Justia Insurance Law Opinion Summaries

Following a preliminary hearing, petitioner Dr. Sanjoy Banerjee was charged in an information with two counts of presenting a false or fraudulent health care claim to an insurer (a form of insurance fraud, counts 1-2), and three counts of perjury (counts 3-5). The superior court denied Banerjee’s motion to dismiss the information as unsupported by reasonable or probable cause. Banerjee petitioned for a writ of prohibition to direct the superior court to vacate its order denying his Penal Code section 995 motion and to issue an order setting aside the information. The Court of Appeal issued an order to show cause and an order staying further proceedings on the information, pending the Court's resolution of the merits of Banerjee’s petition. The State filed a return, and Banerjee filed a traverse. The State argued the evidence supported a strong suspicion that Banerjee committed two counts of insurance fraud and three counts of perjury, based on his violations of Labor Code section 139.3(a) between 2014 and 2016. During that period, Banerjee billed a workers’ compensation insurer for services he rendered to patients through his professional corporation and through two other legal entities he owned and controlled. The insurance fraud charges are based on Banerjee’s 2014-2016 billings to the insurer through the two other entities. The perjury charges were based on three instances in which Banerjee signed doctor’s reports, certifying under penalty of perjury that he had not violated “section 139.3.” Banerjee argued: (1) the evidence showed he did not violate the statute's referral prohibition; (2) even if he did not comply with section 139.3(e), the “physician’s office” exception to the referral prohibition applied to all of his referrals to his two other legal entities; and (3) the patient disclosure requirement of section 139.3(e), the referral prohibition of section 139.3(a), and the physician’s office exception to the referral prohibition were unconstitutionally vague. The Court of Appeal concluded: (1) Banerjee did not violate section 139.3(a) by referring his patients to his two other legal entities; and (2) the evidence supported a strong suspicion that Banerjee specifically intended to present false and fraudulent claims for health care benefits, in violation of Penal Code section 550(a)(6), by billing the workers’ compensation insurer substantially higher amounts through his two other legal entities than he previously and customarily billed the insurer for the same services he formerly rendered through his professional corporation and his former group practice. Thus, the Court granted the writ as to the perjury charges but denied it as to the insurance fraud charges. View "Banerjee v. Super. Ct." on Justia Law

The issue on appeal in this case stemmed from an insurance claim filed by Bonbeck Parker, LLC and BonBeck HL, LC (collectively, BonBeck) for hail damage. The Travelers Indemnity Company of America (Travelers) acknowledged that some of the claimed damage to BonBeck’s property was caused by a covered hailstorm, but argued the remaining damage was caused by uncovered events such as wear and tear. BonBeck requested an appraisal to determine how much damage occurred, but Travelers refused this request unless BonBeck agreed the appraisers would not decide whether the hailstorm in fact caused the disputed damage. When BonBeck rejected this condition, Travelers filed suit, seeking a declaration that the appraisal procedure in BonBeck’s policy did not allow appraisers to decide the causation issue. The district court disagreed, ruling that the relevant policy language allowed appraisers to decide causation. After the appraisal occurred, the district court granted summary judgment to BonBeck on its breach of contract counterclaim, concluding that Travelers breached the policy’s appraisal provision. Travelers appealed. Applying Colorado law, the Tenth Circuit Court of Appeals affirmed: the disputed policy provision allowed either party to request an appraisal on “the amount of loss,” a phrase with an ordinary meaning in the insurance context that unambiguously encompassed causation disputes like the one here. "And contrary to Travelers’ view, giving effect to this meaning aligns both with other related policy language and with the appraisal provision’s purpose of avoiding costly litigation. For these reasons, the district court appropriately allowed the appraisers to resolve the parties’ causation dispute and granted summary judgment for BonBeck on its breach of contract claim." View "BonBeck Parker, et al. v. Travelers Indemnity" on Justia Law

Ben E. Keith Company, Inc. ("BEK"), appealed a circuit court order entering summary judgment in favor of Lyndon Southern Insurance Company ("Lyndon") on Lyndon's complaint for a declaratory judgment. On December 14, 2018, Felicia Edwards and Robert Allen Marak were involved in a motor-vehicle accident in Dadeville. Felicia was driving a 2009 Toyota Camry automobile that was owned by Annette Edwards and insured by Lyndon. Marak was driving a tractor-trailer that was owned by BEK. As a result of the accident, BEK incurred damage to its tractor-trailer. BEK sued Felicia and Annette claiming negligence and wantonness against both Felicia and Annette and a claim of negligent entrustment against Annette. BEK later amended the complaint to add a negligent-maintenance claim against Annette. Lyndon filed a complaint for a declaratory judgment against Felicia, Annette, and BEK, asserting the policy it issued to Annette excluded coverage for "[a]ny operator of a vehicle who is not listed as a driver on the Policy Applications, Declarations, and/or added by Endorsement who is under the age of twenty-five and is either a Family Member or resides in the same household as the Named Insured" and for "[a]n operator of a vehicle who is an unlicensed driver or whose driving privileges have been terminated or suspended." BEK argued the trial court erroneously granted Lyndon's motion for a summary judgment because Lyndon did not produce substantial admissible evidence to establish that Felicia was a noncovered person under the policy that insured Annette's vehicle at the time of the accident. Specifically, it contended Lyndon did not produce substantial admissible evidence to establish that Felicia did not have a valid driver's license at the time of the accident or to establish Felicia's age and residence at the time of the accident. After review, the Alabama Supreme Court concurred Lyndon did not produce substantial evidence to establish that Felicia did not have a valid driver's license at the time of the accident and did not produce substantial evidence to establish that Felicia was under the age of 25 and resided in Annette's household at the time of the accident. Therefore, Lyndon did not shift the burden of proof to BEK. Accordingly, the trial court erred in granting Lyndon's motion for a summary judgment. Judgment was therefore reversed. View "Ben E. Keith Company, Inc. v. Lyndon Southern Insurance Company" on Justia Law

