Justia Insurance Law Opinion Summaries

In 1998, a driver hit pedestrian-plaintiff Roberta Folks with the side mirror of his vehicle and injured her. State Farm, the driver’s insurer, informed Folks she could receive basic personal injury protection (“PIP”) benefits under the driver’s policy. She received $104,000 in medical expenses and essential services. In 2002, State Farm told her she had exhausted the benefits available to her under the policy. Folks subsequently joined a lawsuit seeking additional PIP benefits in 2004. Over the course of the litigation, Folks unsuccessfully sought to certify a class on three attempts. In response to her last attempt in 2011, the district court determined she failed to satisfy the requirements of Rule 23(a) and Rule 23(b)(2) and denied class certification. A jury heard Folks’s individual claims and found in her favor in 2012. The district court amended the judgment in 2013 to correct errors in the calculation of damages. On appeal, Folks alleged the district court erred in denying class certification. She also argued the district court miscalculated the treble damages and statutory prejudgment interest to which she is entitled. Finding no error, the Tenth Circuit affirmed. View "Folks v. State Farm Mutual" on Justia Law

From 1998 to 2012 Abbott marketed the anticonvulsant medication Depakote for applications that had not been FDA-approved (off-label uses). Physicians may prescribe drugs for off-label uses, but pharmaceutical companies are generally prohibited from marketing drugs for those same applications. Qui tam actions were filed under the False Claims Act. In 2009, Abbott disclosed in an SEC filing that the Department of Justice was investigating its marketing. Abbott pleaded guilty to illegally promoting Depakote from 2001 through 2006 and agreed to pay $1.6 billion to settle the criminal and qui tam actions. Employee benefits funds filed suit 15 months later, alleging that Abbott misrepresented Depakote’s safety and efficacy for off-label uses, paid kickbacks to physicians, established and funded intermediary entities to promote the drug for off-label uses, and concealed its role in these activities, in violation of the Racketeer Influenced and Corrupt Organizations Act. The district court dismissed, finding that the statute of limitations for the RICO claim began to run in 1998, when the funds initially reimbursed a prescription for off-label use. The court refused to toll the limitations period until the guilty plea, finding that Abbott’s concealment efforts were not designed to hinder potential lawsuits. The Seventh Circuit reversed, finding that dismissal was premature without an opportunity for discovery into when a reasonable fund should have known about its injuries from off-label marketing. View "Sidney Hillman Health Ctr. of Rochester v. Abbott Labs., Inc." on Justia Law

Baldwin Mutual Insurance Company appealed a circuit court order certifying the action filed against it by Gloria McCain as a class action. McCain owned a house in Montgomery on which she held a homeowner's insurance policy issued by Baldwin Mutual. That policy provided that any covered property losses would be settled "at actual cash value at the time of loss but not exceeding the amount necessary to repair or replace the damaged property." In July 2005, McCain's house was damaged as the result of a windstorm. She filed a claim with Baldwin Mutual, and Baldwin Mutual thereafter retained an independent adjuster to examine McCain's damaged property and to prepare an estimate to repair the damage. Baldwin Mutual paid McCain's claim in accordance with the estimate prepared by the adjuster. Pursuant to a work-authorization form signed by McCain, Baldwin Mutual paid the funds directly to McCain's contractor. In June 2006, McCain filed another claim after her house suffered damage as a result of a lightning strike. After the same adjuster prepared an estimate, Baldwin Mutual paid the new claim in accordance with the adjuster's estimate. The genesis of the claims underlying this suit was that Baldwin Mutual had wrongfully been reducing the amount paid on claims made on actual-cash-value polices inasmuch as its practice was to deduct some amount for depreciation not only of the damaged materials and the labor costs of initially installing those damaged materials (based on their condition prior to the covered damage and their expected life span), but also of the labor costs associated with the removal of the damaged materials. It was improper and impossible to depreciate those labor costs, McCain argued, because they had not previously been incurred at some defined time in the past; rather, they were being incurred at the time of the current repair. Noting that hundreds or thousands of Baldwin Mutual policyholders were likely negatively affected by Baldwin Mutual's practices in this regard, McCain sought class action certification of her claims. The Alabama Supreme Court reversed the class certification, finding that the trial court here exceeded its discretion with a definition proposed by McCain without giving Baldwin Mutual the opportunity to oppose the certification of the proposed class at a hearing conducted for that purpose pursuant to statute. The case was remanded for further proceedings. View "Baldwin Mutual Ins. Co. v. McCain" on Justia Law

