Justia Insurance Law Opinion Summaries

After being diagnosed with fibromyalgia, chronic pain, anxiety, and depression, plaintiff was awarded long-term disability benefits under an employee benefit plan issued and administered by defendant. Benefits were discontinued about 24 months later, when defendant determined that plaintiff had received all to which she was entitled under the planâs self-reported symptoms limitation. Because plaintiff had retroactively received social security benefits, defendant also sought to recoup equivalent overpayments as provided by the plan. The district court dismissed. The Seventh Circuit reversed in part and remanded for reinstatement. The self-reported symptom limitation violates ERISA, 29 U.S.C., 1022; the policy sets out that long-term benefits will be discontinued after 24 months if disability is due to mental illness or substance abuse, but does not mention that the time limitation applies if a participantâs disability is based primarily on self-reported symptoms. The Social Security Act does not bar recovery of overpayments occasioned by receipt of social security benefits.

Respondent, on behalf of the estate of her deceased sister, filed suit against petitioner, a nursing home, alleging that while the sister was being cared for by petitioner, she was bitten by a brown recluse spider and died. At issue was whether the claims were healthcare liability claims that required an expert report to be served. The court held that the claims fell within the statutory definition of a health care liability claim and therefore, the statute required the suit to be dismissed unless respondent timely filed an expert report. Accordingly, the court granted the petition for review and reversed and remanded.

Carlin Jewett was employed as a welder by Real Tuff where Jewett often worked on his knees. In 2006, Jewett suffered a right knee injury. Jewett received arthroscopic surgery, during which the surgeon found pre-existing bilateral osteoarthritis in Jewett's knee. Jewett subsequently filed a petition with the state Department of Labor, seeking workers' compensation for a right knee replacement. Two years later, Jewett suffered a second work-related injury to his left knee. Jewett added a workers' compensation claim for diagnostic treatment of his left knee. The Department and the circuit court ruled that Jewell failed to sustain his burden of proof on the alternate theories that (1) work-related injuries to both knees were a major contributing cause of the need for medical treatment, and (2) the cumulative effect of Jewett's work-related activities was a major contributing cause of the osteoarthritis. On appeal, the Supreme Court affirmed, holding the Department and circuit court did not err in finding (1) Jewett's first injury was not a major contributing cause of Jewett's need for a right knee replacement, and (2) Jewett did not prove that working on his knees was a major contributing cause of his osteoarthritis.

Following the death of his mother, Jeffery McCabe asserted a medical malpractice claim against his mother's medical care providers, who agreed to a settlement sufficient to allow McCabe to petition Indiana Patient's Compensation Fund for additional compensation. McCabe then filed an action pursuant to the Adult Wrongful Death Statute (AWDS), seeking additional recovery from the Fund for, inter alia, medical expenses and attorney fees. The trial granted granted partial summary judgment to the Fund, finding that the AWDS does not allow recovery of attorney fees. The court of appeals affirmed. The Supreme Court reversed the entry of partial summary judgment, holding that reasonable attorney fees incurred in the prosecution of an action under the AWDS are within the damages permitted by the statute. Remanded.

This case involved the construction and application of a combined professional and general liability insurance policy issued by appellant to appellee where appellee requested a defense from appellant under the policy for a civil lawsuit. In that underlying suit, plaintiff alleged that while her mother was terminally ill, she consented to appellee's harvesting of some of her mother's organs and tissues after her mother's death and consented to the harvesting because appellee was a non-profit corporation. Appellee, instead, transferred the tissues to a for-profit company, which sold the tissues to hospitals at a profit. Appellee subsequently sought coverage under its general liability insurance with appellant and appellant denied coverage because the conduct alleged was outside the scope of the insurance policy's coverage. The court certified the following questions to the Supreme Court of Texas: (1) "Does the insurance policy provision for coverage of 'personal injury,' defined therein as 'bodily injury, sickness, or disease including death resulting therefrom sustained by any person,' include coverage for mental anguish, unrelated to physical damage to or disease of the plaintiff's body?" (2) "Does the insurance policy provision for coverage of 'property damage,' defined therein as 'physical injury to or destruction of tangible property, including consequential loss of use thereof, or loss of use of tangible property which has not been physically injured or destroyed,' include coverage for the underlying plaintiff's loss of use of her deceased mother's tissues, organs, bones, and body parts?"