Consolidated cases presented a certified question from the United States District Court for the District of Oregon. The Oregon Supreme Court was asked to determine whether Oregon law precluded an insurer from limiting its liability for uninsured/underinsured motorist (UM/UIM) benefits on the basis that another policy also covered the insured’s losses. Each plaintiff suffered injuries caused by an uninsured or underinsured motorist, and each plaintiff incurred resulting damages that qualify as covered losses under multiple motor vehicle insurance policies issued by defendant State Farm Mutual Automobile Insurance Company (State Farm). Each plaintiff alleged a loss that exceeded the declared liability limits of any single applicable policy and sought to recover the excess under additional applicable policies, up to the combined total of the limits of liability. In each case, however, State Farm refused to cover the excess loss, citing a term in the policies that allowed State Farm to limit its liability to the amount that it agreed to pay under the single policy with the highest applicable limit of liability. The Oregon Supreme Court concluded that that term made State Farm’s uninsured motorist coverage less favorable to its insureds than the model coverage that the legislature has required and, thus, was unenforceable. View "Batten v. State Farm Mutual Automobile Ins. Co." on Justia Law

The Eleventh Circuit affirmed the district court's order dismissing National Trust's federal declaratory judgment action without prejudice. Plaintiff filed a wrongful death action against Southern Heating and others in Alabama state court after his parents died from carbon monoxide poisoning. National Trust, Southern Heating's insurer, filed suit in federal court seeking a declaration that it has no duty to defend or indemnify Southern Heating because there is no coverage under its policy. The district court found that the Alabama state court action was parallel to the federal declaratory judgment action and that the non-exhaustive guideposts set out in Ameritas Variable Life Ins. Co. v. Roach, 411 F.3d 1328, 1331 (11th Cir. 2005), weighed in favor of not hearing National Trust's action.The court concluded that, when relevant, the degree of similarity between concurrent state and federal proceedings is a significant consideration in deciding whether to entertain an action under the Declaratory Judgment Act. In this case, the district court properly took into account that similarity in its consideration of the Ameritas guideposts. The court explained that the district court's perspective may not be the only way to view the two proceedings at issue, but it is a permissible way to look at them, and that is enough to constitute a reasonable exercise of discretion. View "National Trust Insurance Co. v. Southern Heating and Cooling Inc." on Justia Law

The U.S. Appeals Court for the Ninth Circuit certified several questions of law to the Washington Supreme Court. When the homeowner failed to insure his property, the mortgage servicer purchased insurance to cover the property pursuant to the mortgage agreement - known as “force placed insurance” or “lender placed insurance.” The policy was underwritten by the insurers and passed through a broker to the mortgage servicer. The homeowner claimed that these parties participated in an unlawful kickback scheme that artificially inflated the premiums. In Washington, insurers must generally file their rates and receive approval from the Office of the Insurance Commissioner (OIC) before selling insurance. Once the rates are filed and approved by the governing agency, the rates were “per se reasonable” and claims that run squarely against these rates had to be dismissed (known as the "filed rate doctrine”). While the filed rate doctrine historically applied to shield entities that file rates, the Washington Court was asked whether the filed rate doctrine also applied to bar suit against intermediaries who did not file rates: the mortgage servicer (Nationstar Mortgage LLC) and broker (Harwood Service Company) who participated in the procurement of the policy from the insurers. If the filed rate doctrine applied to these intermediaries, the Supreme Court was then asked to determine whether damages would be barred under Washington's only case applying the doctrine, McCarthy Fin., Inc. v. Premera, 1347 P.3d 872 (2015). The Washington Supreme Court held that the filed rate doctrine had to also apply to bar suit against intermediaries where awarding damages or other relief would squarely attack the filed rate. In light of this holding, the Court returned the second question pertaining to damages to the Ninth Circuit to first revisit and apply McCarthy to the specific allegations of the appellant-homeonwer's outstanding claims. View "Alpert v. Nationstar Mortg., LLC" on Justia Law

