Justia Insurance Law Opinion Summaries

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

Bridgeview Health Care Center filed a class action complaint against Clark, an Illinois resident who operates Affordable Digital Hearing, a sole proprietorship out of Terre Haute, Indiana. Bridgeview alleged that Clark sent Bridgeview and others unsolicited faxes and claimed violation of the Telephone Consumer Protection Act of 1991, 47 U.S.C. 227; common law conversion of its fax paper and toner; and violation of the Consumer Fraud and Deceptive Business Practices Act, 815 ILCS 505/2. Clark had a comprehensive general liability policy issued by State Farm, an Illinois corporation. The policy was purchased through an Indiana agent and issued to Clark’s Indiana business address. State Farm sought declaratory judgment that it had no duty to defend in Indiana state court. The action was dismissed for lack of personal jurisdiction over Bridgeview. Bridgeview sought a declaration, in Illinois state court that State Farm had a duty to defend and indemnify Clark under the advertising injury and property damage provisions of the policy. State Farm argued that Illinois law conflicts with Indiana law on coverage issues and that Indiana law should apply. The circuit court found that there was no conflict and no need to conduct a choice-of-law analysis. The appellate court reversed, finding that decisions cited by State Farm were sufficient to raise the possibility of a conflict, requiring a choice-of-law analysis The Illinois Supreme Court reversed, finding that State Farm failed to meet its burden of demonstrating that an actual conflict exists between Illinois and Indiana law.View "Bridgeview Health Care Ctr., Ltd. v. State Farm Fire & Cas. Co." on Justia Law

Plaintiffs challenged an insurance company's use of "retained asset accounts" (RAAs) as a method of paying life insurance benefits in the ERISA context. They presented the district court with two basic questions: (1) whether the insurer's method of paying death benefits in the form of RAAs constitute self-dealing in plan assets in violation of ERISA section 406(b); and (2) whether this redemption method offended the insurer's duty of loyalty toward the class of beneficiaries in violation of ERISA section 404(a). The district court answered the first question in favor of the insurer and the second in favor of the plaintiff class. The court then awarded class-wide relief totaling more than $12,000,000. Both sides appealed. Upon review, the First Circuit Court of Appeals agreed with the district court that the insurer's use of RAAs in this case did not constitute self-dealing in plan assets. However, the Court disagreed with the district court's answer to the second question and held that the insurer's use of RAAs did not breach any duty of loyalty owed by the insurer to the plaintiff class. View "Merrimon, et al v. Unum Life Insurance Company" on Justia Law

Nationwide Retirement Solutions, Inc. ("NRS"), appealed a circuit court judgment awarding PEBCO,Inc. over a million dollars in attorney fees and $29,132.01 in expenses. In 2007, participants in the State of Alabama Public Employees Deferred Compensation Plan filed a class action against Nationwide Life Insurance Company ("NL"), NRS, the Alabama State Employees Association ("ASEA"), and PEBCO, Inc., alleging breach of fiduciary duty, conversion, and breach of contract in the administration of the Plan. The parties filed a "Stipulation of Settlement," which the trial court approved in its final order entered in 2011. Pursuant to the settlement, NL and NRS paid $15.5 million to the participants in the Plan and $2.9 million in attorney fees to settle class claims against all defendants, including ASEA and PEBCO. In its findings of fact, the trial court stated: "ASEA is being permitted to retain more than $12 million in sponsorship payments that it allegedly received unlawfully, and ASEA is receiving full release from any liability." A day before the parties filed their "Stipulation of Settlement," Nationwide moved for an order barring ASEA and PEBCO from filing any indemnification claims. The trial court granted the order except for claims for attorney fees and costs. "[I]n light of Nationwide's substantial contributions to the settlement," the court wrote that it was "fair and reasonable that ASEA and PEBCO be barred from pursuing any claims against Nationwide for reimbursement, indemnification, or contribution other than claims for attorney fees and costs ...." A month before entering its final order in the class action, the trial court ordered severance of ASEA and PEBCO's claim for fees and directed the Circuit Court clerk to docket that claim as "a separate and independent action," with ASEA and PEBCO as plaintiffs and NL and NRS as defendants. The trial court found that the indemnification clause in the agreement required that NRS pay the fees and costs incurred by ASEA and PEBCO in defending the class action. Noting that NRS "has contended, and still contends, that indemnification is improper based on the language of the agreement and the attending facts," the trial court stated that it "has held hearings on that issue and by prior order has ruled that indemnification is appropriate. The instant action was filed to enforce indemnification." The court ordered NRS to pay PEBCO $863,988.50 in attorney fees and $15,297.54 in expenses for the class-action litigation, and $210,039 in attorney fees and $13,834.47 in expenses for litigating the severed cross-claim. NRS timely appealed that decision to the Supreme Court. The Supreme Court reversed and remanded: "[b]ecause NRS did not fail to perform those duties under the agreement that ultimately gave rise to the class action, it did not, as a matter of law, breach the indemnification clause in the agreement. . . . Alabama does not permit a party to seek indemnification for defending against its own allegedly wrongful acts." View "Nationwide Retirement Solutions, Inc. v. PEBCO,Inc. " on Justia Law

The State filed a class action suit against several insurers to recover on the homeowner insurance policies purchased by individual Louisiana citizens but assigned by the respective policy holders to the State in return for State financial assistance in repairing and rebuilding their homes in the wake of the hurricanes. Defendants removed to federal court. The State eventually dropped its class allegations and severed this individual action from the original class action case. At issue was whether there was federal jurisdiction over these individual cases, once part of the Class Action Fairness Act (CAFA), 28 U.S.C. 1332(d)(2), class action. The court held that the general rule regarding federal jurisdiction over a removed case controlled; jurisdictional facts were determined at the time of removal, not by subsequent events; because at the time of removal CAFA supplied federal subject matter jurisdiction over these cases, the court held that CAFA continued to provide jurisdiction over these individual cases notwithstanding their severance from the class. View "State of Louisiana v. American National Property and Casualty Co., et al." on Justia Law

Plaintiff was injured in an accident while driving a business vehicle owned by Mattress King, Inc. and insured by Mountain West Farm Bureau. Plaintiff, whose personal vehicles were insured by Safeco Insurance Company of Illinois, filed a claim with Safeco for medical payment benefits. Plaintiff received medical payment benefits from Safeco and an undisclosed amount of underinsured motorist benefits from Mountain West. Believing Safeco wrongfully refused to pay additional claimed benefits, Plaintiff brought a class action suit against Safeco. The district court ultimately ruled in favor of Safeco. The Supreme Court affirmed, holding that the “other insurance” clauses in Plaintiff’s automobile liability policy were valid and, as applied in this case, did not constitute de facto subrogation. View "Scheafer v. Safeco Ins. Co. of Ill." on Justia Law