Justia Insurance Law Opinion Summaries

Douglas Ghee, as the personal representative of the estate of Billy Fleming, appealed a circuit court order dismissing a wrongful-death claim brought against USAble Mutual Insurance Company d/b/a Blue Advantage Administrators of Arkansas ("Blue Advantage"). Fleming presented to the emergency department complaining of constipation and abdominal pain. He would ultimately need a colectomy, but the hospital informed him Blue Advantage had decided that a lower quality of care (continued non-surgical management) was more appropriate than the higher quality of care (surgery) that Fleming's surgeon felt was appropriate. Fleming and his family had multiple conversations with agents of Blue Advantage in an unsuccessful attempt to convince the company that the higher surgery was the more appropriate course of care. Ultimately, an agent of Blue Advantage suggested to Fleming that he return to the hospital in an attempt to convince hospital personnel and physicians to perform the surgery on an emergency basis. For five days, Fleming would present to the emergency room, each time he was treated by non-surgical means, then returned home. On the evening of July 15, 2013, Fleming's condition had deteriorated such that he had to be intubated. He died after midnight of septic shock due to a perforated sigmoid colon with abundant fecal material in the peritoneal cavity. A lawsuit was filed against Blue Advantage, asserting that the combined negligence of the hospitals and clinics involved and Blue Advantage, proximately caused Fleming's death. Because the trial court determined that Ghee's allegations against Blue Advantage as stated in the original complaint were defensively preempted by ERISA, the Alabama Supreme Court found Ghee should have had the right to amend his complaint to clarify his state-law claims. Because the Court concluded that Ghee should have been afforded the right to amend his complaint, it reversed the judgment of the trial court and remanded for further proceedings. View "Ghee v. USAble Mutual Insurance Company d/b/a Blue Advantage Administrators of Arkansas" on Justia Law

Defendant-appellant Ricardo Lara, the California Insurance Commissioner, filed a notice of noncompliance against plaintiffs-respondents Mercury Insurance Company, Mercury Casualty Company, and California Automobile Insurance Company (collectively Mercury) alleging Mercury charged rates not approved by the California Department of Insurance (CDI) and that the rates were unfairly discriminatory in violation of Insurance Code sections 1861.01 (c) and 1861.05 (b). The allegedly unapproved rates were in the form of broker fees charged by Mercury agents, which should have been disclosed as premium. After prevailing at an administrative hearing, the Commissioner imposed civil penalties against Mercury totaling $27,593,550 for almost 184,000 unlawful acts. Mercury filed a petition for writ of mandate, which the court granted, reversing the Commissioner’s decision. The court found the “broker fees” were not premium because they were charged for separate services. The court also rejected the Commissioner’s interpretation of the term premium under the Insurance Code and regulations. In addition, the court ruled Mercury did not have proper notice it was subject to penalties, in violation of due process, and the action was barred by laches because CDI had unduly delayed in bringing the action. Commissioner and intervener-appellant, Consumer Watchdog (CWD), appealed on several grounds, among them: (1) the trial court did not use the proper standard of review; (2) failed to give the Commissioner’s findings a strong presumption of correctness and failed to put the burden of proof on Mercury to show the findings were against the weight of the evidence; (3) the trial court’s finding the fees were charged for separate services was precluded by collateral estoppel; (4) Mercury received proper notice of the potential imposition of a penalty; and (5) laches did not bar the action. The Court of Appeal agreed with Commissioner and CWD the writ was issued in error and reversed the judgment. View "Mercury Insurance Co. v. Lara" on Justia Law

The Alaska Workers’ Compensation Board denied a Bryce Warnke-Green's request that his employer pay for a van modified to accommodate his work-related disability. On appeal, the Alaska Workers’ Compensation Appeals Commission decided that a modifiable van was a compensable medical benefit. Warnke-Green moved for attorney’s fees. The Commission reduced the attorney’s hourly rate, deducted a few time entries, and awarded him less than half of what was requested. Warnke-Green asked the Commission to reconsider its award, but the Commission declined to do so because of its view that the Alaska Workers’ Compensation Act (the Act) allowed it to reconsider only the final decision on the merits of an appeal. The Alaska Supreme Court granted Warnke-Green's petition for review, and held that the Commission had the necessarily incidental authority to reconsider its non-final decisions. The Court also reversed the Commission’s award of attorney’s fees and remanded for an award that was fully compensable and reasonable. View "Warnke-Green v. Pro-West Contractors, LLC" on Justia Law

In a consolidated appeal, the New Jersey Supreme Court considered one central issue: whether the New Jersey Legislature intended to deviate from its highly regulated no-fault system of first-party self-insurance to cover medical expenses arising from automobile accidents when it amended the statutory scheme to allow an insured to elect smaller amounts of personal injury protection (PIP) under a standard policy. Each plaintiff in this appeal was injured in a car accident. Each was insured under a standard policy with insurance that provided for $15,000 in PIP coverage instead of the default amount of $250,000. Neither was able to sustain a claim for bodily injury (noneconomic loss) due to each policy’s limitation-on-lawsuit option. Each sued for outstanding medical bills in excess of their elected PIP coverage ($28,000 and $10,000, respectively). The trial courts ruled against plaintiffs in each matter and prohibited plaintiffs from admitting evidence of their medical expenses that exceeded their $15,000 PIP limits. The Appellate Division consolidated the cases on appeal, and, in a published opinion, reversed both trial court orders. After its review, the Supreme Court could not concluded there was evidence of a clear intention on the part of the Legislature to deviate from the carefully constructed no-fault first-party PIP system of regulated coverage of contained medical expenses and return to fault-based suits consisting solely of economic damages claims for medical expenses in excess of an elected lesser amount of available PIP coverage. "Unless the Legislature makes such an intent clearly known, the Court will not assume that such a change was intended by the Legislature through its amendments to the no-fault system in the Automobile Insurance Cost Reduction Act." View "Haines v. Taft" on Justia Law

