Justia Insurance Law Opinion Summaries

Aetna, Inc. filed a coordinated complaint with Kaiser Foundation Health Plan and Kaiser Foundation Hospitals (together, Kaiser) and Guardian Life Insurance Company (Guardian) against Pfizer, Inc. and Warner-Lambert Company (together, Pfizer). The coordinated plaintiffs asserted that they had suffered injury from the fraudulent marketing of Neurontin for off-label uses, and alleged violations of, inter alia, the Racketeer Influenced and Corrupt Organizations Act (RICO) and the Pennsylvania Insurance Fraud Statute (PIFS). The district court dismissed the claims of Guardian and Aetna but denied summary judgment as to Kaiser's claims. The court then entered judgment against Guardian and Aetna and in favor of Pfizer. The First Circuit Court of Appeals (1) reversed the dismissal of Aetna's RICO claim, as Aetna presented evidence of causation and damages sufficient to survive summary judgment; and (2) vacated the district court's dismissal of Aetna's claim under the PIFS. Remanded. View "Aetna, Inc. v. Pfizer, Inc." on Justia Law

Appellant Altrua HealthShare appealed the district court's decision affirming the Idaho Department of Insurance's (Department) determination that Altrua transacted insurance without a certificate of authority. Altrua argued that both the Department and the Ada County district court erred in finding that Altrua was an insurer because Altrua never assumed the risk of paying its members' medical bills. The Department found, and the district court affirmed, that when members make their predetermined monthly payments into the escrow account Altrua operates, the risk of payment shifts from the individual members to the escrow account, and in turn to Altrua. Altrua also contended that the Department's determination that it is an insurer despite the disclaimers in its membership contract to the contrary is an unconstitutional interference with Altrua's right to contract. Upon review, the Supreme Court found that the Department's conclusion that Altrua's membership contract was an insurance contract was clearly erroneous, and reversed the findings. The case was remanded for further proceedings. View "Altrua Healthshare v. Deal" on Justia Law

The insureds in this case filed suit against their insurers claiming they were unaware their insurance policy had a $250,000 per-claim deductible and alleging that the insurer breached its insurance contract by refusing to provide a defense until the they paid the $250,000 deductible for each of five separate claims. The circuit court granted summary judgment for the insurers and the insureds appealed. Upon review of the circuit court record, the Supreme Court affirmed the circuit court’s grant of summary judgment. View "Southern Healthcare Services, Inc. v. Lloyd's of London" on Justia Law

Pearl Archambault died while in the care of Haven Health Center of Greenville (Haven Health) after a nurse mistakenly administered a lethal overdose of morphine. The administratrix of her estate, Plaintiff, filed a medical malpractice action against Haven Health. Health Haven subsequently filed for Chapter 11 bankruptcy. Thereafter, Plaintiff amended her complaint to add Columbia Casualty Company, the professional liability insurer of Health Haven, as a defendant and asserted two counts against Columbia directly based on R.I. Gen. Laws 27-7-2.4, which permits an injured party to proceed against an insurer when the insured has filed for bankruptcy. The superior court entered default judgment against Haven Health. The court then granted summary judgment in favor of Columbia. The Supreme Court reversed and remanded with instructions to enter judgment against Columbia, holding that the superior court erred in interpreting Rhode Island law and that the insurance contract between Columbia and Health Haven should be construed in Plaintiff's favor. View "Peloquin v. Haven Health Ctr. of Greenville, LLC" on Justia Law

USCA is a non-profit national civic league with approximately 27,000 members that devotes itself to conservative values and opposes efforts of the federal government to interfere with market processes. Some of USCA’s uninsured members object to the purchase of private health insurance because they do not believe in the effectiveness of traditional medicine, prefer alternative and integrative medicine, or prefer to focus on preventative care that is not covered by traditional health insurance policies. Two individual plaintiffs do not have, nor do they wish to acquire, health insurance, but they are not exempt from the Patient Protection and Affordable Care Act’s individual mandate, 26 U.S.C. 5000A. They challenged the mandate as violating the Commerce Clause, rights to freedom of expressive and intimate association, rights to liberty, and rights to privacy. The district court dismissed in part, without substantive analysis, holding that plaintiffs failed to satisfy the “plausibility standard” and entered summary judgment on the Commerce Clause challenge. The Sixth Circuit affirmed, stating that the Supreme Court’s opinion in National Federation of Independent Business v. Sebelius controls the outcome on the Commerce Clause count and the remaining constitutional claims were correctly dismissed for failure to state a claim. View "U.S. Citizens Ass'n v. Sebelius" on Justia Law