Judon was injured while riding in a commercial passenger vehicle that was insured by Travelers. Judon sought first-party medical benefits of $7,636.40. Travelers paid $5,000, up to the policy’s first-party medical benefits limit. Judon filed a class-action complaint in state court, alleging that Pennsylvania law required that the policy offer up to $25,000 in first-party medical benefits. Judon alleged that “there are hundreds of members of the class” who were wrongfully denied payment of first-party benefits. Travelers removed to federal court, under the Class Action Fairness Act (CAFA), 28 U.S.C. 1332(d), 1453, arguing that the parties were minimally diverse; the proposed class consisted of at least 100 putative members; and the amount in controversy exceeded $5,000,000. The district court remanded, finding that CAFA’s numerosity and amount-in- controversy requirements were disputed and placing the burden of proof on Travelers to establish jurisdiction. The Third Circuit affirmed in part and vacated in part. Judon’s complaint unambiguously pleaded that the numerosity requirement was satisfied, so the court should have placed the burden of proof on Judon to show, to a legal certainty, that the numerosity requirement was not satisfied. The court correctly applied the preponderance of the evidence standard to the amount-in-controversy requirement. View "Judon v. Travelers Prop. Cas. Co. of Am." on Justia Law

Accretive provides cost control, revenue cycle management, and compliance services to non-profit healthcare providers. Accretive and Fairview entered into a Revenue Cycle Operations Agreement (RCA), accounting for about 12% of Accretive’s revenue during the class period, and a Quality and Total Cost of Care (QTCC) contract, promoted as the future for healthcare services. In 2012, the Minnesota Attorney General sued Accretive for noncompliance with healthcare, debt collection, and consumer protection laws. Accretive wound down its RCA contract short of its term, expecting a loss of $62 to $68 million. The AG released a damaging report on Accretive’s business practices. Fairview cancelled its QTCC contract. Accretive’s stock fell from over $24 to under $10 per share. Plaintiffs filed a class action under Sections 10(b) and 20(a) of the Securities Exchange Act of 1934, alleging that Accretive concealed its practices to artificially inflate its common stock. The parties negotiated a settlement of $14 million: $0.20 per share ($0.14 with attorneys’ fees and expenses deducted). Notice was sent to 34,200 potential class members. Only one opted out; only Hayes filed an objection. At the fairness hearing, the district court granted approval, awarding attorneys’ fees of 30% and expenses of $63,911.14. Hayes did not attend. The Seventh Circuit affirmed. View "Hayes v. Accretive Health, Inc." on Justia Law

Plaintiffs Brett Woods and Kathleen Valdes were state employees and representatives of a class of New Mexico state and local government employees who alleged they paid for insurance coverage through payroll deductions and premiums pursuant to a policy issued by Standard Insurance Company (Standard), but did not receive the coverage for which they paid and, in some cases, were denied coverage entirely. Plaintiffs filed suit in New Mexico state court against three defendants: Standard, an Oregon company that agreed to provide the subject insurance coverage; the Risk Management Division of the New Mexico General Services Department (the Division), the state agency that contracted with Standard and was responsible for administering benefits under the policy; and Standard employee Martha Quintana, who Plaintiffs allege was responsible for managing the Division’s account with Standard and for providing account management and customer service to the Division and state employees. Plaintiffs' ninety-one-paragraph complaint, stated causes of action against Standard and the Division for breach of contract and unjust enrichment; against Standard for breach of fiduciary duty, breach of the implied duty of good faith and fair dealing, and Unfair Practices Act violations; and against Standard and Ms. Quintana for breach of the New Mexico Trade Practices and Fraud Act. The issue this appeal presented for the Tenth Circuit's review centered on whether remand to the state court pursuant to the Class Action Fairness Act (CAFA) was required under either of two CAFA provisions: the state action provision, which excludes from federal jurisdiction cases in which the primary defendants are states; or the local controversy exception, which requires federal courts to decline jurisdiction where, among other things, there is a local defendant whose alleged conduct forms a significant basis for the claims asserted by plaintiffs and from whom plaintiffs seek significant relief. The Court concluded that neither provision provided a basis for remand, and therefore reversed the decision of the magistrate judge remanding the case to state court. But because the Tenth Circuit could not determine whether Defendants have established the amount in controversy required to confer federal jurisdiction, the case was remanded to the district court for the resolution of that issue. View "Woods v. Standard Insurance Co." on Justia Law

