Justia Insurance Law Opinion Summaries

At issue in this case was (1) how Utah Code 30-3-5(1)(e) should be interpreted in correlation with Utah Code 75-2-804, and (2) the proper interpretation of “express terms” in section 75-2-804(2). Tyler Hertzske and Linda Snyder each claimed sole entitlement to the death benefits of a life insurance policy held by Edward Hertzske, deceased. The district court granted summary judgment to Tyler, concluding that Tyler was entitled to judgment as a matter of law. In so holding, the judge concluded (1) where section 30-3-5(1)(e) was not considered or included in the divorce proceedings, it did not apply, and (2) the Policy did not contain “express terms” that would except it from revocation under section 75-2-804(2). The Supreme Court affirmed, holding (1) section 75-2-804(2) creates a rebuttable presumption that a beneficiary designation in a life insurance policy is revoked upon divorce; (2) section 30-3-5(1)(e) does not apply in this instance, and, rather, section 75-2-804 governs; (3) a life insurance policy must contain “express terms” referring to divorce in order for the beneficiary designation of a former spouse to survive revocation by section 75-2-804(2); and (4) the Policy did not contain “express terms” that would except it from revocation under section 75-2-804(2). View "Snyder v. Hertzske" on Justia Law

American Family Insurance Company (American Family) issued automobile insurance policies to policyholders that were later injured in automobile accidents. The policy contained an anti-assignment clause, but, in order to obtain medical treatment, the policyholders assigned their interests in basic economic loss benefits to their medical provider, Stand Up Multipositional Advantage MRI, P.A. (Stand Up). Stand Up filed suit against the policyholders, their attorneys, and American Family for failing to make payment directly to Stand Up in accordance with the assignments. The district court granted summary judgment for the defendants, concluding that the anti-assignment clause was unenforceable, and therefore, the assignments to Stand Up were valid. The court of appeals reversed. The Supreme Court affirmed, holding that the anti-assignment clause was valid and precluded the assignments the policyholders made to Stand Up. View "Stand Up Multipositional Advantage MRI, P.A. v. American Family Insurance Co." on Justia Law

The Riverwalk at Arrowhead Country Club and Magnolia North Horizontal Property Regime developments were constructed between 1997 and 2000. After construction was complete and the units were sold, the purchasers became aware of significant construction problems, including building code violations, structural deficiencies, and significant water-intrusion problems. In 2003, the purchasers filed suit to recover damages for necessary repairs to their homes. Lawsuits were filed by the respective property owners' associations (POAs), which sought actual and punitive damages for the extensive construction defects under theories of negligent construction, breach of fiduciary duty, and breach of warranty. As to the Riverwalk development, individual homeowners also filed a class action to recover damages for the loss of use of their property during the repair period. The defendants in the underlying suits were the related corporate entities that developed and constructed the condominium complexes: Heritage Communities, Inc. (the parent development company), Heritage Magnolia North, Inc. and Heritage Riverwalk, Inc. (the project-specific subsidiary companies for each separate development), and Buildstar Corporation (the general contracting subsidiary that oversaw construction of all Heritage development projects), referred to collectively as "Heritage." The issues presented to the Supreme Court by these cases came from cross-appeals of declaratory judgment actions to determine coverage under Commercial General Liability (CGL) insurance policies issued by Harleysville Group Insurance. The cases arose from separate actions, but were addressed in a single opinion because they involved virtually identical issues regarding insurance coverage for damages. The Special Referee found coverage under the policies was triggered and calculated Harleysville's pro rata portion of the progressive damages based on its time on the risk. After review of the arguments on appeal, the Supreme Court affirmed the findings of the Special Referee in the Magnolia North matter, and affirmed as modified in the Riverwalk matter. View "Harleysville Group Ins. v. Heritage Communities, Inc." on Justia Law

Frye was seriously injured in an accident while driving for his job. Frye accepted $100,000, the per-person limit, from the other driver’s insurer, assigning it to his lawyer and to his employer’s insurer, Auto-Owners, from which Frye had received $692,895.79 in workers’-compensation benefits. Frye’s injuries were also covered by commercial automobile and commercial umbrella policies, issued by Auto-Owners to Frye’s employer. The automobile policy required Auto-Owners to pay any compensatory damages Frye was legally entitled to recover for bodily injuries caused by an underinsured motorist. The umbrella policy afforded follow-on coverage. Auto-Owners agreed to pay Frye $1,282,314.21: $900,000 under the automobile policy ($1 million in total coverage, less $100,000 from the other insurer); and $382,314.21 under the umbrella policy ($1 million in UIM coverage, less $617,685.79 in net workers’-compensation payments). Frye argued that Indiana law required Auto-Owners to provide through its umbrella policy UIM coverage in an amount equal to the policy’s general liability limit ($5 million) and that the setoff for workers’-compensation payments was impermissible under the contract and Indiana public policy. The district court awarded AutoOwners summary judgment. The Seventh Circuit reversed. While Indiana law allowed Auto-Owners to abstain from providing UIM coverage in the umbrella policy, once it provided such coverage it was required under Section 27-7-5-2(a) to provide that coverage in limits equal to the policy’s general liability limit: $5 million. It cannot decrease that cap based on workers’ compensation payments. View "Frye v. Auto-Owners Insurance Co." on Justia Law

