Justia Insurance Law Opinion Summaries

John Boman appealed the grant of summary judgment in favor of the City of Gadsden. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. Following his retirement, Boman elected to pay for retiree health coverage through a group plan offered by Gadsden to retired employees. This retired-employee-benefit plan was also administered by Blue Cross and provided substantially similar benefits to those Boman received as an active employee. In 2000, however, Gadsden elected to join an employee-health-insurance-benefit plan ("the plan") administered by the State Employees' Insurance Board ("the SEIB"). When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and severe osteoarthritis of the spine. After his 65th birthday, Blue Cross began denying his claims for medical treatment based on the failure to provide Blue Cross with a "record of the Medicare payment." However, Boman had no Medicare credits. Boman was hired before March 31, 1986, and, although Gadsden did begin participation in the Medicare program in 2006, Boman's employee group had not opted to obtain Medicare coverage before Boman retired. Consequently, Boman never paid Medicare taxes and did not claim to have Medicare coverage. The SEIB ultimately determined that the plan was the secondary payer to Medicare. Boman sued Gadsden, asserting that it had broken an agreement, made upon his employment, to provide him with lifetime health benefits upon his retirement. Boman also sued the members of the SEIB charged with administering the plan, challenging the SEIB's interpretation of the plan. Finding no reversible error in the grant of summary judgment to Gadsden, the Supreme Court affirmed. View "Boman v. City of Gadsden" on Justia Law

Respondent suffered a work-related back injury. Respondent and her employer entered into a “full, final, and complete” settlement of Respondent’s claims for workers’ compensation benefits related to that injury. Respondent later filed a claim petition seeking additional benefits for the back injury, alleging a lumbar spine injury with consequential depression and anxiety. The employer moved to dismiss the petition on the ground that Respondent was first required to bring a motion to vacate the existing settlement agreement before bringing a new claim. The workers’ compensation judge denied the motion, concluding that the settlement agreement did not foreclose a later claim for consequential psychological injury. The Workers’ Compensation Court of Appeals affirmed, concluding that the settlement agreement did not foreclose claims from the same incident that were not mentioned in the agreement without evidence that those claims were contemplated by the parties at the time they entered into the agreement. The Supreme Court reversed, holding that the language of the settlement agreement was sufficient settle conditions and complications that arise out of, and are a consequence of, Respondent’s workers’ compensation injury. View "Ryan v. Potlatch Corp." on Justia Law

Bonnie Jones was injured during the course of her employment. Her employer’s comp carrier, American Home Assurance Company, paid her various benefits but did not pay her supplemental income benefits (SIBs) for the fourteenth quarter of 2011. Jones sued, and the parties settled. Under the Texas workers’ compensation regime, where SIBs are concerned, settlements cannot bypass a statutory formula or facilitate benefits were none were due as a matter of law. In this case, the settlement was noncompliant. The trial court approved the proposed settlement, and the court of appeals affirmed. The Supreme Court reversed, holding that a court cannot condone a noncompliant settlement regarding an SIBs award. View "Tex. Dep’t of Ins., Div. of Workers’ Comp. v. Jones" on Justia Law

Arrowood Indemnity Company, a member of the Mississippi Windstorm Underwriting Association (“the Windpool”), submitted its premium data as required for a post-Katrina data-correction process. Arrowood failed to claim the appropriate credits available to it by statute which, it alleged, resulted in a nearly five-million-dollar overpayment. Arrowood had based its data submission on incorrect information provided by the Windpool, so it requested an opportunity to submit the correct information. The Windpool denied its request because the deadline for corrections had passed. The Mississippi Insurance Commissioner and the Chancery Court affirmed the Windpool’s decision. After its review, the Mississippi Supreme Court found that the Windpool’s deadline was tolled under the facts of this case because its incorrect representation precipitated Arrowood’s incorrect data submission. The Court reversed the decisions of the Insurance Commissioner and the Hinds County Chancery Court and remanded this case for further proceedings. View "Arrowood Indemnity Company v. Mississippi Windstorm Underwriting Association" on Justia Law

Employee was severely injured while traveling abroad on a business trip. Employer had purchased two workers’ compensation policies from two different insurers, the Insurance Company of the State of Pennsylvania (ISOP) and Great Northern Insurance Company (Great Northern). Both policies provided primary coverage. Employee pursued a workers’ compensation claim. Employer gave notice of the claim only to ISOP. ISOP began making payments pursuant to the policy and defended the claim. When ISOP learned that Employer also had workers’ compensation coverage under its Great Northern policy, ISOP filed a complaint against Great Northern seeking a judgment declaring that the doctrine of equitable contribution required Great Northern to pay one-half of the past and future defense costs and indemnity payments related to Employer’s claim. A federal district court granted summary judgment for Great Northern. ISOP appealed, and the United States Court of Appeals for the First Circuit certified a question to the Supreme Court. The Court answered that, where two primary workers’ compensation insurance policies provide coverage for the same loss arising from an injury to an employee, the insurance company that pays that loss has a right of equitable contribution from the coinsurer, regardless of whether the insured gives notice of the injury only to one insurer. View "Ins. Co. of State of Penn. v. Great N. Ins. Co." on Justia Law