The Eleventh Circuit dismissed this insurance dispute case, holding that Gerber, as assignee of the insured, did not have standing to bring a declaratory judgment class action against GEICO. In this case, the action did not assert any claims for money damages and there was no substantial likelihood that the insured would suffer a future injury. Accordingly, the court reversed and remanded with instructions to dismiss the complaint for lack of standing. View "A&M Gerber Chiropractic LLC v. Geico General Insurance Co." on Justia Law

Plaintiffs, operators of a gas purification plant, filed suit against its insurer, Ace, after the insurer denied coverage for damage caused by broken metal brackets that secured crucial components. The Ninth Circuit affirmed the district court's application of Washington law and its discovery sanctions against plaintiffs.However, the panel reversed the district court's grant of summary judgment in favor of the insurer and held that there was a triable issue of fact as to whether the insurer was prejudiced by plaintiffs' remedial actions, whether plaintiffs' loss was fortuitous, whether the policy's Boiler and Machinery endorsement applied to independently confer coverage for plaintiffs' losses, whether the Endorsement's "accident" coverage applied, and whether a 16 month shutdown was consistent with the exercise of due diligence and dispatch. View "Ingenco Holdings, LLC v. ACE American Insurance Co." on Justia Law

John Teets, a participant in an employer retirement plan, invested money in Great-West Life Annuity and Insurance Company’s investment fund which guaranteed investors would never lose their principal or the interest they accrued. The investment fund was offered to employers as an investment option for their employees’ retirement savings plans, which were governed by the Employee Retirement Income Security Act (“ERISA”). Teets later sued Great-West under ERISA, alleging Great-West breached a fiduciary duty to participants in the fund or that Great-West was a nonfiduciary party in interest that benefitted from prohibited transactions with his plan’s assets. After certifying a class of 270,000 plan participants like Mr. Teets, the district court granted summary judgment for Great-West, holding that: (1) Great-West was not a fiduciary; and (2) Mr. Teets had not adduced sufficient evidence to impose liability on Great-West as a non-fiduciary party in interest. Finding no reversible error in that judgment, the Tenth Circuit affirmed the district court’s judgment. View "Teets v. Great-West Life" on Justia Law

A district court ordered Jackson National Life to pay about $191,000 on a policy of life insurance. The court added that the insurer had litigated unreasonably and ordered it to reimburse Cooke’s legal fees under 215 ILCS 5/155. The insurer paid the death benefit and appealed the attorneys’ fees. Because the district court had not specified the amount, the Seventh Circuit dismissed the appeal as premature. The district court then awarded $42,835 plus interest. The district judge concluded that there had been a good faith coverage dispute, so the insurer could not be penalized for insisting that a judge resolve the parties’ dispute, but added, “Jackson’s behavior in this litigation has been much less reasonable.” The Seventh Circuit reversed, first rejecting Cooke’s appeal on the merits award. Cooke did not appeal within 30 days of the order specifying the amount payable on the policy, and a later award of fees did not reopen that subject. The court erred in applying Illinois state law to the conduct of litigation in federal court and Jackson’s litigation conduct did not violate the Federal Rules of Civil Procedure. View "Cooke v. Jackson National Life Insurance Co." on Justia Law

The Georgia Supreme Court granted certiorari in this case to review whether the Court of Appeals erred in reversing the grant of summary judgment to the insurer on the insured’s failure-to-settle claim. The Court also asked the parties to address whether an insurer’s duty to settle arises only when the injured party presents a valid offer to settle within the insured’s policy limits or whether, even absent such an offer, a duty arises when the insurer knows or reasonably should know that settlement within the insured’s policy limits is possible. As to this threshold issue, the Court concluded an insurer’s duty to settle arises only when the injured party presents a valid offer to settle within the insured’s policy limits. Applying the applicable rules of contract construction to correspondence from two injured parties in the instant case, the Court concluded the injured parties presented to the insurer a valid offer to settle within the insured’s policy limits but that the offer did not include any deadline for accepting the offer. Based on the undisputed evidence, as a matter of law, the insurer did not act unreasonably in failing to accept the offer before it was withdrawn by the injured parties. As the insurer was entitled to summary judgment, the Court reversed the decision of the Court of Appeals. View "First Acceptance Insurance Company of Georgia, Inc. v. Hughes" on Justia Law

The Ninth Circuit affirmed the district court's denial of plaintiffs' motion to remand to state court. The panel joined the Fourth Circuit in holding that receipt of an initial pleading by a statutorily designated agent does not begin the thirty-day removal clock under 28 U.S.C. 1446(b)(1), and that it was instead actual receipt by State Farm that started the removal clock. The panel applied this rule and held that State Farm timely removed the case where removal was calculated from when the forwarded copy of the complaint reached State Farm's designated recipient. View "Anderson v. State Farm Mutual Automobile Insurance Co." on Justia Law