Justia Insurance Law Opinion Summaries

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

The State enacted an Act in 2011 pursuant to which health insurers were required to disclose, upon written request from a public school district, aggregate loss information pertaining to any group policies held by the district's employees. Maine Education Association Benefits Trust, which managed a statewide health insurance plan for a substantial segment of Maine's public school work force, subsequently filed suit in the district court, seeking to permanently enjoin the law prior to its enforcement. The Trust alleged that because its information constituted a confidential trade secret, the Act's disclosure requirement resulted in an uncompensated taking proscribed by the Fifth Amendment. The district court denied the Trust's motion for a preliminary injunction. The Supreme Court affirmed, holding that the Trust did not have a reasonable likelihood of success on the merits of its takings claim. View "Me. Educ. Ass'n Benefits Trust v. Cioppa" on Justia Law

In a 2009 opinion, the Sixth Circuit held that, in a 1998 collective bargaining agreement, CNH agreed to provide health-care benefits to retirees and their spouses for life, but rejected the suggestion that the scope of this commitment in the context of healthcare benefits, as opposed to pension benefits, meant that CNH could make no changes to the healthcare benefits provided to retirees. The court remanded for a determination of reasonableness with respect to CNH’s proposed changes to its retiree healthcare benefits, under which retirees, previously able to choose any doctor without suffering a financial penalty, would be put into a managed-care plan. The court listed three considerations: Does the modified plan provide benefits “reasonably commensurate” with the old plan? Are the proposed changes “reasonable in light of changes in health care”? And are the benefits “roughly consistent with the kinds of benefits provided to current employees”? On remand, the district court granted CNH summary judgment without reaching the reasonableness question or creating a factual record from which the determination could be made on appeal. The Sixth Circuit again remanded.View "Reese v. CNH America LLC" on Justia Law

Adams worked in coal mines for 17 years, leaving A & E Coal in 1988, after 12 years, because he was having difficulty breathing. He has not worked since. Adams also smoked cigarettes for about 25 years, averaging a pack a day before quitting in 1998 or 1999. Adams filed his first claim for benefits under the Black Lung Benefits Act 30 U.S.C. 901 in 1988. His claim was denied: He did not prove that his pneumoconiosis was caused in part by his coal-mine work, or that his pneumoconiosis totally disabled him. In 2007, Adams filed a second claim. Two pulmonologists agreed that he was completely disabled, but disagreed on what lung diseases Adams had, and on what caused them. An Administrative Law Judge awarded benefits, finding that Adams had pneumoconiosis, that the disease was caused by Adams’s exposure to coal dust during his coal-mine employment, and that he was totally disabled because of the disease. The Benefits Review Board and the Third Circuit affirmed. Although the ALJ was not required to look at the preamble to the regulations to assess the doctors’ credibility, he was entitled to do so. View "A & E Coal Co. v. Adams" on Justia Law

Four plaintiffs each established an employee benefit plan under the Employee Retirement Income Security Act funded by a combination of employer contributions and covered employee payroll deductions; each entered into a Benefit Management Service Agreement with PBA, which specified that PBA would provide services, such as paying medical providers for claims incurred under the Plans. Each Agreement required PBA to establish a segregated bank account for each Plan into which it would deposit the funds that it received from the corresponding plaintiff for paying the medical claims and authorized PBA to pay medical claims by writing checks from this account. PBA not only failed to use funds supplied by plaintiffs to pay the claims incurred under the corresponding Plan, but commingled and misappropriated Plan funds. PBA did not pay all claims, despite receiving money for payment of those claims from the respective plaintiffs. The amounts unpaid for the plaintiffs are: $501,380.75, $409,943.88, $384,574.17, and $44,290.12. The district court found that PBA was a fiduciary under ERISA (29 U.S.C. 1002(21)(A)), had breached its fiduciary duties, and that ERISA preempted Permco’s breach-of-contract claims. The Sixth Circuit affirmed. View "Guyan Int'l, Inc. v. Prof'l Benefits Adm'rs, Inc." on Justia Law