The City appealed the trial court's issuance of a writ of mandate authorizing the Board to exercise its discretion, previously delegated to it by the City in an ordinance, to set the maximum subsidy contributed by the City to police and firefighter retirees‟ insurance premiums without regard to later City ordinances “freezing” the subsidy until review and increase by the City Council and requiring payment of a voluntary contribution to join an opt-in program. The court agreed with the City's contention that the trial court's grant of a writ of mandate was in error because the City Charter grants the City Council the authority to set the amount of the subsidy and, as a consequence, the Delegation Ordinance can neither restrict the Council's authority nor create a vested right to a Board-determined subsidy as such would conflict with the Charter. Accordingly, the court reversed and remanded. View "Fry v. City of L.A." on Justia Law

Government Employees Insurance Company, GEICO General Insurance Company, GEICO Casualty Company, and GEICO Indemnity Company (collectively, GEICO), as relator, brought a qui tam action asserting statutory and common law claims for damages and civil penalties against Dr. Janice Cruz (and others) arising from her alleged involvement in an insurance fraud conspiracy. The trial court granted Cruz's motion to bind GEICO to certain interrogatory responses, then granted her summary judgment motion on the basis those responses established GEICO was unable to prove its case against Cruz. On appeal, GEICO argued the trial court erred by: (1) binding GEICO to its earlier interrogatory responses; (2) excluding additional evidence offered in opposition to the summary judgment motion; and (3) granting summary judgment on its statutory claim. The Court of Appeal concluded the trial court erred in binding GEICO to its interrogatory responses, and further, found multiple instances of issues of triable facts that should not have been disposed of through summary judgment. The Court accordingly reversed the trial court and remanded the case for further proceedings. View "California ex rel. Gov. Employees Ins. Co. v. Cruz" on Justia Law

Erie Insurance Property and Casualty Company submitted to the Virginia Insurance Commissioner a rate, form, and product filing seeking approval for a new product endorsement entitled Rate Protection Endorsement (RPE). The Commissioner approved the Erie filing, as amended. Respondent, an Erie insured, filed an administrative complaint against Erie seeking a determination as to whether the Commissioner’s approval of Erie’s RPE should be withdrawn. The Commissioner denied Respondent relief. The circuit court reversed, concluding that the Commissioner was statutorily required to withdraw approval of Erie’s RPE. The Supreme Court reversed, holding that the circuit court engaged in an improper re-examination of Erie’s rate and form policy filing for its RPE that was approved by the Commissioner, and therefore, the circuit court erred in reversing the decision of the Commissioner. View "Erie Ins. Prop. & Cas. Co. v. King" on Justia Law

The State of Mississippi brought a civil action against generic pharmaceutical provider Sandoz, Inc., alleging that Sandoz impermissibly exploited Mississippi’s Medicaid reimbursement program by routinely and exponentially reporting fictitious “Average Wholesale Prices,” a key data factor in the federally supervised formula used by the Mississippi Division of Medicaid to reimburse pharmacies serviced by Sandoz. The trial court, sitting as fact-finder, found Sandoz in violation of the Mississippi Consumer Protection Act and liable for common-law fraud. Sandoz appealed, and the State cross-appealed. On a deferential standard of review, the Supreme Court affirmed the trial court in full. View "Sandoz, Inc. v. Mississippi" on Justia Law

Five separate groups of Pennsylvania-domiciled insurance companies (collectively, “Claimants”) were authorized to provide workers’ compensation coverage in Tennessee. As a result of an audit conducted by the State of Tennessee, Claimants were required, under Tennessee’s retaliatory tax statute, to recalculate their Tennessee taxes to include certain Pennsylvania workers’ compensation charges, file amended tax returns, and remit payment of the additional taxes totaling over $16 million. Claimants paid the taxes under protest. Each Claimant subsequently filed a complaint with the Tennessee Claims Commission (the “Commissioner”) seeking a refund of the retaliatory taxes paid under protest. The Commissioner issued five identical judgments, each granting summary judgment in favor of the State. The Court of Appeals affirmed. The Supreme Court reversed, holding that because the Pennsylvania workers’ compensation assessments were no longer paid by the insurance companies but were imposed on the employer-policyholders in conjunction with their premium payments, the administrative task of collecting and remitting those payments did not qualify as a burden on the insurance companies for purposes of the retaliatory tax. View "Chartis Casualty Co. v. State" on Justia Law