Plaintiff Scott Hackett aggravated a pre-existing low back injury while working as a long distance truck driver for Western Express. After Hackett was terminated for reasons unconnected to his injury, Hackett filed a petition for award to the Workers' Compensation Board and was awarded ongoing partial incapacity benefits for a gradual injury to his lower back. When calculating Hackett's weekly wage, the hearing officer (1) excluded the nine cents per mile Hackett received as per diem pay, concluding that it was paid to cover special expenses, and (2) concluded that the per diem payments were not a fringe benefit that could be included to a limited extent in average weekly wage. Hackett appealed. The Supreme Court affirmed the hearing officer's decision but remanded for a recalculation of Hackett's fringe benefits pursuant to Me. W.C.B. R. ch. 1, 5(1).

This case involved a coverage dispute between St. Paul Fire & Marine Insurance Company ("St. Paul") and its insured where the insured wrote a recommendation letter for a former employee who later injured a patient. St. Paul appealed the district court's judgment, in which the court concluded that the commercial general liability policy issued by St. Paul covered the insured's claim for the damages he was required to pay in a misrepresentation lawsuit. The court held that there was no coverage under the policy for the amounts at issue and therefore, reversed the district court's judgment and remanded for entry of judgment in favor of St. Paul.

Appellant Robert Petty is sole owner of Co-Appellant R.G. Petty Masonry. Appellants contracted with Respondent Blue Cross of Northeastern Pennsylvania (Blue Cross), a nonprofit hospital corporation that provides health insurance coverage for its employees. Appellants are covered under the group policy as subscribers. Appellants filed a four-count class action suit against Blue Cross, alleging that it violated the state Nonprofit Law by accumulating excessive profits and surplus well beyond the "incidental profit" permitted by statute. The second count alleged Blue Cross breached its contract with Appellants by violating the Nonprofit Law. The third count alleged Blue Cross owed appellants a fiduciary duty by virtue of their status as subscribers, and that duty was breached when it accrued the excess surplus. The fourth count requested an inspection of Blue Cross' business records. The trial court found Appellants lacked standing to challenge Blue Cross' alleged violations of the Nonprofit Law and dismissed the suit. The Commonwealth Court affirmed the trial court. Upon careful consideration of the briefs submitted by the parties in addition to the applicable legal authorities, the Supreme Court found that Appellants indeed lacked standing under the Nonprofit Law to challenge Blue Cross by their four-count complaint. Accordingly, the Court affirmed the lower courts' decisions and dismissed Appellants' case.

Defendant appealed from a final judgment that was entered in favor of plaintiffs, as subrogees of Harbor Health Care and Rehabilitation Center, Inc. (collectively, "Harbor Health"). At issue was whether the superior court erred as a matter of law in denying his motion for summary judgment and renewed motion for judgment as a matter of law, both based upon the statute of limitations. Also at issue was whether the superior court erred as a matter of law in denying defendant's motion for judgment as a matter of law following the conclusion of plaintiffs' case-in-chief because plaintiffs failed to establish the element of causation in their claim against him. The court held that Harbor Health's claim for contribution was timely filed where a three-year statute of limitations separately governed contribution claims. The court also held that there was sufficient record evidence to support the jury's determination that the failure to have corrective surgery performed for the patient at issue was proximately caused by defendant's negligent conduct. Accordingly, the judgment of the superior court was affirmed.

Appellant Jane Henry, as the personal representative of the estate of her deceased husband Ernest, sued multiple parties, including Continental Casualty Company (Continental), Washington Regional Medical Center (Washington), Irma De La Cruz R.N., and Amber Hefner R.N. Among other things, Mrs. Henry asserted that Washington was vicariously liable for the conduct of its employees, including nurses De La Cruz and Hefner. Mrs. Henry proceeded against the hospital's insurer, Continental, under the state's "direct-action" statute. All Defendants moved to dismiss, because Mrs. Henry failed to obtain service of process on the nurses before the statute of limitations expired. Because Washington's alleged negligence arose from its vicarious liability based on the actions of the nurses, Defendants argued that claims against Washington and Continental must also be dismissed. The circuit court granted Defendants' motion, and Mrs. Henry appealed. The Supreme Court held that "because direct-action statutes are remedial in nature, we liberally construe them for the benefit of the injured parties and to effectuate the intended purposes." On review of the applicable case law, the Court found that failing include the nurses in this case was not fatal. Appellant could still pursue the hospital and its insurance carrier for the alleged negligence of its employees. The Court reversed the lower courts' decisions and remanded the case for further proceedings.