Fleet Owners Fund is a multi-employer “welfare benefit plan” under the Employee Retirement Security Act (ERISA), 29 U.S.C. 1001, and a “group health plan” under the Patient Protection and Affordable Care Act (ACA), 26 U.S.C. 5000A. Superior Dairy contracted with Fleet for employee medical insurance; the Participation Agreement incorporated by reference a 2002 Agreement. In a purported class action, Superior and its employee alleged that, before entering into the Agreement, it received assurances from Fleet Owners and plan trustees, that the plan would comply in all respects with federal law, including ERISA and the ACA. Plaintiffs claim that, notwithstanding the ACA’s statutory requirement that all group health plans eliminate per-participant and per-beneficiary pecuniary caps for both annual and lifetime benefits, the plan maintains such restrictions and that Superior purchased supplemental health insurance benefits to fully cover its employees. Fleet argued that the plan is exempt from such requirements as a “grandfathered” plan. The district court dismissed the seven-count complaint. The Sixth Circuit affirmed, concluding that plaintiffs lacked standing to bring claims under ERISA and ACA, having failed to allege concrete injury, and did not allege specific false statements. View "Soehnlen v. Fleet Owners Insurance Fund" on Justia Law

Barnie’s Bar & Grill, Inc. held an insurance policy by the United States Liability Insurance Company (USLIC) when Barnie’s was sued for negligence in connection with one man’s attack by a group of other patrons of the bar. USLIC declined to defend Barnie’s in the litigation, relying on the policy’s exclusions for assault and battery. Barnie’s sued USLIC in superior court seeking a declaratory judgment that USLIC had a duty to defend it and seeking damages for breach of contract. The superior court granted summary judgment for USLIC, concluding that USLIC had no contractual duty to defend Barnie’s. The Supreme Judicial Court affirmed, holding that USLIC was not obligated to defend Barnie’s in the underlying litigation because the allegations of the underlying complaint fell squarely within the policy’s exclusions for assault and battery. View "Barnie's Bar & Grill, Inc. v. United States Liability Insurance Company" on Justia Law

Privilege Underwriters Reciprocal Exchange ("PURE"), a Florida-domiciled insurance exchange, obtained a judgment, entered on a jury verdict, declaring that Peter Grayson was not entitled to coverage under the uninsured-motorist ("UM") portion of an automobile insurance policy under which Grayson's sister, Alice Grayson, was a named insured. The Circuit Court granted Grayson's motion to set aside that judgment on the basis that it was void for lack of subject-matter jurisdiction. PURE now appealed. Finding that the trial court had jurisdiction over the matter, the judgment in favor of PURE was not void. The Court therefore reversed the Circuit Court and remanded. View "Privilege Underwriters Reciprocal Exchange v. Grayson" on Justia Law

Prather, age 31, tore his left Achilles tendon playing basketball. He scheduled surgery for July 22. On July 21, he called the surgeon’s office complaining of swelling and that an area of the left calf was sensitive and warm to the touch. The surgery was uneventful and he was discharged from the hospital the same day. He returned to work and was doing well in a follow-up visit to his surgeon on August 2. Four days later he collapsed, went into cardiopulmonary arrest, and died as a result of a blood clot in the injured leg that had traveled to a lung. Prather’s widow applied for benefits under his Sun Life group life insurance policy (29 U.S.C. 1132(a)(1)), which limited coverage to “bodily injuries ... that result directly from an accident and independently of all other causes.” The district court granted Sun Life summary judgment. The Seventh Circuit reversed, noting that deep vein thrombosis and pulmonary embolism are risks of surgery, but that even with conservative treatment, such as immobilization of the affected limb, the insured had an enhanced risk of a blood clot. The forensic pathologist who conducted a post-mortem examination of Prather did not attribute his death to the surgery. View "Prather v. Sun Life & Health Insurance Co." on Justia Law

In 2005, John Sebo purchased a home. American Home Assurance Company (AHAC) provided homeowners insurance as of the date of the purchase. It later became clear that the house suffered from major design and construction defects when water began to intrude during rainstorms. Hurricane Wilma further damaged the residence. AHAC denied coverage for most of the claimed losses. Sebo sued AHAC seeking a declaration that the policy provided coverage for his damages. The jury found in favor of Sebo, and the trial court entered judgment against AHAC. The Second District Court of Appeal reversed and remanded for a new trial, concluding that coverage did not exist under Sebo’s all-risk policy when multiple perils combined to create a loss and at least one of the perils was excluded by the terms of the policy. The Supreme Court quashed the Second District’s opinion, holding that the plain language of the policy did not preclude recovery in this case. View "Sebo v. American Home Assurance Co." on Justia Law

A fire destroyed a house. The homeowner’s insurer agreed to pay for the damages resulting from the fire, then sued the contractor who installed the fireplace several years earlier, claiming negligence. The contractor tendered defense of the action to its liability insurer, asserting that even though the fire occurred after the relevant policy periods ended, there was a possibility of coverage because the fire may have been the result of ongoing damage to the wood in the chimney during one or more policy periods due to the exposure of that wood to excessive heat from the chimney every time a fire was burned in the fireplace. The issue this case presented for the Court of Appeal’s review was whether, under the standard language of the commercial general liability policy at issue here, did the liability insurer have a duty to defend the contractor? After review of that policy, the Court answered “yes” and reversed the trial court’s judgment that concluded otherwise. View "Tidwell Enterprises v. Financial Pacific Ins. Co." on Justia Law