Justia Insurance Law Opinion Summaries

American Building Innovation LP (ABI) was hired by Balfour Beatty Construction, LLC (Balfour Beatty) as a subcontractor for a school construction project. ABI had a workers’ compensation insurance policy when it began work, but the policy was canceled due to ABI’s refusal to pay outstanding premiums from a previous policy. This cancellation led to the automatic suspension of ABI’s contractor’s license. Despite knowing it was unlicensed and uninsured, ABI continued working on the project.The Superior Court of Orange County found that ABI was not duly licensed at all times during the performance of its work, as required by California law. ABI’s license was suspended because it failed to maintain workers’ compensation insurance. ABI later settled its premium dispute and had the policy retroactively reinstated, but the court found this retroactive reinstatement meaningless because it occurred long after the statute of limitations for any workers’ compensation claims had expired. The court ruled that ABI could not maintain its action to recover compensation for its work due to its lack of proper licensure.The California Court of Appeal, Fourth Appellate District, Division Three, affirmed the lower court’s judgment. The court held that ABI was not entitled to retroactive reinstatement of its license because the failure to maintain workers’ compensation insurance was not due to circumstances beyond ABI’s control. ABI’s decision not to pay the premiums and its false representations to the Contractors’ State License Board were within its control. Consequently, ABI was barred from bringing or maintaining the action under section 7031 of the Business and Professions Code. The court also affirmed the award of attorney fees to Balfour Beatty under the subcontract’s prevailing party attorney fee provision. View "American Building Innovations v. Balfour Beatty Construction" on Justia Law

Mychal Byrd was injured in an automobile accident caused by an unknown motorist and subsequently died from his injuries. Byrd's medical expenses, totaling $474,218.24, were covered by the Gilster-Mary Lee Corporation Group Health Benefit Plan, a self-funded plan subject to ERISA. Byrd had an automobile insurance policy with Nationwide Insurance Company, which provided $50,000 in uninsured-motorist coverage. After Byrd's death, his family sued Nationwide in state court to collect the insurance proceeds. The Plan intervened, removed the case to federal court, and claimed an equitable right to the insurance proceeds.The United States District Court for the Eastern District of Missouri granted summary judgment in favor of the Plan, determining that the Plan was entitled to the insurance proceeds under the plan document. The plaintiffs, initially proceeding pro se, did not respond to the motion for summary judgment. After obtaining counsel, they moved for reconsideration, which the district court denied. The plaintiffs then appealed the decision.The United States Court of Appeals for the Eighth Circuit reviewed the case and concluded that the district court lacked subject-matter jurisdiction. The appellate court determined that the plaintiffs' claim did not fall within the scope of ERISA's civil enforcement provisions because the plaintiffs were neither plan participants nor beneficiaries. Consequently, the claim was not completely preempted by ERISA, and the federal court did not have jurisdiction. The Eighth Circuit vacated the district court's judgment and remanded the case with instructions to return it to Missouri state court. View "Kellum v. Gilster-Mary Lee Corporation Group Health Benefit" on Justia Law

Plaintiffs Nhiem Tran and Nung Ha had a fire insurance policy with Nationwide General Insurance Company. Nationwide canceled the policy due to property hazards, including an unfenced swimming pool and rotting wood. Nationwide mailed a cancellation notice on May 22, 2015, and terminated the policy on June 6, 2015. Plaintiffs claimed they never received the cancellation letter but did receive, sign, and cash a refund check for the excess premium over a month before their house burned down on July 24, 2015. Nationwide denied their insurance claim, leading to this lawsuit.The Superior Court of Wake County found that Nationwide had properly canceled the policy by mailing the cancellation notice, satisfying statutory requirements. The Court of Appeals reversed, holding that the statute required actual receipt of the cancellation notice. Nationwide appealed, and the Supreme Court of North Carolina remanded the case to determine the applicable statute. On remand, the trial court again ruled in favor of Nationwide, and the Court of Appeals affirmed, stating that proof of mailing was sufficient for cancellation.The Supreme Court of North Carolina reviewed the case and affirmed the Court of Appeals' decision but on different grounds. The Court held that plaintiffs had actual notice of the cancellation due to several factors: their prior knowledge of property hazards, receipt and cashing of the refund check, and the cessation of monthly premium withdrawals. The Court emphasized that actual notice was sufficient to meet statutory requirements, making the manner of giving notice secondary. Therefore, Nationwide effectively canceled the policy before the fire, and the judgment for Nationwide was affirmed. View "Ha v. Nationwide Gen. Ins. Co" on Justia Law

