Justia Insurance Law Opinion Summaries

Plaintiff-appellant Richard Salzer received medical care at an SSM Healthcare of Oklahoma (SSM) facility for injuries he sustained in an accident. At the time of his treatment, he had a health insurance plan (the "Plan"). Salzer entered into a contract with SSM to receive its services (the "Hospital Services Agreement"), under which he "authorized disclosure of [his] medical information for billing purposes and authorized [his] health insurance company to pay." SSM had an existing contract with Salzer's health insurance company (the "Provider Agreement") which required SSM to submit covered medical charges to Salzer's insurance company and accept discounted payment from the insurer. Although the Provider Agreement prohibited SSM from seeking payment for a covered charge from Salzer, SSM sought the non-discounted amount directly from him. Salzer sued SSM alleging breach of contract and other state law claims based on SSM's attempt to collect payment for medical care from Salzer instead of his health insurance company. SSM removed the case to federal district court. Salzer challenged the district court's denial of his motion to remand based on its determination that his claims were completely preempted by the Employee Retirement Income Security Act of 1974 (ERISA). Finding no reversible error, the Tenth Circuit affirmed the district court. View "Salzer v. SSM Health Care of Oklahoma" on Justia Law

The district court entered summary judgment relieving Kentucky Farm Bureau Mutual Insurance of its duty to defend Elk Glenn against certain breach of contract and related claims arising from the sale of a residential lot. The Sixth Circuit dismissed an appeal. A certification to appeal under Rule 54(b) requires the district court to determine that there is no just reason for delay, which requires the district court to balance the needs of the parties against the interests of efficient case management. The district court’s only reason supporting immediate appeal was the “real prejudice” Kentucky Farm Bureau would suffer. That reference, without further explication, does not provide reasoning supporting the necessity of immediate review. Without proper certification for an interlocutory appeal under Rule 54(b), an order disposing of fewer than all claims in a civil action is not immediately appealable. The Sixth Circuit declined to order the district court to make the necessary findings supporting jurisdiction. View "Adler v. Elk Glenn, LLC" on Justia Law

The Patient Protection and Affordable Care Act, 42 U.S.C. 18002, provides $5 billion to reimburse employers and their proxies for outlays on early retirees’ medical care. WEA, which administers health-care programs on behalf of Wisconsin school districts, told them that it would collect on their behalf. It decided to use the money to reduce future premiums. The school districts claim that WEA should have rebated premiums for the years in which the retirees received the medical care that led to the federal payments. The difference matters to school districts that want to switch carriers. WEA’s plan to cut future rates, rather than provide rebates, gave it a competitive advantage. Districts filed suit, characterizing WEA’s choice to allocate no money to districts, that switch carriers as a form of conversion. All of the claims arise under state law and all litigants are citizens of Wisconsin. WEA removed to federal court, contending that the Act and its implementing regulations are the crux of the litigation. The Seventh Circuit ordered the case returned to state court, reasoning that the suit does not necessarily raise any issue of federal law and that the McCarran-Ferguson Act, 15 U.S.C. 1011–15, gives states preeminence in the domain of insurance regulation. View "Hartland Lakeside Joint No. 3 Sch. Dist. v. WEA Ins. Corp." on Justia Law

In this insurance coverage dispute, the driver involved in an accident filed a claim with the Insurer of the other vehicle involved in the accident. The Insurer denied the claim. The Office of the Insurance Commissioner reviewed the denial and ordered the Insurer to adjust and resolve the claim. The Insurer did not file an appeal and instead filed a complaint for declaratory and injunctive relief in the federal district court. The district court dismissed the federal court action on res judicata grounds. The First Circuit Court of Appeals affirmed, holding that res judicata barred this action and no exceptions to res judicata applied. View "Universal Ins. Co. v. Office of the Ins. Comm'r" on Justia Law

Plaintiff filed a class action suit in an Illinois circuit court against Ernida, LLC alleging that Ernida had faxed unsolicited advertisements to Plaintiff and more than thirty-nine other recipients without first obtaining their permission. Ernida’s insurer, American Economy Insurance Company (American), took up Ernida’s defense in Illinois. While the Illinois action was ongoing, Plaintiff filed suit in federal district court against American, asserting diversity jurisdiction and seeking a declaration that American had a duty to defend Ernida in the Illinois action and had a responsibility to indemnify and pay any judgment in that action. The district court granted American’s motion to dismiss, concluding that Plaintiff had not presented a justiciable controversy. On appeal, American claimed that Plaintiff’s claim did not meet the amount-in-controversy requirement for diversity jurisdiction since Plaintiff had expressly waived any right to recover anything over $75,000 in its Illinois complaint. The First Circuit Court of Appeals vacated the district court’s order dismissing the case for lack of standing and remanded with instructions to dismiss for lack of subject-matter jurisdiction, as the matter in controversy did not not exceed the sum or value of $75,000. View "CE Design, Ltd. v. Am. Economy Ins. Co." on Justia Law

