Justia Insurance Law Opinion Summaries

Prime Hospitals provide inpatient services under the Medicare program, submitting payment claims to private contractors, who make initial reimbursement determinations. Prime alleged that many short-stay claims were subject to post-payment review and denied. Prime appealed through the Medicare appeal process. Prime alleged short-stay claims audits were part of a larger initiative that substantially increased claim denials and that the Center for Medicare & Medicaid Services (CMS) was overwhelmed by the number of appeals. CMS began offering partial payment (68 percent) in exchange for dismissal of appeals. Prime alleged that it executed CMS's administrative settlement agreement so that CMS was contractually required to pay their 5,079 Medicare appeals ($23,205,245). CMS ultimately refused to allow the Prime to participate because it was aware of ongoing False Claims Act cases or investigations involving the facilities. Prime alleged that the settlement agreement did not authorize that exclusion. The district court denied a motion to dismiss Prime’s suit but transferred it to the Court of Federal Claims. The Federal Circuit affirmed in part. The breach of contract claim is fundamentally a suit to enforce a contract and does not arise under the Medicare Act, so the Claims Court has exclusive jurisdiction under the Tucker Act, 28 U.S.C. 1491. That court does not have jurisdiction, however, over Prime’s alternative claims seeking declaratory, injunctive, and mandamus relief from an alleged secret and illegal policy to prevent and delay Prime from exhausting administrative remedies. View "Alvarado Hospital, LLC v. Cochran" on Justia Law

Kelly was in a collision a drunk driver, who had been drinking at Princeton Tavern. Princeton's dram shop liability policy was issued by State National. Kelly sued Princeton in state court, obtained a default judgment, and settled for $5 million. When that lawsuit was filed, Princeton requested that its broker, Carman, notify State of its obligation to defend and indemnify. Carman did not do so. Lacking notice, State refused to cover Princeton’s liability. Princeton assigned its rights to sue Carman; Kelly sued Carman in state court for negligence and breach of contract and filed a separate state-court action, seeking a declaratory judgment that Carmen's insurer, Maxum, was obligated to defend and indemnify. Maxum removed the Declaratory Action to federal district court, asserting diversity jurisdiction. Kelly and Carman are Pennsylvania citizens. Maxum (a Georgia company) argued that the two are together interested in securing Maxum’s coverage so that diversity of citizenship would exist once Carman was realigned to join Kelly as a plaintiff. The district court remanded to state court, reasoning that the state tort action constituted a parallel proceeding. The Third Circuit reversed. Contemporaneous state and federal proceedings are parallel under the Declaratory Judgment Action when they are substantially similar; the proceedings here were not. The nonexistence of a parallel state proceeding weighed significantly in favor of the district court entertaining the Declaratory Action but did not require it. Considerations of practicality and wise judicial administration counseled against abstention. View "Kelly v. Maxum Specialty Insurance Group" on Justia Law

Defendant-appellant Christopher Klick was seriously injured after suffering carbon monoxide poisoning while aboard a friend’s fishing boat. An exhaust pipe had broken off at the spot where it connected with the engine. As a result, the engine had been expelling carbon monoxide gas into the engine compartment rather than through the exhaust pipe and out behind the boat. When the engine compartment hatch from within the wheelhouse was opened, carbon monoxide flowed up into the wheelhouse. Klick quickly lost consciousness and fell into the engine compartment. He awoke there several hours later, severely burned from lying on the engine. He also suffered brain damage from the carbon monoxide. The gas killed the boat’s two other occupants, but Klick survived. Klick sued the boat dealer in state court. The dealer had an insurance policy from Travelers Property Casualty Company of America that required Travelers to pay for liabilities resulting from bodily injury. The policy, however, had a pollution exclusion providing that the policy did not cover liability for injuries arising out of the release, dispersal, or migration of certain pollutants. Travelers sued in federal court, seeking a declaration that the policy did not cover liability for Klick’s injuries. The district court granted summary judgment for Travelers. We conclude that the pollution exclusion applies, and we therefore affirm. View "Travelers Property Casualty v. Klick" on Justia Law

