Justia Insurance Law Opinion Summaries

In this dispute over the amount that air ambulance providers may recover from workers' compensation insurers, the Supreme Court held that Texas law requiring that private insurance companies reimburse the fair and reasonable medical expenses of injured workers is not preempted by a federal law deregulating aviation and that federal law does not require Texas to mandate reimbursement of more than a fair and reasonable amount for air ambulance services.PHI Air Medical, LLC, an air ambulance provider, argued that the federal Airline Deregulation Act (ADA) preempted the Texas Workers' Compensation Act's (TWCA) fee schedules and reimbursement standards. An administrative law judge held that PHI was entitled to reimbursement under the TWCA's standards. On judicial review, the trial court declared that the ADA did not preempt the TWCA's reimbursement provisions. The court of appeals reversed. The Supreme Court reversed, holding (1) because the price of PHI's service to injured workers is not significantly affected by a reasonableness standard for third-party reimbursement of those services, the ADA does not preempt that standard; and (2) the ADA does not require that Texas compel private insurers to reimburse the full charges billed for those services. View "Texas Mutual Insurance Co. v. PHI Air Medical, LLC" on Justia Law

Travelers Insurance Co. appealed a district court decision to affirm a final order of the Idaho Department of Insurance in favor of Ultimate Logistics, LLC (“Ultimate”). The Department of Insurance’s final order upheld a hearing officer’s determination that two mechanics working for Ultimate were improperly included in a premium-rate calculation made by Travelers. In its petition for review, Travelers argued the Department of Insurance acted outside the scope of its statutory authority in determining that the mechanics could not be included in the premium-rate calculation. The district court rejected this argument. Finding no reversible error in the district court's order, the Idaho Supreme Court affirmed. View "Travelers Insurance v. Ultimate Logistics, LLC" on Justia Law

Defendant ReadyLink Healthcare, Inc. (ReadyLink) was a nurse staffing company that placed nurses in hospitals, typically on a short-term basis. Plaintiff State Compensation Insurance Fund (SCIF) was a public enterprise fund created by statute as a workers' compensation insurer. Premiums that SCIF charged were based in part on the employer's payroll for a particular insurance year. SCIF and ReadyLink disputed the final amount of premium ReadyLink owed to SCIF for the 2005 policy year (September 1, 2005 to September 1, 2006). ReadyLink considered certain payments made to its nurses as per diem payments; SCIF felt those should have been considered as payroll under the relevant workers' compensation regulations. The Insurance Commissioner concurred with SCIF's characterization of the payments. A trial court rejected ReadyLink's petition for a writ of administrative mandamus to prohibit the Insurance Commissioner from enforcing its decision, and an appellate court affirmed the trial court's judgment. SCIF subsequently filed the action underlying this appeal, later moving for a judgment on the pleadings, claiming the issue of the premium ReadyLink owed for the 2005 policy year had been previously determined in the administrative proceedings, which was then affirmed after judicial review. The trial court granted SCIF's motion for judgment on the pleadings. On appeal, ReadyLink conceded it previously litigated and lost its challenge to SCIF's decision to include per diem amounts as payroll for the 2005 insurance year, but argued it never had the opportunity to challenge whether SCIF otherwise properly calculated the premium amount that it claims was due pursuant to the terms of the contract between the parties, or whether SCIF's past conduct, which ReadyLink alleged included SCIF's acceptance of ReadyLink's exclusions of its per diem payments from payroll in prior policy years and SCIF's exclusion of per diem amounts in paying out on workers' compensation claims filed by ReadyLink employees, might bar SCIF from being entitled to collect that premium amount under the contract. To this, the Court of Appeal concurred the trial court erred in granting SCIF's motion for judgment on the pleadings. Judgment was reversed, and the matter remanded for further proceedings. View "State Comp. Ins. Fund v. ReadyLink Healthcare, Inc." on Justia Law

The Louisiana Supreme Court granted review in this case to determine whether the Louisiana Commissioner of Insurance was bound by an arbitration clause in an agreement between a health insurance cooperative and a third-party contractor. The Louisiana Health Cooperative, Inc. (“LAHC”), a health insurance cooperative created in 2011 pursuant to the Patient Protection and Affordable Care Act, entered an agreement with Milliman, Inc. for actuarial and other services. By July 2015, the LAHC was out of business and allegedly insolvent. The Insurance Commissioner sought a permanent order of rehabilitation relative to LAHC. The district court entered an order confirming the Commissioner as rehabilitator and vesting him with authority to enforce contract performance by any party who had contracted with the LAHC. The Commissioner then sued multiple defendants in district court, asserting claims against Milliman for professional negligence, breach of contract, and negligent misrepresentation. According to that suit, the acts or omissions of Milliman caused or contributed to the LAHC’s insolvency. Milliman responded by filing a declinatory exception of lack of subject matter jurisdiction, arguing the Commissioner must arbitrate his claims pursuant to an arbitration clause in the agreement between the LAHC and Milliman. The Supreme Court concluded, however, the Commissioner was not bound by the arbitration agreement and accordingly could not be compelled to arbitrate its claims against Millman. The Court reversed the appellate court's judgment holding to the contrary, and remanded the case for further proceedings. View "Donelon v. Shilling" on Justia Law

