Justia Insurance Law Opinion Summaries

The case involves the Pennsylvania Professional Liability Joint Underwriting Association (JUA), which was established by the General Assembly of the Commonwealth of Pennsylvania nearly fifty years ago to address a medical malpractice insurance crisis. The JUA acts as a professional liability insurer of last resort for high-risk medical providers and is funded solely by premiums paid by its policyholders. Over the years, the JUA has accumulated a surplus of about $300 million through investments. From 2016 to 2019, the Commonwealth attempted to transfer the JUA’s surplus to the General Fund or assume control of the JUA through legislative actions.The United States District Court for the Middle District of Pennsylvania reviewed the case multiple times. In 2017, the JUA sued the Governor after the enactment of Act 44, which mandated the transfer of $200 million from the JUA to the General Fund. The District Court granted a preliminary injunction and later summary judgment in favor of the JUA, holding that the JUA was a private entity and that the Act violated the Takings Clause. In 2018, after the enactment of Act 41, which placed the JUA under the control of the Insurance Department and mandated the transfer of all its assets, the JUA again sued. The District Court ruled in favor of the JUA, reiterating its earlier decision. In 2019, the JUA challenged Act 15, which required the JUA to be funded by the Commonwealth and categorized it as a Commonwealth agency. The District Court granted partial summary judgment for the JUA, holding that certain provisions of Act 15 constituted a regulatory taking and violated the First Amendment.The United States Court of Appeals for the Third Circuit reviewed the case and applied the principles from Trustees of Dartmouth College v. Woodward to determine whether the JUA is a public or private entity. The Court concluded that the JUA is a public entity because it was created to serve a public purpose, exercises the Commonwealth’s coercive power, and only the Commonwealth has a legally protectable interest in the JUA. Consequently, the JUA cannot assert constitutional claims against the Commonwealth. The Court reversed the District Court’s rulings in part, affirmed in part, and remanded for further proceedings. View "Pennsylvania Professional Liability Joint Underwriting Association v. Governor of Pennsylvania" on Justia Law

The case involves the Police Jury of Calcasieu Parish, a political subdivision of Louisiana, which suffered property damage from Hurricanes Laura and Delta in 2020. The Police Jury had insurance policies with a syndicate of eight domestic insurers. The insurers sought to compel arbitration in New York under New York law for the approximately 300 property damage claims. The Police Jury alleged underpayment and untimely payments by the insurers and filed suit in state court, which was later removed to the United States District Court for the Western District of Louisiana.The Western District Court granted the Police Jury's motion to certify three questions of Louisiana law to the Louisiana Supreme Court. The questions concerned the validity of arbitration clauses in insurance policies issued to Louisiana political subdivisions, particularly in light of a 2020 amendment to La. R.S. 22:868 and the applicability of La. R.S. 9:2778, which bars arbitration clauses in contracts with the state or its political subdivisions.The Louisiana Supreme Court addressed the certified questions. First, it held that the 2020 amendment to La. R.S. 22:868, which allowed forum or venue selection clauses in certain insurance contracts, did not implicitly repeal the prohibition of arbitration clauses in all insurance contracts under La. R.S. 22:868(A). Second, the court determined that La. R.S. 9:2778 applies to all contracts with political subdivisions, including insurance contracts, thereby prohibiting arbitration outside Louisiana or the application of foreign law. Third, the court held that a domestic insurer cannot use equitable estoppel to enforce an arbitration clause in another insurer’s policy against a political subdivision, as it would contravene the positive law prohibiting arbitration clauses in La. R.S. 22:868(A)(2).The Louisiana Supreme Court answered all three certified questions, maintaining the prohibition of arbitration clauses in insurance policies issued to Louisiana political subdivisions and affirming the applicability of La. R.S. 9:2778 to such contracts. View "POLICE JURY OF CALCASIEU PARISH VS. INDIAN HARBOR INSURANCE CO." on Justia Law