This case concerned defects in the execution of two life insurance annuity polices that the decedent purchased through National Western Life Insurance Co. Plaintiffs, the decedent’s wife and children, sued National Western seeking a declaration that the policies were void and a return of the premiums paid by the decedent. National Western filed a motion to dismiss because Plaintiffs failed to join a necessary party - the decedent’s brother, who was named under both policies as the sole beneficiary - even though National Western had already paid him. The district court denied the motion, ruling that the beneficiary at issue was not “required to be joined if feasible” under Fed. R. Civ. P. 19(a). The court then granted summary judgment for Plaintiffs. The First Circuit vacated the judgment of the district court, holding that the sole beneficiary of the annuities was required to be joined if feasible under rule 19(a). The court remanded the case to the district court to determine whether it was equitable for the case to proceed without him. View "Maldonado-Vinas v. National Western Life Insurance Co." on Justia Law

Ashley Palmer (Palmer) and Stephen Palmer appealed a district court’s order granting Lisa Ellefson’s motion for a new trial under Idaho Rule of Civil Procedure 59(a)(6). Ellefson was involved in an automobile accident caused by Palmer. A jury found that Ellefson was not injured in the accident. However, the district court determined that the jury verdict of “no injury” was against the clear weight of evidence and granted a new trial subject to an additur in the amount of $50,000. On appeal, Palmer argued that the district court abused its discretion in granting the new trial and in setting additur at $50,000. Finding no such error, the Idaho Supreme Court affirmed. View "Ellefson v. Palmer" on Justia Law

Laser Line Construction Company, LLC,(“Laser Line”) purchased statutory workers’ compensation insurance coverage from the Builders and Contractors Association of Mississippi (“BCAM”) Self Insurers’ Fund. Because Laser Line was a general contractor, BCAM sought premium payments for all employees of Laser Line’s subcontractors who did not independently secure workers’ compensation coverage. Laser Line refused to pay premiums for employees of subcontractors who had fewer than five employees and claimed they were thus exempt from the coverage requirement. BCAM canceled Laser Line’s coverage for nonpayment. Laser Line filed suit for damages and a declaratory judgment. The defendants answered, and BCAM separately filed a counterclaim. The parties filed competing summary judgment motions. The trial court granted Laser Line a partial summary judgment on the statutory interpretation issue. BCAM sought and was granted permission to file an interlocutory appeal. Mississippi Code Section 71-3-7 required general contractors secure workers’ compensation coverage for the employees of its uninsured subcontractors; the Mississippi Supreme Court found consistent with the unambiguous language of the statute and its own prior opinions, the number of employees of the subcontractor was not a factor in determining general-contractor liability under the Act. Thus, the trial judge’s contrary ruling was in error. View "Builders & Contractors Association of Mississippi, v. Laser Line Construction Company, LLC" on Justia Law

