Justia Insurance Law Opinion Summaries

KCC, Inc., d/b/a Vital Care of Meridian (Vital Care) filed a complaint against the Mississippi State and School Employees' Life and Health Plan ("the Plan") and the Plan’s pharmacy benefits manager, Catalyst Rx, alleging that the Plan and Catalyst had violated Mississippi Code Section 83-9-6 by designating Walgreens Pharmacy as the sole provider of specialty pharmacy services. Later, Vital Care moved for partial summary judgment on the question of whether Section 83-9-6 applied to the Plan. The Chancery Court granted Vital Care’s motion for partial summary judgment, and the Plan and Catalyst appealed. Upon review of the applicable statute, the Supreme Court found that Section 83-9-6 applied to the Plan because it applies to "all health benefit plans providing pharmaceutical services benefits, including prescription drugs, to any resident of Mississippi" and was not ambiguous. View "Mississippi State & School Employees' Life and Health Plan v. KCC, Inc." on Justia Law

Steven Pham represented the estate of a driver of a car involved in a traffic accident. He appealed (along with the driver's parents and the five passengers in the car at the time of the accident) the court of appeals' judgment which affirmed summary judgment in favor of the insurer, State Farm, on the grounds that plaintiffs' claims were bound by the statute of limitations governing underinsured motorist claims. Upon review, the Supreme Court found that plaintiffs failed to file their action or demand arbitration of their underinsured motorist claims within either three years of the accrual of their cause or within two years after receiving payment of a settlement or judgment on an underlying bodily injury liability claim preserved as prescribed by the applicable statute. Accordingly, the Supreme Court affirmed the appellate court's decision. View "Pham v. State Farm Auto Ins. Co." on Justia Law

Nationwide Mutual Fire Insurance Company and State Farm Mutual Automobile Insurance Company filed a declaratory-judgment action in the federal district court seeking, among other things, a determination of the status of a settlement agreement they had reached with D.V.G., a minor, resolving her claims for coverage stemming from injuries she received in an automobile accident, following her death in a subsequent unrelated automobile accident. The federal district court ultimately concluded that the issue presented involved a question of Alabama law for which there was no clear controlling precedent, and it certified the following question to the Alabama Supreme Court: "Under Alabama law, is an insurance company bound to a settlement agreement negotiated on behalf of an injured minor, if that minor dies before the scheduling of a pro ami hearing which was intended by both sides to obtain approval of the settlement?" The Court answered in the affirmative: "an insurance company is bound to a settlement agreement negotiated on behalf of an injured minor, even if that minor dies before the scheduling of the court hearing that all parties agreed was necessary to obtain approval of the settlement agreement. In accordance with the parties' understanding, such a hearing is still required, and the minor's death does not render that hearing impossible." View "Nationwide Mutual Insurance Company v. Wood" on Justia Law

Petitioner Bruce Cedell lost his home in a fire. After hearing nothing from his insurer for several months, the company threatened to deny coverage and issued an ultimatum to Petitioner to accept one quarter of what the trial court eventually found Petitioner's claims to be worth. Petitioner brought suit alleging bad faith. The company resisted disclosing its claims file, among other things, and Petitioner moved to compel production. After a hearing and a review of the claims file in camera, the trial court granted Petitioner's motion. On interlocutory review, the Court of Appeals held that the attorney-client privilege applied to a bad faith claim by a first party insured, that the fraud exception to the attorney-client privilege required a showing of actual fraud, and that the trial court erred in reviewing Petitioner's claims file in camera because Petitioner had not made a sufficient prima facie showing of fraud. Upon review, the Supreme Court affirmed in part, reversed in part, and remanded to the trial for further proceedings. "In first party insurance claims by insured's claiming bad faith in the handling and processing of claims, other than UIM claims, there is a presumption of no attorney-client privilege. However, the insurer may assert an attorney-client privilege upon a showing in camera that the attorney was providing counsel to the insurer and not engaged in a quasi-fiduciary function. Upon such a showing, the insured may be entitled to pierce the attorney-client privilege. If the civil fraud exception is asserted, the court must engage in a two-step process. First, upon a showing that a reasonable person would have a reasonable belief that an act of bad faith has occurred, the trial court will perform an in camera review of the claimed privileged materials. Second, after in camera review and upon a finding there is a foundation to permit a claim of bad faith to proceed, the attorney-client privilege shall be deemed to be waived. . . . Cedell is entitled to broad discovery, including, presumptively the entire claims file. The insurer may overcome this presumption by showing in camera its attorney was not engaged in the quasi-fiduciary tasks of investigating and evaluating the claim." View "Cedell v. Farmers Ins. Co. of Wash." on Justia Law

The questions certified to the Supreme Court by the Court of Appeals pursuant to NMSA 1978, Section 34-5-14(C) (1972), required the Court to determine whether the primary or the secondary underinsured motorist (UIM) insurer, if either, should be given the statutory offset for the tortfeasor’s liability coverage. "[T]he short answer to the certified question is that neither the primary nor the secondary insurers are directly awarded the offset because under existing case law, the offset is applied before any UIM insurer is required to pay UIM benefits." View "State Farm v. Safeco Ins. Co." on Justia Law