Since enacting a program for black-lung benefits in 1969, known as the Black Lung Benefits Act,83 Stat. 742, Congress has repeatedly amended the claim-filing process, sometimes making it harder for miners and survivors to obtain benefits, sometimes making it easier. The most recent adjustment, part of the 2010 Patient Protection and Affordable Care Act, reinstated a presumption that deceased workers who had worked for at least 15 years in underground coal mines and had developed a totally disabling respiratory or pulmonary impairment were presumed to be totally disabled by pneumoconiosis and to have died from it. The presumption is rebuttable. The Act also reinstated automatic benefits to any survivor of a miner who had been awarded benefits on a claim filed during his lifetime, 124 Stat. at 260. Groves, a miner for 29 years, filed a claim for benefits in 2006 and died four months later. An ALJ denied his widow benefits. The law changed while her appeal was pending. The Benefits Review Board concluded that the new law covered this claim. The Sixth Circuit affirmed. View "Vision Processing, LLC v. Groves" on Justia Law

Plaintiff filed a medical malpractice action against a dentist (Dentist) and his dental practice, alleging that Dentist's failure to diagnose and treat his dental conditions resulted in a bone infection and a worsening of his dental problems, which caused severe and permanent physical and emotional damage. In preparation for trial, there was an ex parte predeposition conference conducted between Plaintiff's nonparty treating physician and counsel provided by Defendant's insurance company. Plaintiff contended that the ex parte meeting violated the State's physician-patient confidentiality statute as delineated in Fla. Stat. 456.057(8). The Supreme Court held that section 456.057 prohibits such meetings and quashed the decision of the Fourth District holding otherwise. In particular, the Court held that an ex parte meeting such as the one attempted here is prohibited irrespective of whether the attorney and physician claim they will discuss only non-privileged matters. View "Hasan v. Garvar" on Justia Law

When Cody Metheny underwent brain surgery, the physician (Doctor) mistakenly operated on the wrong side of his brain. Fifteen months later, Cody's parents (the Methenys) learned tissue had been removed from the wrong side of Cody's brain. The Methenys filed a direct-action suit, alleging medical negligence on the part of Hospital where Doctor practiced and against Hospital's liability-insurance carrier (Insurer). The jury returned a verdict in favor of the Methenys. Insurer appealed, arguing that the circuit court erred in (1) failing to instruct the jury in a manner that would allow it to apportion liability among it and certain physicians who were sued in a prior case but ultimately settled; (2) refusing to allow Insurer to present evidence of fault attributable to the settling physicians; and (3) denying Insurer's motion for judgment notwithstanding the verdict where the evidence supporting Cody's future damages was based on improperly bundled calculations. The Methenys cross-appealed the circuit court's order reducing the jury's verdict from $20 million to $11 million. The Supreme Court affirmed on direct appeal and cross-appeal, holding that the circuit court did not err in its judgment. View "ProAssurance Indem. Co. v. Metheny" on Justia Law

In the instant case, the Supreme Court was once again asked to consider whether medical protective orders are valid and enforceable to limit the dissemination and retention of medical records obtained through discovery. Such orders had been entered in lawsuits filed by plaintiffs seeking compensation for the injuries they sustained in motor vehicle accidents caused by other motorists. Repeatedly, the insurers from whom such compensation had been sought requested the West Virginia Supreme Court, the United States Supreme Court, and a federal district court to invalidate these protective orders as burdensome, restrictive, and/or unconstitutional. Each time the reviewing Court examined these medical protective orders, it upheld the order as substantively valid and enforceable as a proper exercise of the issuing court's supervisory authority over discovery. In the instant case, the Court again declined insurance companies' invitation to invalidate the subject medical protective orders, finding that the insurance companies' arguments were insufficient to overturn precedent. View "State ex rel. State Farm Mut. Auto. Ins. Co. v. Circuit Court" on Justia Law

Respondent Robert Lego admitted his wife to Porter Hospital's emergency room. She stayed there for approximately two months. The Legos' insurance provider notified Respondent in writing that it would stop covering Mrs. Lego's hospital care after six weeks. Respondent disputed the insurer's position and refused to discharge his wife from the hospital after six weeks. The hospital followed the insurer in notifying Respondent the insurance coverage for Mrs. Lego would end, and that the Legos would be responsible for any uncovered charges. In an effort to recoup those charges Respondent refused to pay, the hospital sued on the grounds of unjust enrichment with recovery in quantum meruit. Respondent moved to dismiss, arguing that the action was barred by a general statute of limitations codified in section 13-80-103.5(1)(a) C.R.S. (2011). The trial court denied the motion; the appellate court reversed, finding the trial court erred in determining the amount the insurance company did not pay was liquidated or determinable damages within the meaning of the statute. The Supreme Court reversed the appellate court, interpreting section 13-80-103.5(1)(a) C.R.S. (2011) to mean its six-year limitations period applied in this case, particularly when the amount owed was ascertainable either by reference to the agreement, or by simple computation using extrinsic evidence. View "Portercare Adventist Health System v. Lego" on Justia Law