sequoia allegedly exercised control over plan assets through its operation of the Tech Benefits Program. Plaintiffs alleged that Sequoia violated its fiduciary duties by receiving and retaining commission payments from insurers, which Plaintiffs regarded as kickbacks, and by negotiating allegedly excessive administrative fees with insurers, leading to higher commissions for Sequoia.   The Ninth Circuit affirmed the district court’s dismissal for lack of Article III standing. The court held that Plaintiffs failed to establish Article III standing as to either of their two theories of injury. The panel held, as to the out-of-pocket-injury theory, Plaintiffs failed to establish the injury in fact required for Article III standing because their allegations did not demonstrate that they paid higher contributions because of Sequoia’s allegedly wrongful conduct. And Plaintiffs failed to plead the third element, that their injury would likely be redressed by judicial relief. View "RACHAEL WINSOR, ET AL V. SEQUOIA BENEFITS & INSURANCE, ET AL" on Justia Law

National Union Fire Insurance Co. of Pittsburgh (National Union) filed suit to obtain a declaration that it owed no payment to Cargill, Inc. under the employee theft clause of the insurance policy held by Cargill. Cargill counterclaimed for breach of contract. The district court granted judgment on the pleadings for Cargill, ruling that Cargill had suffered a covered loss resulting directly from an employee’s theft. National Union appealed.   The Eighth Circuit affirmed and held that the district court did not err by concluding there were no disputes as to any material facts that precluded granting Cargill’s Rule 12(c) motion. Further, the court wrote that Cargill’s insurance policy provided coverage for employee “theft,” which was defined in the policy as “the unlawful taking of property to the deprivation of the Insured.” Additionally, the insured’s loss must have resulted “directly from” employee theft to be covered by the policy. Finally, the court concluded that the date of Cargill’s notice letter was the appropriate date to begin calculating prejudgment interest. View "National Union v. Cargill" on Justia Law

Lindenwood Female College (Lindenwood) asserted class action claims against its casualty insurer, Zurich American Insurance Company (Zurich), alleging a wrongful denial of coverage for COVID-19 business interruption at its Missouri and Illinois properties. The district court granted Zurich’s motion to dismiss, finding no plausible allegation of coverage.   The Eighth Circuit affirmed. The court concluded that Lindenwood’s argument fails to identify an ambiguity. The court explained that in its view, no lay person—no reasonable insured—could look at the policy as a whole and fail to appreciate that the state-specific endorsements are intended to apply in the respective states. The references to Louisiana and other states are not mere titles; they serve to establish the structure of the policy as a whole. And it would simply make no sense to define a contamination exclusion with express reference to viral contamination in the main body of the policy only to wholly eliminate that same exclusion nationwide in a later endorsement that references an individual state. View "Lindenwood Female College v. Zurich American Insurance Co." on Justia Law

Martinique Properties, LLC filed a complaint against Certain Underwriters at Lloyd’s, London (Underwriters), seeking to vacate an arbitration award. The district court dismissed the complaint for failure to state a claim for vacatur. Martinique Properties appealed. Martinique Properties argues that the appraisal award must be vacated because the appraisers “used figures and measurements which are contrary to the actual conditions of the Property” and failed to “consider certain buildings” and certain portions of a damaged roof when determining the appraisal award. These alleged errors, Martinique Properties argues, show that the appraisers were either “guilty of misconduct” or “so imperfectly executed” their powers that “a mutual, final, and definite award . . . was not made,” two of the four grounds for vacating an award under the FAA.   The Eighth Circuit affirmed. The court found that Martinique Properties has alleged only factual errors that challenge the merits of the appraisal award, and the court has no authority to reconsider the merits of an arbitration award, even when the parties allege that the award rests on factual errors. Accordingly, the appraisers’ use of certain figures and measurements in calculating the amount of loss here, and their alleged failure to consider particular buildings and portions of roof damage, even if incorrect, are not sufficient for vacatur under the FAA. View "Martinique Properties, LLC v. Certain Underwriters at Lloyd's of London" on Justia Law