The issue before the Supreme Court centered on the award of attorney's fees against an insurance company under the peer-review provisions of the Motor Vehicle Financial Responsibility Law (MVFRL). The MVFRL limits the amount providers may charge for treatment, products or services rendered to patients injured in automobile accidents where the injury is covered by an insurance policy. An individual obtained treatment from Appellee Herd Chiropractic Clinic for injuries sustained in a motor vehicle accident. The insurance company submitted the clinic's invoices to a Peer Review Organization (PRO) pursuant to the MVFRL. The PRO determined that certain treatments were not necessary or reasonable, and the insurance company subsequently refused to pay for such treatment The Clinic then sued for unpaid bills, plus treble damages and attorney's fees under the theory that the MVFRL authorized payment. The Common Pleas court found an award of fees proper and mandatory under the MVFRL. The Superior Court affirmed. The Supreme Court, however, reversed, finding that the MVFRL did not allow for what amounted to "fee shifting" by the lower courts' outcome: "We acknowledge [the Clinic's] concerns with the financial incentives in the peer-review industry and with the fact that litigation costs incurred by providers may discourage legitimate challenges. The fee accruals here – in the amount of $27,000 to vindicate a $1380 claim - present a stark example of the difficulty. . . . Nevertheless, fee shifting raises a host of mixed policy considerations in and of itself, which this Court has found are best left to the General Assembly, in the absence of contractual allocation or some other recognized exception to the general, American rule." View "Herd Chiropractic Clinic v. State Farm Mutual Automobile Ins. Co." on Justia Law

A bail bond company challenged the district court's decision affirming an order of the Director of the Idaho Department of Insurance. That order, which was based on I.C. 41-1042, prohibited a bail bond company from contemporaneously writing a bail bond and contracting with a client to indemnify the company for the cost of apprehending a bail jumper. It also prohibited a bail bond company from later requiring a client to agree to such indemnification as a condition of the bond's continuing validity. While the proceedings before the district court were pending, the Director promulgated I.D.A.P.A. 18.01.04.016.02, which by rule expressed the Final Order. Upon review of the applicable statutory authority and the trial court record below, the Supreme Court concluded that: (1) the plain text of I.C. 41-1042 permits a bail bond company to contemporaneously write a bail bond and contract with a client to indemnify the company for the cost of apprehending a defendant who jumps bail; and (2) the Director's interpretation of I.C. 41-1042 prejudiced PetitionerTwo Jinn's substantial rights. The Court reversed the district court's memorandum decision and remanded the case for further review. View "Two Jinn, Inc. v. Idaho Dept of Insurance" on Justia Law

USCA is a non-profit national civic league with approximately 27,000 members that devotes itself to conservative values and opposes efforts of the federal government to interfere with market processes. Some of USCA’s uninsured members object to the purchase of private health insurance because they do not believe in the effectiveness of traditional medicine, prefer alternative and integrative medicine, or prefer to focus on preventative care that is not covered by traditional health insurance policies. Two individual plaintiffs do not have, nor do they wish to acquire, health insurance, but they are not exempt from the Patient Protection and Affordable Care Act’s individual mandate, 26 U.S.C. 5000A. They challenged the mandate as violating the Commerce Clause, rights to freedom of expressive and intimate association, rights to liberty, and rights to privacy. The district court dismissed in part, without substantive analysis, holding that plaintiffs failed to satisfy the “plausibility standard” and entered summary judgment on the Commerce Clause challenge. The Sixth Circuit affirmed, stating that the Supreme Court’s opinion in National Federation of Independent Business v. Sebelius controls the outcome on the Commerce Clause count and the remaining constitutional claims were correctly dismissed for failure to state a claim. View "U.S. Citizens Ass'n v. Sebelius" on Justia Law

Plaintiff filed an action in the U.S. district court against a Maine police officer, alleging that the officer used force in arresting Plaintiff in violation of state and federal law. A jury found the officer liable on Plaintiff's state law negligence claim and awarded Plaintiff $125,000 in damages. The district court amended the judgment to reduce the damages award to $10,000 pursuant to Me. Rev. Stat. 14, 8104-D. Plaintiff appealed to the First Circuit Court of Appeals. The First Circuit certified two questions for the Supreme Court's review. The Court answered only the first question by holding that whether or not an insurance policy is available to cover a judgment against a government employee sued in his personal capacity, the applicable limit on the award of damages is $10,000 pursuant to section 8104-D rather than $400,000 or the policy limit pursuant to Me. Rev. Stat. 14, 8105(1) and 8116. View "Fortin v. Titcomb" on Justia Law

The underlying tort action in this appeal resulted from a car accident in which the insured, while driving a rental truck, hit a person who was lying in the middle of the road. Both the driver and the person struck were intoxicated, in addition to a passenger in the truck. The person who was struck died from his injuries. The victim's estate sued. The insurance company offered to settle the case against both the driver and the passenger (who may have faced liability for his actions after the accident) for policy limits. These offers were rejected. The estate offered to settle for the release of the named insured only, but the insurer rejected that offer. The occupants of the vehicle later settled with the estate. Unable to reach settlement, the insurer filed a declaratory action to clarify its duties under the policy and resolve issues of who was driving the vehicle, the number of occurrences, and possible breaches of the insurance contract by the insureds. The insureds assigned their claims against the insurer to the estate, which answered and counterclaimed for breach of contract and bad faith. The insurer prevailed on nearly all issues. The personal representative of the estate, for herself and as assignee of the insureds, appealed that result. After review, the Supreme Court found that the insurer did not breach its duties to the insured, and accordingly the Court affirmed the superior court's decision. View "Williams v. GEICO" on Justia Law