Jeranek, a beneficiary of the Humana Plan, was hospitalized in 2006. Three days later, she was admitted at Nu-Roc Nursing Home. She was 88 years old and suffered from a variety of maladies that required her to use 14 prescription medications. A physician estimated at the time of her admission that Jeranek had a life expectancy of about one year. Jeranek was a resident at Nu-Roc for 702 days. On several occasions she declined medical treatment and her physician understood that she was to receive comfort care only. From November 15 until November 19, 2006, Jeranek’s stay at Nu-Roc was paid for by Medicare. Humana paid $50,097.67 to Nu-Roc for services provided from November 20, 2006, to September 30, 2007, but later determined that its disbursement had been a mistake, reasoning that “custodial” care was not covered by the Plan. Humana sought reimbursement for its previous payments and denied coverage for October 1, 2007 through October 22, 2008, when costs for Jeranek’s care totaled $64,669.74. The district court determined that Humana’s denial of coverage was not arbitrary and granted summary judgment for the Plan. The Seventh Circuit affirmed. View "Becker v. Chrysler LLC Health Care Benefits Plan" on Justia Law

In this putative class action, Plaintiffs were doctors of chiropractic who alleged they had been victimized by the discriminatory practices of Iowa's largest health insurer, Wellmark, Inc. The district court (1) granted Wellmark's motion to dismiss claims brought under Iowa's insurance regulatory statutes because no private cause of action was provided therein; (2) granted Wellmark's motion for summary judgment on Plaintiffs' antitrust claims based on the "state action" exemption found in Iowa Code 553.6(4); (3) granted summary judgment on claims alleging Wellmark breached its obligations under a judicially approved national class action settlement in Love v. Blue Cross Blue Shield Ass'n; and (4) granted summary judgment on several specific antitrust claims. The Supreme Court (1) reversed in part, holding that the district court erred in granting summary judgment on Plaintiffs' antitrust claims based on the state action exemption, as the record failed to establish the challenged conduct fell within the exemption; and (2) otherwise affirmed. Remanded. View "Mueller v. Wellmark, Inc." on Justia Law

A "discrete, narrow legal question" came before the Supreme Court: is a health care provider who has received an assignment of personal injury protection (PIP) benefits from an insured obligated upon request to furnish to the insurer broad information with respect to the provider’s ownership structure, billing practices, and regulatory compliance? Plaintiffs in this matter consist of six “Selective Insurance Company” entities. Individuals insured by Selective sought medical treatment from defendants for injuries received in automobile accidents. Those insureds assigned to defendants the benefits to which they were entitled under their PIP coverage, giving defendants the contractual right to seek PIP reimbursement under those policies. In reviewing claims submitted for payment, Selective detected what it considered to be suspicious patterns in both the treatments defendants had provided and the corporate links among the treating entities. Selective requested that defendant supply to it a variety of data with respect to their ownership, structure, billing practices, and compliance with certain regulations. In support of its request, Selective cited the provision within the insureds’ insurance policies requiring the insureds to cooperate with Selective in the investigation of any claim under the policy. When defendants refused to supply the material Selective sought, Selective sued, alleging that defendants' failure to supply the information was a breach of they duty to cooperate and a violation of the PIP discovery statute. After hearing oral argument, the trial court denied defendants’ motion to dismiss and granted Selective the relief it had requested by directing defendants to respond to Selective’s discovery requests. Defendants thereafter moved for reconsideration, but the trial court denied that motion, together with defendants’ request for a stay. Upon review of the matter, the Supreme Court held that an insured had no duty to provide information to plaintiff with respect to the ownership structure, billing practices, or referral methods of the medical providers from whom he or she sought treatment for his or her injuries. Because an insured had no obligation to supply that information to plaintiff, the assignment of benefits executed by an insured could not serve to impose that duty on the providers. View "Selective Insurance Company of America v. Hudson East Pain Management" on Justia Law

This suit was filed by a daughter against an organ donation charity when she discovered that the charity - contrary to an earlier representation to her - would allegedly profit from harvesting her deceased mother's tissues. The charity requested a defense from its insurer, and the insurer denied a defense. The insurer's subsequent suit against the charity resulted in two certified questions from the Fifth Circuit Court of Appeals. The Supreme Court held (1) the insurance policy provision for coverage of "personal injury" does not include coverage for mental anguish, unrelated to physical damage to or disease of the daughter's body; and (2) the insurance policy provision for coverage of "property damages," does not include coverage for the underlying plaintiff's loss of use of her deceased mother's tissues, organs, bones, and body parts. View "Evanston Ins. Co. v. Legacy of Life, Inc." on Justia Law