Illinois insurance regulators permitted WellPoint to acquire RightCHOICE health insurance. WellPoint caused RightCHOICE Insurance to withdraw from the Illinois market. WellPoint offered the policyholders costlier UniCare policies as substitutes. Those who chose not to pay the higher premiums had to shop for policies from different insurers, which generally declined to cover pre-existing conditions. Former RightCHOICE policyholders filed a purported class action. The district court declined to certify a class and entered judgment against plaintiffs on the merits. No one appealed. Absent certification as a class action, the judgment bound only the named plaintiffs. Their law firm found other former policyholders and sued in state court. Defendants removed the suit under 28 U.S.C. 1453 (Class Action Fairness Act); the proposed class had at least 100 members, the amount in controversy exceeded $5 million, and at least one class member had citizenship different from at least one defendant. Plaintiffs sought remand under section 1332(d)(4), which says that the court shall “decline to exercise” jurisdiction if at least two-thirds of the class’s members are citizens of the state in which the suit began and at least one defendant from which “significant relief” is sought is a citizen of the same state. The district court declined remand, declined to certify a class, and again rejected the case on the merits. The Seventh Circuit affirmed, stating that “Counsel should thank their lucky stars that the district court did not sanction them under 28 U.S.C. 1927 for filing a second suit rather than pursuing the first through appeal."View "Phillips v. Wellpoint Inc." on Justia Law

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 Louisiana Supreme Court granted this writ application to determine whether a plaintiff had a private right of action for damages against a health care provider under the Health Care and Consumer Billing and Disclosure Protection Act. Plaintiff Yana Anderson alleged that she was injured in an automobile accident caused by a third party. She received medical treatment at an Ochsner facility. Anderson was insured by UnitedHealthcare. Pursuant to her insurance contract, Anderson paid premiums to UnitedHealthcare in exchange for discounted health care rates. These reduced rates were available pursuant to a member provider agreement, wherein UnitedHealthcare contracted with Ochsner to secure discounted charges for its insureds. Anderson presented proof of insurance to Ochsner in order for her claims to be submitted to UnitedHealthcare for payment on the agreed upon reduced rate. However, Ochsner refused to file a claim with her insurer. Instead, Ochsner sent a letter to Anderson’s attorney, asserting a medical lien for the full amount of undiscounted charges on any tort recovery Anderson received for the underlying automobile accident. Anderson filed a putative class action against Ochsner, seeking, among other things, damages arising from Ochsner’s billing practices. Upon review of the matter, the Supreme Court found the legislature intended to allow a private right of action under the statute. Additionally, the Court found an express right of action was available under La. R.S. 22:1874(B) based on the assertion of a medical lien. View "Anderson v. Ochsner Health System" on Justia Law

A putative class action was filed against West Calcasieu Cameron Hospital for alleged violations of La. R.S. 22:1874, also known as the "Balance Billing Act." This case was expanded to name several health insurance issuers as defendants. The claim under review by the Louisiana Supreme Court was asserted by plaintiff Laura Delouche against her insurer, Louisiana Health Service & Indemnity Company, d/b/a Blue Cross and Blue Shield of Louisiana (Blue Cross). The Supreme Court granted certiorari to determine whether a cause of action existed, whereby Delouche could pursue a legal remedy against Blue Cross. Finding no cause of action, and no reversible error in the trial court's decision, the Supreme Court affirmed. View "Emigh v. West Calcasieu Cameron Hospital" on Justia Law