Justia Insurance Law Opinion Summaries

Petitioner Lisa French went to respondents Centura Health Corporation and Catholic Health Initiatives Colorado d/b/a St. Anthony North Health Campus (collectively, “Centura”) for surgery. Upon reviewing French’s insurance information prior to surgery, Centura advised her that she would personally be responsible for $1,336.90 of the amounts to be billed. After the surgery, however, Centura determined that it had misread French’s insurance card and that she was, in fact, an out-of-network patient. Centura then billed French $229,112.13 and ultimately sued her to collect. The Colorado Supreme Court granted certiorari to review: (1) whether here, Centura’s database used by listing rates for specific medical services and supplies, was incorporated by reference into hospital services agreements (“HSAs”) that French had signed; and (2) if so, whether the price term in the HSAs was sufficiently unambiguous to render the HSAs enforceable. The Court concluded that because French neither had knowledge of nor assented to the chargemaster, which was not referenced in the HSA or disclosed to her, the chargemaster was not incorporated by reference into the HSA. Accordingly, the HSA left its price term open, and therefore, the jury appropriately determined that term. The Court reverse the judgment of the division below, and did not decide whether the price that French was to pay was unambiguous, even if the HSA incorporated the chargemaster. View "French v. Centura Health" on Justia Law

In September 2016, Legend’s Creek filed a claim with Travelers for hail and wind damage that had occurred in May 2016 to the north-facing sides of insured condominium buildings. Legend’s Creek retained Kassen to negotiate the claim with Travelers’ agent Knopp. The two initially agreed to repair the north-facing sides of the buildings. Travelers issued a $644,674.87 check. In January 2017, Kassen informed Knopp that the repairs were unacceptable. Travelers investigated and submitted additional checks of $238,766.88 and $28,438.02. Kassen told Knopp that the north-facing sides had to be completely replaced. Travelers agreed and, in February 2018, submitted an estimate. Less than three weeks before the contractual deadline to file suit Kassen demanded the replacement of all sides of the buildings because the new sides did not match to his satisfaction the undamaged ones. Knopp informed Kassen that Travelers would only replace the damaged north-facing sides and paint them to match.Legend’s Creek sued, alleging breach of contract and bad faith. Travelers argued that the lawsuit was brought outside the two-year contractual window and later moved to compel Travelers to submit to an appraisal. The magistrate compelled an appraisal for discovery purposes. The appraiser granted an “award” to Legend’s Creek based on the mismatched sides. The district court granted Travelers summary judgment. The Seventh Circuit affirmed, citing the limitations clause and rejecting claims of waiver. View "Legend's Creek Homeowners Associaton, Inc. v. Travelers Indemnity 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

Illinois Insurance Guaranty Fund is a state-created insolvency insurer; when a member insurer becomes insolvent, the Fund pays covered claims. In cases involving insolvent health insurance, many claims are for patients who are eligible for both Medicare benefits and private health insurance. The Fund sought a determination that it is not subject to reporting requirements under section 111 of the 2007 Medicare, Medicaid, and SCHIP Extension Act, 42 U.S.C. 1395y(b)(7) & (b)(8), which is intended to cut Medicare spending by placing financial responsibility for medical costs with available primary plans first. Because time may be of the essence in medical treatment, the government may make conditionally cover medical expenses for Medicare beneficiaries insured by a primary plan, subject to later reimbursement from a primary plan. Section 111 imposes reporting requirements so that the government can identify the primary plan responsible for payment. The Fund believes that it is not an “applicable plan.”The district court dismissed for lack of subject-matter jurisdiction, reasoning the government had not made a final decision through its administrative processes. The Seventh Circuit affirmed. The Fund can obtain judicial review of its claim in a federal court only by channeling its appeal through the administrative process provided under 42 U.S.C. 405(g). The usually-waivable defense of failure to exhaust administrative remedies is a jurisdictional bar here. View "Illinois Insurance Guaranty Fund v. Becerra" on Justia Law

Plaintiff-appellant John Coates brought an action for breach of contract and breach of the duty of good faith and fair dealing against defendant-appellee Progressive Direct Insurance Company. Plaintiff was injured after a motorcycle collision; he was insured by Progressive under a motorcycle policy, an auto policy, and a policy providing UM coverage. Coates moved for partial summary judgment regarding his entitlement to uninsured/underinsured motorist benefits. Progressive moved for summary judgment regarding Coates' bad faith claim. Coates sought more time to conduct discovery to address Progressive's counterclaim on bad faith. The trial court granted Coates' Motion for Partial Summary Judgment, allowing his UM claim against Progressive. The trial court also granted Progressive's Motion for Summary Judgment, denying Coates' claim for breach of duty of good faith and fair dealing. The trial court denied Coates' Motion for Additional Time to Respond. After review of the parties’ arguments on appeal, the Oklahoma Supreme Court affirmed the trial court’s grant of partial summary judgment on Coates' UM claim. The Court reversed, however, the decisions granting Progressive's Motion for Summary Judgment and denying Coates additional time to respond to that motion. View "Coates v. Progressive Direct Ins. Co." on Justia Law

Plaintiff filed a petition for damages in the 19th Judicial District Court in East Baton Rouge Parish. Plaintiff totaled his car in an accident and alleged that GoAuto, his car insurance carrier, paid less in policy benefits than his policy and Louisiana law required. GoAuto filed its notice of removal, Plaintiff received permission from the Louisiana court to amend his complaint again and, as accepted on appeal, filed the amended complaint. This amendment changed the definition of the class from class “residents of Louisiana” to class “citizens of Louisiana.” After removal, the parties filed several competing motions disputing which complaint controlled and the sufficiency of GoAuto’s notice of removal.   The Fifth Circuit affirmed the district court’s order remanding the case to state court, finding that Defendant is a citizen of Louisiana and thus the suit lacks the minimal diversity necessary to vest a federal court with jurisdiction. The court declined Defendant’s request to disregard the Louisiana state court’s pre-removal procedural rulings applying Louisiana law and substituted its own Erie guesses at how a Louisiana court ought to rule on a motion to amend a pleading.   Further, in regards to Defendant’s argument that it is plausible that some class members are not citizens of Louisiana, the court held that none of these individuals, assuming they had relocated to Colorado, Texas, or Florida before the filing of the complaint, qualify as citizens of Louisiana. Finally, the court held that Defendant points to nothing in the text of the statute that would bar Plaintiff’s class definition. View "Turner v. GoAuto Insurance" on Justia Law

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