The Tenth Circuit Court of Appeals certified a question of law to the Colorado Supreme Court. The certified question arose from a dispute in which plaintiff Amica Life Insurance Company sought a declaratory judgment that it was not required to pay defendant Michael Wertz benefits under a life insurance policy naming Wertz as the beneficiary. The policy, which was issued in compliance with a standard enacted by the Interstate Insurance Product Regulation Commission (the “Commission”), contained a two-year suicide exclusion, and the insured committed suicide more than one year but less than two years after Amica had issued the life insurance policy to him. Wertz contended that the policy’s two-year suicide exclusion was unenforceable because it conflicted with Colorado statute, section 10-7-109, C.R.S. (2019). Wertz asserted that the Colorado General Assembly could not properly delegate to the Commission the authority to enact a standard that would effectively override this statute. After review, the Colorado Supreme Court agreed with Wertz, and accordingly, answered the certified question narrowly: the General Assembly did not have the authority to delegate to the Commission the power to issue a standard authorizing the sale of life insurance policies in Colorado containing a two-year suicide exclusion when a Colorado statute prohibited insurers doing business in Colorado from asserting suicide as a defense against payment on a life insurance policy after the first year of that policy. View "Amica Life Insurance Company v. Wertz" on Justia Law

The Patient Protection and Affordable Care Act established online exchanges where insurers could sell their healthcare plans. The now-expired “Risk Corridors” program aimed to limit the plans’ profits and losses during the first three years (2014-2016). Under 31 U.S.C. 1342, eligible profitable plans “shall pay” the Secretary of the Department of Health and Human Services, while the Secretary “shall pay” eligible unprofitable plans. The Act neither appropriated funds nor limited the amounts that the government might pay. There was no requirement that the program be budget-neutral. The total deficit exceeded $12 billion. At the end of each year, the appropriations bills for the Centers for Medicare and Medicaid Services included a rider preventing the Centers from using the funds for Risk Corridors payments. The Federal Circuit rejected Tucker Act claims for damages by health-insurance companies that claimed losses under the program.The Supreme Court reversed. The Risk Corridors statute created an obligation to pay insurers the full amount set out in section 1342’s formula. The government may incur an obligation directly through statutory language, without details about how the obligation must be satisfied. The Court noted the mandatory term “shall,” and adjacent provisions, which differentiate between when the Secretary “shall” act and when she “may” exercise discretion. Congress did not impliedly repeal the obligation through its appropriations riders. which do not indicate “any other purpose than the disbursement of a sum of money for the particular fiscal years.”The Risk Corridors statute is fairly interpreted as mandating compensation for damages, and neither Tucker Act exception applies. Nor does the APA bar a Tucker Act suit. The insurers seek specific sums already calculated, past due, and designed to compensate for completed labors. Because the Risk Corridors program expired this litigation presents no special concern about managing a complex ongoing relationship. View "Maine Community Health Options v. United States" on Justia Law

In May 2015, the Chickasaw County School District entered into a contract with Sullivan Enterprises, Inc., for window restoration work on the Houlka Attendance Center. In July 2015, during construction, a fire began that completely consumed the attendance center. Liberty Mutual, the school district’s insurer, paid the school district $4.3 million for the damage to the building. Liberty Mutual then filed a subrogation suit against Sullivan Enterprises, Fowlkes Plumbing, LLC, and Quality Heat & Air, Inc. The United States District Court for the Northern District of Mississippi found that the waiver of subrogation did not apply to damages to the “non-Work” property, thus Liberty Mutual could proceed in litigation as to “non-Work” property damages. The United States Court of Appeals for the Fifth Circuit allowed an interlocutory appeal and certified a question to the Mississippi Supreme Court regarding whether the subrogation waiver applied to “non-Work” property. The Supreme Court determined that based on the plain meaning of the contract language, the waiver of subrogation applied to both work and non-work property. View "Liberty Mutual Fire Insurance Co. v. Fowlkes Plumbing, L.L.C." on Justia Law