Nicholas and Stacy Boerson, owners of New Heights Farm I and II in Michigan, faced a disappointing corn and soybean harvest in 2019. They submitted crop insurance claims to Great American Insurance Company, which were delayed due to an ongoing federal fraud investigation. The Boersons sued Great American, the Federal Crop Insurance Corporation, and the U.S. Department of Agriculture for breach of contract, bad faith adjustment, and violations of insurance laws.The United States District Court for the Western District of Michigan dismissed the Boersons' claims. It ruled that claims related to Great American's nonpayment were unripe due to the ongoing investigation, while claims alleging false measurements and statements by Great American were ripe but subject to arbitration. The court also dismissed claims against the federal defendants on sovereign immunity grounds.The United States Court of Appeals for the Sixth Circuit affirmed the district court's dismissal. It held that the claims related to nonpayment were unripe because the insurance policy barred payment until the investigation concluded. The court also found that the arbitration agreement in the insurance policy covered the ripe claims against Great American, requiring those disputes to be resolved through arbitration. Additionally, the court ruled that sovereign immunity barred the claims against the federal defendants, as there was no clear waiver of immunity for constructive denial claims under the Federal Crop Insurance Act. View "New Heights Farm I, LLC v. Great American Insurance Co." on Justia Law

Elizabeth Holt, a former insurance agent for Medicare Medicaid Advisors, Inc. (MMA), alleged that MMA and several insurance carriers (Aetna, Humana, and UnitedHealthcare) violated the False Claims Act (FCA). Holt claimed that MMA engaged in fraudulent practices, including falsifying agent certifications and violating Medicare marketing regulations, which led to the submission of false claims to the Centers for Medicare and Medicaid Services (CMS).The United States District Court for the Western District of Missouri dismissed Holt's complaint. The court found that no claims were submitted to the government, the alleged regulatory violations were not material to CMS’s contract with the carriers, and the complaint did not meet the particularity standard required by Federal Rule of Civil Procedure 9(b). The court also denied Holt's motion for reconsideration, which introduced a fraudulent inducement theory and requested leave to amend the complaint.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court affirmed the district court's dismissal, agreeing that Holt's allegations did not meet the materiality requirement under the FCA. The court applied the materiality standard from Universal Health Services, Inc. v. United States ex rel. Escobar, considering factors such as whether the government designated compliance as a condition of payment, whether the violations were minor or substantial, and whether the government continued to pay claims despite knowing of the violations. The court found that the alleged violations did not go to the essence of CMS’s contract with the carriers and were not material to the government's payment decisions.The Eighth Circuit also upheld the district court's denial of Holt's motion for reconsideration and request to amend the complaint, concluding that adding a fraudulent inducement claim would be futile given the immateriality of the alleged violations. View "United States ex rel. Holt v. Medicare Medicaid Advisors" on Justia Law

Nevada Health CO-OP, a health insurance provider, received two loans from the Centers for Medicare & Medicaid Services (CMS) under the Affordable Care Act’s CO-OP program. These loans included a start-up loan and a solvency loan. In 2015, Nevada Health faced financial difficulties and was placed into receivership by the Nevada Commissioner of Insurance. CMS subsequently terminated the loan agreement and began offsetting payments owed to Nevada Health against the start-up loan debt.The United States Court of Federal Claims reviewed the case and granted summary judgment in favor of the Nevada Commissioner of Insurance, acting as the receiver for Nevada Health. The court found that the government improperly withheld statutory payments owed to Nevada Health under the ACA. The court also held that the government could not invoke 31 U.S.C. § 3728 to withhold these payments in the future.The United States Court of Appeals for the Federal Circuit reviewed the case. The court affirmed the lower court’s judgment that the government improperly withheld payments owed to Nevada Health. The court held that the loan agreement subordinated the government’s claim to those of policyholders and basic operating expenses, thus precluding the government from asserting offset rights to jump ahead of these senior creditors. However, the appellate court vacated the portion of the lower court’s order that addressed the government’s ability to invoke 31 U.S.C. § 3728, ruling that the lower court exceeded its jurisdiction by addressing this issue, which was not raised by the parties. View "Richardson v. United States" on Justia Law

