Justia Insurance Law Opinion Summaries

Defendant Russell Blodgett appealed a superior court order granting summary judgment in favor of plaintiff Cincinnati Specialty Underwriters Insurance Company (CSU). Blodgett argued the trial court erred by concluding that the terms of a commercial general liability policy issued by CSU clearly and unambiguously excluded coverage for Blodgett’s damages in a separate personal injury action against CSU’s insured resulting from Blodgett’s fall from an alleged negligently constructed staircase. The New Hampshire Supreme Court concluded that, pursuant to the policy’s clear and unambiguous language, CSU had no duty or obligation to defend or indemnify its insured in the underlying litigation. View "Cincinnati Specialty Underwriters Insurance Company v. Best Way Homes, Inc. & a." 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

Vista Health Plan, Inc., a small health insurance company in Texas, was assessed risk-adjustment fees that exceeded its premium revenue, causing the company to cease operations. The company and its parent, Vista Service Corporation, (collectively, Vista) sued HHS, HHS Secretary, the Centers for Medicare and Medicaid Services (CMS), and CMS Administrator Seema Verma (collectively, the HHS Defendants), challenging the risk-adjustment program and two rules promulgated pursuant to the program.The Fifth Circuit explained that determining whether the district court’s “final judgment” was truly an appealable judgment is necessary to establish whether the court has jurisdiction. The court explained that it has recognized an exception to the general rule and determined it had jurisdiction “when the agency would be unable to later appeal the issue that is the subject of the remand order,” such as when “all that is left for remand is a ministerial accounting.”Here, though the district court denied summary judgment as to Vista’s procedural due process claim, the court then explicitly entered a “Final Judgment” stating “nothing remains to resolve ... the case is hereby CLOSED”— suggesting the court “end[ed] the litigation on the merits.” The court held that the district court, in denying summary judgment on Vista’s procedural due process claim and then remanding it for further proceedings, did not yet fully dispose of the case., Thus, there was no appealable final judgment, and the court lacks jurisdiction to reach the substance of Vista’s appeal. View "Vista Health Plan v. HHS" on Justia Law

A fire erupted at a cannabidiol oil extraction factory, leased and operated by JDBC Holdings, Inc, d/b/a The CBD Factories (“JDBC”). JDBC filed a claim for insurance coverage with Kinsale Insurance Company (“Kinsale”)., Kinsale filed a suit in the U.S. District Court for the Northern District of West Virginia alleging that it was not bound to provide coverage. The district court denied Kinsale’s motion for summary judgment, granted in part JDBC’s motion for partial summary judgment, and declared that Kinsale was bound to provide coverage. The district court certified its Order as a final judgment pursuant to Fed. R. Civ. P. 54(b) and stayed JDBC’s counterclaims for breach of contract and bad faith pending appeal.The Fourth Circuit held that it lacked jurisdiction to consider the appeal because the district court’s order was not a final decision. The court reasoned that though the district court resolved the key question of whether Kinsale was liable for providing coverage for the damage at the JDBC facility, “the order does not embody the essential elements of a money judgment because the court has not found all of the facts necessary to compute the amount of damages due.”Further, the court found that even if the district court’s order was a final judgment, the district court abused its discretion in concluding that there was no just reason for the delay to certify the partial summary judgment order for the court’s review. Therefore, the court dismissed the appeal and remanded the matter for further proceedings. View "Kinsale Insurance Company v. JDBC Holdings, Inc." on Justia Law

PCS Nitrogen sought insurance coverage for liability arising from contamination of a fertilizer manufacturing site in Charleston, South Carolina, claiming its right to coverage stemmed from an assignment of insurance benefits executed by Columbia Nitrogen Corporation in 1986. Respondents, the insurance carriers who issued the policies at issue, claimed they owed no coverage because Columbia Nitrogen Corporation executed the assignment without their consent. The circuit court granted summary judgment to Respondents, and the court of appeals affirmed. The South Carolina Supreme Court granted PCS's petition for a writ of certiorari, finding Columbia Nitrogen Corporation executed a valid post-loss assignment of insurance rights in 1986. "PCS cannot be denied coverage on the basis that Respondents did not consent to the assignment." The case was remanded to the trial court for further proceedings. View "PCS Nitrogen, Inc. v Continental Casualty Company, et al." 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