Donna Vanek, an employee of a construction company, was driving her personal Kia Optima to pick up supplies when a semitruck struck her car, killing her and her young nephew. The company’s Ford F-250, which Vanek would have used for the task, was in the repair shop at the time. The estates of Vanek and her nephew sued Ohio Casualty Insurance Company, arguing that the Kia qualified as a "temporary substitute" for the F-250 under the company’s insurance policy.The United States District Court for the Eastern District of Kentucky granted summary judgment to Ohio Casualty, ruling that the Kia did not qualify as a "temporary substitute" under the policy. The court accepted Ohio Casualty’s interpretation that a non-covered vehicle could not be a "temporary substitute" unless all covered vehicles were out of service.The United States Court of Appeals for the Sixth Circuit reviewed the case and reversed the district court’s decision. The appellate court held that a reasonable jury could find that the Kia qualified as a "temporary substitute" for the F-250. The court noted that witnesses testified Vanek would have used the F-250 if it had been available and that the Kia was used temporarily while the F-250 was in the shop. The court rejected Ohio Casualty’s interpretation that all covered vehicles must be out of service for a vehicle to qualify as a "temporary substitute," finding no basis for this in the policy’s text. The case was remanded for further proceedings consistent with this opinion. View "Olenik v. Ohio Casualty Insurance Co." on Justia Law

Acuity issued a commercial auto policy to Terra-Tek, LLC, which included John Waba and Sheila Foreman as additional named insureds. Waba was injured in an auto accident with an underinsured motorist while driving a vehicle not listed under Terra-Tek’s policy. Acuity denied Waba’s claim for underinsured motorist (UIM) benefits, arguing that the vehicle he was driving was not covered under the policy. Acuity then sought a declaratory judgment to confirm that Waba was not entitled to UIM benefits.The Circuit Court of the First Judicial Circuit in Brule County, South Dakota, reviewed the case. The court found that the UIM endorsement in Terra-Tek’s policy unambiguously provided coverage to Waba for the injuries sustained in the accident, despite the vehicle not being listed as a covered auto. The court granted summary judgment in favor of Waba, determining that the policy’s language did not require Waba to be occupying a covered auto to receive UIM benefits. Acuity appealed this decision.The Supreme Court of the State of South Dakota affirmed the lower court’s decision. The court held that the UIM endorsement’s language did not limit coverage to injuries sustained while occupying a covered auto. The court noted that the policy’s definition of an insured for UIM coverage did not include such a limitation, unlike the liability coverage section, which explicitly required the insured to be occupying a covered auto. The court concluded that the policy provided UIM coverage to Waba for the accident, affirming the circuit court’s judgment in favor of Terra-Tek and Waba. View "Acuity V. Terra-Tek" on Justia Law

This case involves a dispute over insurance coverage following a family business conflict. Brian Flood and his sons, Chris and Shawn, were involved in a waste collection business, Flood Brothers Waste Disposal Company. After being pushed out of the family business, they started a new company, S.B.C. Flood Waste Solutions, Inc. They obtained insurance from Grinnell Mutual Reinsurance Co. without disclosing the ongoing dispute with Flood Brothers over the use of the "Flood" name. When Flood Brothers sued them for improper use of the name, they sought coverage from Grinnell, which refused and sought to rescind the policies due to material misrepresentations.The United States District Court for the Northern District of Illinois granted summary judgment in favor of Grinnell, finding that S.B.C. Flood Waste Solutions, Inc. had made material misrepresentations in their insurance applications. The court identified three categories of false statements: failure to disclose potential claims or occurrences, failure to disclose the existence of another business venture (Flood, Inc.), and misrepresenting the start date of business activities. The court found these misrepresentations material based on the testimony of Grinnell’s underwriter, who stated that the insurance would not have been issued if the true facts were known.The United States Court of Appeals for the Seventh Circuit affirmed the district court’s decision. The appellate court agreed that the misrepresentations were material under Illinois law, which allows for rescission of an insurance policy if a false statement materially affects the acceptance of risk. The court emphasized that the undisclosed dispute and the existence of Flood, Inc. were significant factors that would have influenced Grinnell’s decision to issue the policies. The court did not need to address the alter ego argument, as the material misrepresentations alone were sufficient to justify rescission. View "Grinnell Mutual Reinsurance Company v. S.B.C. Flood Waste Solutions, Inc." on Justia Law