David Howard, a former coal miner, worked from 1978 to 1997, with his last employer being Apogee Coal Company, which was self-insured by Arch Resources at the time. Howard filed a claim for benefits under the Black Lung Benefits Act (BLBA) in 2014. Initially, the District Director identified Patriot Coal Company as the liable insurer, but after Patriot's bankruptcy, the Department of Labor (DOL) issued a bulletin directing that Arch Resources be notified as the liable insurer. Arch contested this designation but failed to submit evidence within the required timeframe.The District Director issued a Proposed Decision and Order (PDO) naming Arch as the liable insurer. Arch's subsequent motions for discovery and to hold the case in abeyance were denied by the Administrative Law Judge (ALJ). Arch then appealed to the Benefits Review Board, which affirmed the ALJ's decision. Arch petitioned the United States Court of Appeals for the Sixth Circuit for review, arguing that the DOL's bulletin was a new rule requiring notice and comment, and that the evidentiary procedures violated the Administrative Procedure Act (APA).The Sixth Circuit denied Arch's petition for review and its motion to supplement the administrative record. The court held that the BLBA regulations, which require evidence to be submitted to the District Director within 90 days, were consistent with the APA and did not violate due process. The court also found that the DOL's bulletin did not constitute a new rule requiring notice and comment, as it merely provided guidance and did not alter any rights or obligations. The court concluded that Arch had received adequate notice and an opportunity to defend against its designation as the liable insurer. View "Apogee Coal Co. v. Office of Workers' Compensation Programs" on Justia Law

In this case, a private insurance company, TIG Insurance Company, sought to enforce two judgments against the Republic of Argentina. The dispute centers on whether Argentina, as the successor to a state-owned Argentine company, Caja Nacional de Ahorro y Seguro, is liable under reinsurance contracts that Caja entered into with TIG in 1979. TIG alleged that Caja failed to pay as promised under these contracts, leading to arbitral awards and subsequent judgments in TIG's favor.The United States District Court for the District of Columbia initially ruled in favor of Argentina, finding that Argentina's property was immune from execution under the Foreign Sovereign Immunities Act (FSIA) because it was not used for commercial activity at the time the writ would issue. The court also held that the Illinois district court lacked jurisdiction over Argentina for the 2018 judgment and that TIG needed to amend the 2001 judgment in Illinois to name Argentina before seeking enforcement in D.C. TIG appealed these decisions.The United States Court of Appeals for the District of Columbia Circuit reviewed the case and concluded that two FSIA exceptions—the arbitration and waiver exceptions—might apply. The court held that an agreement could be "made by" a sovereign if it legally binds that sovereign to arbitrate, even if the sovereign was not an original signatory. The court also found that implied waiver does not require evidence of subjective intent but can be based on objective actions, such as agreeing to arbitration or a choice-of-law clause. The court vacated the district court's decisions and remanded for further analysis and factfinding on these issues.The appellate court affirmed the denial of TIG's request for jurisdictional discovery and precluded TIG from advancing an alter ego theory or arguing that Argentina failed to raise its immunity in a responsive pleading. The case was remanded for further proceedings consistent with the appellate court's instructions. View "TIG Insurance Company v. Republic of Argentina" on Justia Law