The Office of Personnel Management (OPM), manages the Federal Employees’ Group Life Insurance Act (FEGLIA), 5 U.S.C. 8705(a). Absent a valid beneficiary selection, FEGLIA provides an order of precedence for the proceeds, starting with the policyholder's surviving spouse, followed by the policyholder's descendants. FEGLIA will not follow that order if a “court decree of divorce, annulment, or legal separation, or . . . any court order or court-approved property settlement agreement” “expressly provides” for payment to someone else. The decree, order, or agreement must be “received” by the policyholder’s “employing agency” or OPM before the policyholder’s death. At the time of his death, Miller worked at Tinker Air Force Base and maintained a MetLife policy. Coleman's 27-year marriage to Donna ended in divorce in 2011. Their property settlement agreement states that “[Donna] shall remain the beneficiary of the life insurance policy.” The court ordered Coleman to assign his FEGLI benefits to Donna.Upon Coleman’s death, his only child, Courtenay, was appointed administratrix of his estate. The Air Force informed Courtenay that the court order had not been filed with Coleman’s employing office. Courtenay was paid $172,000 in proceeds and sought a declaration that she is the rightful owner. Citing lack of subject-matter jurisdiction, the district court dismissed the suit. The Sixth Circuit affirmed, noting the lack of a substantial federal question. FEGLIA does not contain an express cause of action for Donna. There is no federal agency involved. View "Miller v. Bruenger" on Justia Law

Among its reforms, the Patient Protection and Affordable Care Act (“ACA”) required private health insurers to provide coverage for individuals regardless of their gender or health status, including preexisting conditions. Congress anticipated these reforms might hamper the ability of insurers to predict health care costs and to price health insurance premiums as more individuals sought health insurance. To spread the risk of enrolling people who might need more health care than others, Congress established a risk adjustment program for the individual and small group health insurance markets. Congress tasked the Department of Health and Human Services (“HHS”) with designing and implementing this risk adjustment program with the states. HHS developed a formula to calculate how much each insurer would be charged or paid in each state. The formula relied on the “statewide average premium” to calculate charges and payments. Plaintiff-Appellee New Mexico Health Connections (“NMHC”), an insurer that was required to pay charges under the program, sued the HHS Defendants-Appellants under the Administrative Procedure Act (“APA”), alleging that HHS’s use of the statewide average premium to calculate charges and payments in New Mexico from 2014 through 2018 was arbitrary and capricious. The district court granted summary judgment to NMHC, holding that HHS violated the APA by failing to explain why the agency chose to use the statewide average premium in its program. It remanded to the agency and vacated the 2014, 2015, 2016, 2017, and 2018 rules that implemented the program. After the district court denied HHS’s motion to alter or amend judgment under Federal Rule of Civil Procedure 59(e), HHS appealed. The Tenth Circuit Court of Appeals: (1) determined NMHC’s claims regarding the 2017 and 2018 rules were moot, so the matter was remanded to the district court to vacate its judgment on those claims and dismiss them as moot; (2) reversed the district court’s grant of summary judgment to NMHC as to the 2014, 2015, and 2016 rules because it determined HHS acted reasonably in explaining why it used the statewide average premium in the formula. Because the Court reversed the district court on its summary judgment ruling in favor of NMHC, it did not address the denial of HHS’s Rule 59(e) motion. View "New Mexico Health Connections v. HHS" on Justia Law

In separate incidents, claimants Miguel Velazquez and Servando Velazquez suffered injuries within the scope of their employment, and each required Spanish language interpreting services in connection with their medical care. Meadowbrook Insurance Company was the workers’ compensation carrier for the claimants’ employers and accepted both claims and administered benefits. DFS Interpreting (“DFS”), which provided interpreter services to each claimant, timely submitted invoices to Meadowbrook for the services provided. Meadowbrook refused to pay the invoices DFS submitted. DFS objected to the insurance company’s explanations of review, but did not request a second review pursuant to Labor Code section 4603.2 (e) or California Code of Regulations, title 8, section 9792.5.5. Meadowbrook petitioned for writ of review of the Workers’ Compensation Appeal Board’s (WCAB) decision on reconsideration that liens held by DFS Interpreting (DFS) against Meadowbrook regarding unpaid invoices for interpreter services DFS provided to Meadowbrook’s insureds were not foreclosed by DFS’s failure to follow procedural rules. The Court of Appeal issued the writ, and held that DFS’s failure to comply with required procedures resulted in DFS’s bills being deemed satisfied. This result meant Meadowbrook was not liable for further payment. The Court annulled the WCAB’s decision to the contrary and remanded for further proceedings. View "Meadowbrook Ins. Co. v. Workers' Comp. Appeals Bd." on Justia Law