The Fifth Circuit withdrew its prior opinion and substituted the following opinion.In this insurance coverage dispute, at issue is who counts as an "employee" under the Texas Anti-Indemnity Act (TAIA). The Fifth Circuit concluded that Zurich was not required to file a cross-appeal and thus dismissed the cross-appeal. The court also concluded that the Maxim Policy does not assign Maxim's rights to Zurich, and thus Maxim can pursue this claim against Zurich under the Berkel Policy.The court certified the following question to the Supreme Court of Texas: Whether the employee exception to the TAIA, Texas Insurance Code 151.103, allows additional insured coverage when an injured worker brings a personal injury claim against the additional insured (indemnitee), and the worker and the indemnitee are deemed "co-employees" of the indemnitor for purposes of the TWCA. View "Maxim Crane Works, LP v. Zurich American Insurance Co." on Justia Law

Dwayne Harris appealed a circuit court order dismissing his counterclaim against Dubai Truck Lines, Inc., pursuant to Rule 12(b)(6), Ala. R. Civ. P. On February 18, 2018, three vehicles were involved in an accident in Jefferson County, Alabama: a vehicle owned by Dubai and driven by Jose Martinez, one of Dubai's employees; a vehicle driven by Harris; and a vehicle driven by Annika Schaefer. Schaefer's vehicle was insured by State Farm Mutual Automobile Insurance Company. On February 28, 2019, Schaefer and State Farm, as subrogee of Schaefer sued Dubai and Martinez. According to Dubai, it was not served with the complaint until June 2020, after the expiration of the applicable two-year statute-of- limitations period. On August 7, 2020, Dubai filed an answer denying all liability for the accident and adding Harris as a third-party defendant pursuant to Rule 14, Ala. R. Civ. P. Dubai specifically impleaded Harris to allege that Harris's negligence was the proximate cause of the accident. On November 13, 2020, Harris filed a counterclaim against Dubai, alleging that Martinez, Dubai's employee, had been negligent and/or wanton in causing the accident, that Harris had suffered injuries as a result of the accident and that Dubai was vicariously liable for those injuries. Dubai then moved to dismiss the counterclaim, alleging Harris' counterclaim was barred by the applicable statute of limitations. The Alabama Supreme Court found Harris's counterclaim was compulsory, and not subject to a statute-of-limitations defense. Thus, there was no basis for the circuit court to dismiss Harris's counterclaim pursuant to Rule 12(b)(6). View "Harris v. Dubai Truck Lines, Inc." on Justia Law

Melvin James appealed a circuit court's grant of summary judgment in favor of Assurance America Insurance Company ("Assurance") on its complaint for a declaratory judgment. In February 2019, Bernardino Mejia and James were involved in a motor-vehicle accident in Montgomery, Alabama. Mejia was driving a 2003 Chrysler Town and Country minivan, and James was driving a 2004 Toyota Camry automobile. As a result of the accident, Mejia's three children were ejected from the Town and Country. One of Mejia's children died, and the other two were seriously injured. James was also injured as a result of the accident. Mejia was arrested, and, on September 23, 2019, he was indicted for one count of reckless murder and four counts of first- degree assault as a result of the accident. He was incarcerated on those charges. In April 2019, James sued Mejia, ALFA Insurance Corporation, USAA Casualty Insurance Company, and various fictitiously named defendants for negligence, negligence per se, wantonness, and breach of contract. Mejia moved to stay the civil proceeding until the accident-related criminal proceedings against him were concluded; this motion was granted. Assurance sought the summary judgment motion at issue here, against Mejia and James. Assurance contended Mejia was not the named insured under the Assurance policy that covered the Town & Country he was driving, and that policy excluded coverage for injury or damage caused by an insured vehicle when driven by a person who was not listed as a driver on the declarations page of the policy and who did not have a valid driver's license. The Alabama Supreme Court reversed and remanded, finding Assurance did not produce substantial, admissible evidence to establish Mejia did not have a valid driver's license at the time of the accident and therefore did not shift the burden of proof to James. Accordingly, the trial court erred in granting Assurance's motion for a summary judgment. View "James v. Assurance America Insurance Company" on Justia Law

The three restaurants in these consolidated appeals each brought its own action in state court seeking a declaration that its respective Insurer was obligated to provide coverage for COVID-19-related losses under an insurance policy. Each Insurer removed its case to federal court invoking diversity jurisdiction; each district court exercised its discretion under the Declaratory Judgment Act (DJA), 28 U.S.C. 2201–02, to abstain from hearing the case and ordered the matter be remanded to state court. The Third Circuit vacated the orders, concluding that the District Courts erred in weighing factors relevant to the exercise of discretion under the DJA: the likelihood that a federal court declaration will resolve the uncertainty of obligation which gave rise to the controversy, the general policy of restraint when the same issues are pending in a state court, and the public interest in settlement of the uncertainty of obligation. In this case, a declaratory judgment would be sufficient to afford relief and settle their respective controversies. View "Dianoias Eatery LLC v. Motorists Mutual Insurance Co" on Justia Law