This appeal involved a challenge to how Geico General Insurance Company (“GEICO”) processed insurance claims under 21 Del. C. 2118. Section 2118 provided that certain motor vehicle owners had to obtain personal injury protection (“PIP”) insurance. Plaintiffs, all of whose claims for medical expense reimbursement under a PIP policy were denied in whole or in part, were either GEICO PIP policyholders who were injured in automobile accidents or their treatment providers. Plaintiffs alleged GEICO used two automated processing rules that arbitrarily denied or reduced payments without consideration of the reasonableness or necessity of submitted claims and without any human involvement. Plaintiffs argued GEICO’s use of the automated rules to deny or reduce payments: (1) breached the applicable insurance contract; (2) amounted to bad faith breach of contract; and (3) violated Section 2118. Having reviewed the parties’ briefs and the record on appeal, and after oral argument, the Delaware Supreme Court affirmed the Superior Court’s ruling that the judiciary had the authority to issue a declaratory judgment that GEICO’s use of the automated rules violated Section 2118. The Supreme Court also affirmed the Superior Court’s judgment as to the breach of contract and bad faith breach of contract claims. The Court concluded, however, that the issuance of the declaratory judgment was improper. View "GEICO General Insurance Company v. Green" on Justia Law

Cardinal, a distributor of wholesale pharmaceutical products, purchased commercial umbrella insurance policies from National Union. Various plaintiffs have filed more than 3,000 lawsuits against Cardinal and other manufacturers, distributors, and dispensers of prescription opioids. The majority of federal cases are consolidated in coordinated, multi-district proceedings in the Northern District of Ohio. Plaintiffs “assert a wide variety of federal and state causes of action, many seeking to recover for increased payments, services, treatment, and/or care allegedly necessitated by the opiate-related addictions, overdoses, and deaths of those they serve.”National Union has reserved its right to deny coverage for opioid litigation claims. Cardinal sought a declaratory judgment in the Franklin County, Ohio Court of Common Pleas. National Union removed the suit to the Southern District of Ohio. The district court granted Cardinal’s motion and remanded the case to state court. The Sixth Circuit affirmed. The district court found no evidence of procedural fencing and properly declined to weigh that factor in favor of federal jurisdiction. The court noted a preference to allow state courts to answer questions of insurance contract interpretation and the actively developing nature of insurance coverage claims related to opioid litigation in Ohio state courts. The district court adhered to the principles of federalism and comity and engaged in a reasoned analysis of each factor in declining jurisdiction. View "Cardinal Health, Inc. v. National Union Fire Insurance Co. of Pittsburgh" on Justia Law

The Louisiana Supreme Court granted certiorari in this case to decide whether the district court had jurisdiction over a claim for penalties against an insurer arising from its failure to provide a defense in workers’ compensation proceedings, and, if so, whether the insurer violated its duties of good faith and fair dealing, thereby making it liable for damages and penalties. After review of the trial court record, the Supreme Court concluded the district court had jurisdiction over the claim and correctly found that the insurer breached its duties to its insured. However, the Court found the district court’s damage award rose to the level of an abuse of discretion. The judgment of the court of appeal was amended to award damages in favor of Cox, Cox, Filo, Camel & Wilson, LLC and against Louisiana Workers’ Compensation Corporation in the total amount of $61,655.00, representing $20,550.00 in special damages and $41,100.00 in penalties. View "Cox, Cox, Filo, Camel & Wilson, LLC v. Louisiana Workers' Compensation Corporation" on Justia Law

North Dakota Insurance Reserve Fund (“NDIRF”) appealed a judgment and orders granting Lance Hagen’s amended petition for a writ of mandamus requiring NDIRF to disclose documents under the open records law. NDIRF argued: (1) the amended petition was untimely; (2) NDIRF was not a public entity subject to open records requests; and (3) the documents sought were protected from disclosure under North Dakota court rules. Hagen cross appealed, arguing the district court erred by not requiring NDIRF to disclose all of the documents he sought and by denying him costs and attorney’s fees. After review, the North Dakota Supreme Court affirmed in part, concluding the amended petition was timely, NDIRF was a public entity for purposes of the open records law, and the records sought were not exempt from disclosure. The Court reversed the part of the judgment and orders excluding records from disclosure, and remanded to the district court to review in camera those previously excluded records and those records identified in Appellant’s Brief to determine whether they were exempt from disclosure under the potential liability exception in N.D.C.C. 44-04-19.1(8). The Court affirmed the denial of costs and attorney’s fees. View "Hagen v. North Dakota Insurance Reserve Fund" on Justia Law