Plaintiffs are three skiers who purchased an Ikon Pass for the 2019–20 ski season. Each pass provided purchasers with unlimited ski access at participating Ikon resorts in North America. Along with their Ikon Pass, Plaintiffs purchased an optional Ski Pass Preserver insurance policy from Arch. After Plaintiffs purchased their passes, state and local governments issued orders, colloquially called “stay-at-home orders,” to prevent the spread of COVID-19. In response to these orders, ski resorts throughout North America closed with approximately one-third of the ski season remaining. Plaintiffs sought reimbursement for the loss of their ski pass benefits under the policy based on the Season Pass Interruption coverage. Arch denied their claims. The company took the position that the stay-at-home orders were not quarantines under the policy, later posting a “blanket denial” for such claims on its website. Plaintiffs filed one master consolidated class action complaint on behalf of themselves and a nationwide putative class of individuals who purchased the Ski Pass Preserver policy for the 2019–20 ski season. The district court concluded that Plaintiffs did not plausibly allege a covered loss because the term “quarantined,” as used in the policy, did not encompass stay-at-home orders that merely limited travel and activities.   The Eighth Circuit affirmed. The court explained that the ordinary person at the time the Ski Pass Preserver policy was purchased would have understood “quarantined” to mean the compulsory isolation of the insured. Reading the policy as a whole, this is the only reasonable construction, and the court agreed with the district court that the policy language is unambiguous. View "Mark Rossi v. Arch Insurance Company" on Justia Law

This appeal from summary judgment in favor of Sequoia Insurance Company (Sequoia) was one of thousands of cases nationwide involving a claim for business interruption coverage arising out of the COVID-19 pandemic. The outcome here turned on whether there was evidence creating a triable issue that the insured, Best Rest Motel, Inc. (Best Rest), sustained lost business income “due to the necessary ‘suspension’ ” of its operations “caused by direct physical loss of or damage” to the insured property. Best Rest contended its case fell directly within the exception discussed by the Court of Appeal in Inns-by-the-Sea v. California Mut. Ins. Co., 71 Cal.App.5th 688 (2021). Though the Court found Inns might undermine, if not entirely foreclose Best Rest’s case, the Court limited its holding by positing in dicta a “hypothetical scenario” where “an invisible airborne agent would cause a policyholder to suspend operations because of direct physical damage to property.” Here, the Court determined Best Rest's argument failed because the record contained no evidence creating a triable issue that the hotel “could have otherwise been operating” but for the presence of COVID-19 on the premises. Best Rest’s own evidence established the exact opposite was true: its vice president and operating partner testified that the phones were “ringing off the hook[ ]” with cancellations—not because of COVID-19 in the hotel, but because of government shut down orders and travel restrictions that shuttered tourism. Accordingly, the Court affirmed summary judgment in the insurance company's favor because there was no evidence creating a triable issue that COVID-19 in the hotel caused the claimed lost income. View "Best Rest Motel, Inc. v. Sequoia Insurance Co." on Justia Law

In 2014, plaintiffs Roberta and Kevin Haas' stopped car was struck by a car driven by defendant Mark Carter. Plaintiffs brought this negligence action against defendants, Carter's estate and State Farm Mutual Automobile Insurance Company, seeking to recover economic and noneconomic damages. Carter died after plaintiffs filed suit. State Farm was Roberta Haas' insurer, whom she sued for breach of contract, alleging it failed to pay all the personal injury protection benefits that were due. At trial, one of the primary issues was whether Carter’s driving was a cause-in-fact of the injuries that plaintiffs alleged, and the issue on appeal became whether the trial court properly instructed the jury on causation. The jury returned a verdict for defendants. After review, the Oregon Supreme Court determined the trial court did not err in instructing the jury on causation, and affirmed the circuit court's judgment. View "Haas v. Estate of Mark Steven Carter" on Justia Law

Plaintiff sued Minnesota Life Insurance Company and Securian Life Insurance Company, alleging that their denial of her claim for life insurance benefits violated the Employee Retirement Income Security Act (“ERISA”). The district court dismissed her complaint under the Federal Rule of Civil Procedure 12(b)(6) for failure to state a claim.   The Eighth Circuit affirmed. The court concluded that the district court properly dismissed Plaintiff’s Section 1132(a)(3) claim. First, her contention that Minnesota Life and Securian failed to notify her husband of his conversion right does not amount to a breach of fiduciary duty because the terms of her husband’s policy did not require notice, and Plaintiff points to no provision of ERISA that would require such notice. Second, her assertion that Minnesota Life and Securian misrepresented that her husband’s conversion window would be extended rests on a misreading of the February 24 letter; Minnesota Life and Securian made no such representation. View "Kristina Powell v. Minnesota Life Insurance Co." on Justia Law