This appeal arose from an insurance coverage dispute concerning an industrial accident that occurred on a decommissioned platform in the Outer Continental Shelf. The key issue on appeal was whether the district court entirely disposed of any one claim against Continental. The court need not conclusively determine whether Tetra and Maritech have asserted one claim or two against Continental because, even if the court were to construe their request for a declaration on Continental's indemnity obligations as a single claim, it was clear that the district court did not fully dispose of that one claim. Accordingly, the court dismissed for want of jurisdiction. View "Tetra Technologies, Inc., et al. v. Vertex Services, L.L.C." on Justia Law

Pyramid Tech filed suit against its insurer, alleging express breach of contract and breach of the implied covenant of good faith. Without holding a Daubert hearing, the district court excluded Pyramid Tech's expert witnesses and granted summary judgment to the insurer, finding insufficient evidence that a flood caused damage to Pyramid Tech's property. The court held that, after an expert establishes admissibility to the judge's satisfaction, challenges that go to the weight of the evidence are within the province of a fact finder, not a trial court judge. A district court should not make credibility determinations that are reserved for the jury. In this instance, the district court abused its discretion in excluding the expert evidence of David Spiegel and Ken Pytlewski, but did not abuse its discretion in excluding the expert evidence of Del Mortenson. The district court erred in granting summary judgment against Pyramid Tech's claims where genuine issues of material fact existed as to whether the insurer breached its contract with Pyramid Tech and breached the implied covenant of good faith. However, to the extent such claims were premised on Pyramid Tech's business interruption theory, no material issues of fact existed and the district court did not err in granting summary judgment against that theory of liability. Accordingly, the court affirmed in part, reversed in part, and remanded for retrial. View "Pyramid Tech. v. Allied Public Adjusters" on Justia Law

Plaintiff sought to enforce against Allied a tort judgment she received against a person Allied insured. Plaintiff initially filed suit in state court and Allied removed based on diversity jurisdiction. On appeal, plaintiff contended that the district court erred in denying her motion to remand to state court. The court concluded that the district court properly denied plaintiff's motion to remand because her claim against Allied was not a direct action within the meaning of 28 U.S.C. 1332(c). The court found no error in the district court's order compelling arbitration. Accordingly, the court affirmed the judgment of the district court. View "Kong v. Allied Professional Ins. Co." on Justia Law

Dozens of suits were filed against Irving Oil Limited (IOL) alleging environmental contamination by methyl tertiary butyl ether (MTBE) occurring from 1979 to the present. At the time of this opinion, all of the MTBE suits against IOL had been settled. In 2009, IOL filed a complaint asking the superior court to declare that ACE INA Insurance (ACE) had a duty to defend and indemnify in the MTBE suits. The superior court granted IOL’s motion for summary judgment in part and denied it in part, concluding that it could not declare that IOL was entitled a judgment on the duty-to-defend count as a matter of law. IOL appealed. The Supreme Court dismissed IOL’s appeal and ACE’s cross-appeal, holding that although a decision that an insurer does not have a duty to defend its insured is ordinarily immediately appealable under the death knell exception to the final judgment rule, the exception did not apply in this case because there were no MTBE cases pending against IOL. View "Irving Oil Ltd. et al. v. ACE INA Ins." on Justia Law

Respondent-claimant, Ben Snell was employed by petitioner-employer Kentucky Fried Chicken of McAlester. He alleged that while at work he slipped and fell while carrying a tray of chicken weighing approximately 40 to 50 pounds. The trial court awarded claimant temporary total disability (TTD) and reasonable and necessary medical treatment for injuries to his neck, the second finger of his right hand, and aggravation of pre-existing conditions to his left knee and low back. All other issues were reserved. On appeal, the Court of Civil Appeals (COCA) sustained the award. In its opinion, COCA ruled the standard of review in this case was the "any competent evidence" standard because of a holding in a previous opinion by the same division, "Westoak Industries, Inc. v. DeLeon," which held 85 O.S. 2011 sec. 340(D)(4), setting out "against the clear weight of the evidence" as the appellate standard of review in workers' compensation cases, constituted a violation of the separation of powers provision of the Oklahoma Constitution. Westoak was completely at odds with another COCA opinion, "Harvey v. Auto Plus of Woodward." "Harvey" held section 340(D)(4) was not unconstitutional as a separation of powers violation. The Supreme Court granted certiorari to consider the issue as one of first impression since certiorari was not sought in either of the previous cases. The Court concluded that there was no constitutional separation of powers prohibition in in the Okla.Const., art IV, section 1 against the Legislature's adoption of the "against the clear weight of the evidence" standard of review in 85 O.S. 2011 sec. 340(D)(4). COCA's opinion was therefore vacated. Because "Westoak" and "Harvey" were totally inconsistent with the views expressed in this opinion, they were both specifically overruled. View "Kentucky Fried Chicken of McAlester v. Snell" on Justia Law