In this declaratory judgment proceeding, petitioner Exeter Hospital, Inc. (Exeter) appealed a superior court order denying its motion for partial summary judgment as to the amount at which coverage was triggered under an umbrella policy (the policy) issued to Exeter by respondent Steadfast Insurance Company (Steadfast). In the spring of 2012, an outbreak of Hepatitis C infections among patients serviced by Exeter’s cardiac catheterization lab led investigators to discover that a technician had spread the virus to patients “through a clandestine drug diversion scheme.” The technician allegedly injected certain drugs into his body by way of intravenous needles, then reused the needles on patients, thereby infecting them with the virus. Numerous lawsuits were lodged against Exeter by affected patients. Exeter was primarily insured through a Self-Insurance Trust Agreement (SIT), which provided professional liability coverage in the amount of $1 million per medical incident, with a $4 million annual aggregate cap. Exeter also maintained the policy with Steadfast, which provided excess health care professional liability coverage. Steadfast maintained that it would pay damages only in excess of the $100,000 retained limit for each medical incident. Exeter filed this proceeding, seeking a declaration that it was not required to pay $100,000 retained limit per claim. The trial court interpreted the term “applicable underlying limit” as being a variable amount “dependent on the actual coverage remaining under [the] other [limits of] insurance,” here, the limits of the SIT. Because Exeter had paid out the limits of the SIT, the court found that the “applicable underlying limit” was zero, thereby rendering the $100,000 retained limit greater than the “applicable underlying limit.” Thus, the court determined that, pursuant to “Coverage A,” Steadfast was required “to pay damages in excess of $100,000 for each medical incident.” Exeter sought reconsideration of the court’s order, which the court denied. Although the New Hampshire Supreme Court did not agree with every underlying argument pressed by Exeter, it concluded that its overall argument regarding the interpretation of Coverage A was reasonable, and the trial court therefore erred in granting partial summary judgment as to the terms of Coverage A. View "Exeter Hospital, Inc. v. Steadfast Insurance Company" on Justia Law

Plaintiff-appellee Elizabeth Cates filed on her behalf and a putative class asserting claims against the defendant-appellee INTEGRIS Health, Inc. for breach of contract, violation of the Oklahoma Consumer Protection Act, deceit, specific performance, and punitive damages. INTEGRIS successfully moved to dismiss the claims based on the ground that they are all preempted by the Employee Retirement Income Security Act. Cates appealed. Because the trial court in this matter did not take into consideration the federal Tenth Circuit Court of Appeals’ decision in Salzer v. SSM Health Care of Oklahoma Inc., 762 F.3d 1130 (10th Cir. 2014), which was factually similar to the facts of this case and found that the plaintiff’s claims were not preempted, the Oklahoma Supreme Court reversed and remanded the trial court in this matter for reconsideration in light of Salzer. View "Cates v. Integris Health, Inc." on Justia Law

Plaintiff Carmen Zubillaga was injured in an automobile accident. The other driver was at fault. Her insurer, defendant Allstate Indemnity Company (Allstate), rejected her demand for $35,000, the full amount of her remaining underinsured motorist (UIM) coverage, although it made her a series of offers increasing to $15,584 instead. After an arbitrator awarded plaintiff $35,000, the amount of her demand, she sued Allstate for breach of the implied covenant of good faith and fair dealing. While an insurance company has no obligation under the implied covenant of good faith to pay every claim its insured makes, the insurer cannot deny the claim, without fully investigating the grounds for its denial. To protect its insured’s contractual interest in security and peace of mind, it is essential that an insurer fully inquire into possible bases that might support the insured’s claim before denying it. The Court of Appeal found the problem in this case was that the undisputed facts showed the insurer’s opinions were rendered in October and November 2012, but insurer continued to rely on them through the arbitration in September 2013, without ever consulting with its expert again or conducting any further investigation. Summary judgment in favor of the insurer was reversed and the matter remanded for further proceedings. View "Zubillaga v. Allstate Indemnity Company" on Justia Law

Homeowners sued Builder for failing to construct their home in a good and workmanlike manner. Builder’s commercial general liability insurer (Insurer) refused to defend Builder in the suit. Judgment was granted in favor of Homeowners after a trial, and Builder assigned the majority of its claims against Insurer to Homeowners. Homeowners subsequently sought to recover the judgment from Insurer under the applicable policy. The trial court entered judgment in favor of Homeowners. The court of appeals affirmed. The Supreme Court reversed and, in the interests of justice, remanded the case to the trial court for a new trial, holding (1) the judgment against Builder was not binding on Insurer in this suit because it was not the product of a fully adversarial proceeding; but (2) this insurance litigation may serve to determine Insurer’s liability, although the parties in the case focused on other issues during the trial. View "Great American Insurance Co. v. Hamel" on Justia Law