Justia Insurance Law Opinion Summaries

Gladys Tellis, Sherry Bronson, Gwendolyn Moody, Nadine Ivy, and Uneeda Trammell (collectively, "the policyholders") initiated separate actions against American Bankers Insurance Company of Florida, asserting generally that American Bankers had sold them homeowner's insurance policies providing a level of coverage they could never receive, even in the event of a total loss involving the covered property. American Bankers moved the trial court hearing each action to compel arbitration pursuant to arbitration provisions it alleged were part of the subject policies; however, the trial courts denied those motions, and American Bankers appealed. The Supreme Court consolidated the five appeals for the purpose of writing one opinion, and reversed those orders denying the motions to compel arbitration. The Court based its decision on its holdings that the policyholders manifested their assent to the arbitration provision in their policies by continuing to renew the policies, that the sale of the policies affected interstate commerce, and that the arbitration provision in the policies was not unconscionable. View "American Bankers Ins. Co. of Florida v. Tellis" on Justia Law

Code of Regulations, title 10, section 2695.183 was promulgated in 2010 following complaints by homeowners who lost their residences in wildfires that they did not have enough insurance to cover the full cost of repairing or rebuilding their homes because, when they bought their insurance, the estimates of replacement value were too low. The Regulation prohibits a “licensee” from “communicat[ing] an estimate of replacement cost to an applicant or insured in connection with an application for renewal of a homeowners’ insurance policy that provides coverage on a replacement cost basis” that does not satisfy specific content and format provisions. Noncompliance “constitutes making a statement with respect to the business of insurance which is misleading and which by the exercise of reasonable care should be known to be misleading, pursuant to Insurance Code section 790.03.” Insurance Associations argued that the Insurance Commissioner lacked authority to define new unfair business practices; questioned whether the record established a high volume of complaints and whether the problem was caused by lack of knowledge; and complained that the expense of compliance would discourage carriers from providing insurance. They obtained a declaration that the Regulation was invalid. The court of appeal affirmed, finding that the Commissioner lacked authority under the Unfair Insurance Practices Act. View "Ass'n of Cal. Ins. Cos. v. Jones" on Justia Law

The plaintiffs' complaint alleged that two groups of defendants, (1) Premera, Premera Blue Cross, and Life Wise Health Plan of Washington (collectively Premera) and (2) the Washington Alliance for Healthcare Insurance Trust and its trustee, F. Bentley Lovejoy (collectively WAHIT), colluded and made false and misleading representations to the plaintiffs that induced the plaintiffs to purchase health insurance policies under false pretenses. Plaintiff-policyholders claimed that Premera and WAHIT violated the Washington Consumer Protection Act (CPA). The plaintiffs requested only two specific forms of damages: (1) for the "unfair business practices and excessive overcharges for premiums," the plaintiffs requested "the sum of the excess premiums paid to the defendants;" and (2) "[i]f the surplus is excessive and unreasonable," the plaintiffs asserted that "the amount of the excess surplus should be refunded to the subscribers who have paid the high premiums causing the excess." On Premera and WAHIT's motion, the trial court dismissed the Policyholders' suit in its entirety based on the filed rate, primary jurisdiction, and exhaustion of remedies doctrines. Specifically, the trial court dismissed all claims of class B (small group) and class C (individuals) pursuant to CR 12(b )( 6) and dismissed all claims of class A (large group) on summary judgment under CR 56. The Court of Appeals reversed the trial court in relation to certain of the Policyholders' CPA claims. Because awarding the specific damages requested by the plaintiffs would require a court to inappropriately substitute its judgment for that of the Office of the Insurance Commissioner (OIC), the Supreme Court affirmed the trial court's dismissal of the plaintiffs' claims. View "McCarthy Fin., Inc. v. Premera" 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

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

Paul Lightner filed a consumer complaint on behalf of himself and other policyholders before the Insurance Commissioner against CitiFinancial and Triton Insurance Company challenging the rates for certain insurance products. Following the Commissioner’s investigation and consideration of Lightner’s complaint, the Commissioner denied Lightner’s request for a hearing and found the challenged rates were reasonable. Lightner filed a petition appealing the Commissioner’s order denying his request for a hearing. The circuit court affirmed. The Supreme Court affirmed, holding that the circuit court (1) did not err in upholding the Commissioner’s order denying a hearing because this case did not present any factual disputes warranting a hearing in this case; and (2) properly concluded that the Commissioner’s handling of the rate issues raised in Lightner’s complaint met statutory, regulatory, and constitutional standards.View "Lightner v. Riley" 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

Richard Feingold’s mother purchased a life insurance policy from an Insurer listing her husband as the only beneficiary. Feingold's mother died in 2006. In 2012, Richard informed Insurer of his mother's death. The Insurer issued Feingold a check for death benefits but did not provide a copy of his mother's life insurance policy. Feingold filed a class action complaint against Insurer in 2013, alleging that the Insurer owed Feingold and the putative class of similarly situated beneficiaries damages based on the Insurer’s handling of unclaimed benefits under its life insurance policies. Specifically, Feingold claimed that the Insurer had an obligation, arising from a regulatory agreement (“Agreement”) between the Insurer and several states, to discover the death of its insureds and notify beneficiaries. The district court dismissed the complaint for failure to state a claim, noting that the Agreement was a contract only between Insurer and participating states. The First Circuit affirmed, holding that because Feingold was neither a party nor a third-party beneficiary of the Agreement, he had no authority to enforce the terms of the Agreement. View "Feingold v. John Hancock Life Ins. Co." on Justia Law

Mead Johnson, purchased a primary Commercial General Liability policy from National Union, with a limit of $2 million for liability for “personal and advertising injury” and an excess liability policy from Lexington, with a limit of $25 million. Mead’s main product, Enfamil infant formula, is sold worldwide. Mead’s competitor, PBM, sued Mead for false advertising and consumer fraud and Mead sued PBM for trade dress infringement. PBM claimed that Mead had falsely asserted that PBM’s generic formula lacked key fats that promote brain and eye development. The suit sought $500 million in damages for product disparagement, a tort that the policies cover as a form of “advertising injury.” Mead did not notify the insurers of the suit until December 2009, after the suit ended in the $13.5 million verdict against Mead. Mead wanted its insurers to pay that judgment, plus a $15 million settlement that it made to resolve the class action suit. The insurers obtained declaratory judgments that they were not required to pay. The Seventh Circuit reversed the summary judgment in favor of the insurers in the suit relating to the PBM litigation, but affirmed the judgment in favor of National Union in the suit arising from the class action against Mead. View "Nat'l Union Fire Ins. Co. v. Mead Johnson & Co., LLC" on Justia Law