This case involves a catastrophic wildfire that occurred in 2016 in the Great Smoky Mountains National Park in Eastern Tennessee. The fire spread into Gatlinburg and Sevier County, resulting in the destruction of over 2,500 structures and the death of 14 people. The appellant insurance companies paid claims to policy holders and then filed claims under the Federal Tort Claims Act (FTCA) against the National Park Service (NPS), alleging negligence for failure to follow multiple mandatory fire-management protocols and for the failure to issue mandatory warnings to the public.The government moved to dismiss the case for lack of subject-matter jurisdiction, arguing that it was immune from suit under the discretionary-function exception to the FTCA. The district court granted the motion on all three claims relating to fire-management protocols, but denied the motion on claims relating to the duty to warn. The insurance companies appealed, and the government cross-appealed.The United States Court of Appeals for the Sixth Circuit reversed the district court's order granting the government's motion to dismiss the insurance companies' incident-command claim. The court affirmed the district court's dismissal of the fire-monitoring claim and the Wildland Fire Decision Support System (WFDSS) claim as part of the discretionary fire-suppression decision-making process. The court also affirmed the district court's denial of the government's facial challenge to the insurance companies' duty-to-warn claims, and remanded these claims for further proceedings. View "American Reliable Insurance Co. v. United States" on Justia Law

The case involves the United States of America, et al. ex rel. Michael Angelo and MSP WB, LLC (Relators-Appellants) against Allstate Insurance Company, et al. (Defendants-Appellees). The relators alleged that Allstate Insurance violated the False Claims Act by avoiding its obligations under the Medicare Secondary Payer Act. They claimed that Allstate failed to report or inaccurately reported to the Centers for Medicare & Medicaid Services (CMS) information regarding its beneficiaries, which led to Allstate failing to reimburse Medicare for auto-accident-related medical costs incurred by beneficiaries insured by Allstate.The United States District Court for the Eastern District of Michigan dismissed the case with prejudice, deeming the relators' second amended complaint deficient in numerous respects. The relators then moved for reconsideration, which the district court denied. They also filed a motion to amend or correct under Rule 59(e), asking the district court to amend its judgment to dismiss the case without prejudice to allow them to file another amended complaint. The district court denied the motion on all grounds.The United States Court of Appeals for the Sixth Circuit affirmed the district court's decision. The court found that the relators failed to state a claim for a violation of the False Claims Act. The court noted that the relators did not provide sufficient facts demonstrating that Allstate had an "established duty" to pay money or property owed to the government. The court also found that the relators did not demonstrate Allstate's understanding that its conduct violated its obligations under federal law. Furthermore, the court found that the relators' claim for conspiracy also failed as they did not provide any specific details regarding the alleged plan or an agreement to execute the plan. The court also affirmed the district court's decision to deny the relators leave to amend their complaint again. View "United States ex rel. Angelo v. Allstate Insurance Co." on Justia Law

The case involves Erie Insurance Company and its affiliates (collectively, Erie) and the Maryland Insurance Administration (MIA). In 2021, the MIA initiated two separate administrative investigations into Erie following complaints alleging racial and geographic discrimination. The first investigation broadly examined Erie’s market conduct, while the second focused on the specific allegations in the individual complaints. In 2023, the MIA issued four public determination letters stating that Erie had violated state insurance laws. These letters referenced documents obtained during the market conduct investigation, which had not yet concluded. Erie requested and was granted administrative hearings on all four determination letters.Erie then filed a lawsuit against the MIA and its commissioner in federal district court, alleging due process violations under 42 U.S.C. § 1983 and violations of Maryland state law. Erie sought a declaration that the determination letters were unlawful, an injunction preventing the defendants from disseminating the letters, and a requirement for the defendants to publicly withdraw them. The district court dismissed Erie's complaint, citing the principles of abstention outlined in Younger v. Harris, which generally discourages federal courts from interfering with ongoing state proceedings.The United States Court of Appeals for the Fourth Circuit affirmed the district court's decision. The court found that Erie had an adequate opportunity to raise its constitutional claims in the administrative hearings and subsequent state court review, as required for Younger abstention. The court also rejected Erie's argument that this case fell within an exception to Younger abstention due to extraordinary circumstances or unusual situations. The court concluded that Erie had not demonstrated that the MIA's actions were motivated by bias or that the administrative proceedings would not afford Erie constitutionally adequate process. View "Erie Insurance Exchange v. Maryland Insurance Administration" on Justia Law