Malcolm H. Wiener, the plaintiff, purchased three life insurance policies from AXA Equitable Life Insurance Company in 1986. Over the years, Wiener's policies lapsed multiple times due to insufficient funds, but he managed to reinstate them each time. In 2013, the policies lapsed again, and AXA terminated them after Wiener failed to make the necessary payments within the grace period. Wiener claimed that AXA and his insurance agent, David Hungerford, caused the lapse by not sending premium notices and by changing the mailing address without his authorization. He also alleged that AXA wrongfully denied his application to reinstate the policies.The United States District Court for the Southern District of New York granted summary judgment in favor of AXA and Hungerford on all claims. The court found that AXA was not obligated to send premium notices after the policies lapsed and that Wiener had waived any objection to the address change by acquiescing for nearly five years. The court also concluded that Hungerford had no duty to notify Wiener of the lapse. Regarding the reinstatement claim, the court ruled that AXA's denial was not arbitrary and capricious, as it was based on Wiener’s low serum albumin levels, which were consistent with AXA’s underwriting guidelines.The United States Court of Appeals for the Second Circuit affirmed the district court’s summary judgment on the termination claims, agreeing that Wiener could not show that AXA’s failure to send premium notices caused the policies to lapse and that he had waived any objection to the address change. However, the appellate court vacated the summary judgment on the reinstatement claim, finding that there were genuine disputes of material fact regarding the actual reasons for AXA’s denial and whether those reasons were arbitrary. The case was remanded for further proceedings on the reinstatement claim. View "Wiener v. AXA Equitable Ins. Co." on Justia Law

Paul Carnes, an employee of Consolidated Grain and Barge Co., was diagnosed with degenerative disc disease in 2019 and received medical treatment for it. HMO Louisiana, Inc., the administrator of Consolidated Grain’s employer-sponsored health plan governed by ERISA, paid for some of Carnes’s treatments but not all. Carnes filed a workers’ compensation claim against his employer, which was settled without the employer accepting responsibility for his medical claims. With an outstanding medical balance of around $190,000, Carnes sued HMO Louisiana, alleging it violated Illinois state insurance law by not paying his medical bills and sought penalties for its alleged "vexatious and unreasonable" conduct.The United States District Court for the Central District of Illinois dismissed Carnes’s complaint on the grounds that his state law insurance claim was preempted by ERISA. The court allowed Carnes to amend his complaint to plead an ERISA claim, but instead, Carnes moved to reconsider the dismissal. The district court denied his motion and ordered the case closed. Carnes then appealed the final order.The United States Court of Appeals for the Seventh Circuit reviewed the case de novo. The court affirmed the district court’s decision, agreeing that Carnes’s state law claim was preempted by ERISA. The court noted that ERISA’s broad preemption clause supersedes any state laws relating to employee benefit plans, and Carnes’s claim fell within this scope. The court also found that ERISA’s saving clause did not apply because the health plan in question was self-funded, making it exempt from state regulation. The court concluded that Carnes’s attempt to frame his suit as a "coordination of benefits dispute" was an impermissible effort to avoid ERISA preemption. Consequently, the court affirmed the dismissal of Carnes’s case. View "Carnes v. HMO Louisiana, Inc." on Justia Law

Joel M. Guy, Jr. murdered his parents in 2016 with the intent to collect the proceeds from his mother’s insurance plans. His mother had life insurance and accidental death and dismemberment insurance through her employer, naming Guy and his father as beneficiaries. Guy was convicted of first-degree premeditated murder, felony murder, and abuse of a corpse by a Tennessee jury.The United States District Court for the Eastern District of Tennessee determined that Guy would be entitled to the insurance proceeds if not disqualified. However, the court ruled that Guy was disqualified under Tennessee’s slayer statute or federal common law, which prevents a murderer from benefiting from their crime. The court granted summary judgment in favor of Guy’s family members, who argued that Guy was not entitled to the benefits. Guy appealed, arguing that ERISA preempts Tennessee’s slayer statute and that no federal common-law slayer rule applies.The United States Court of Appeals for the Sixth Circuit reviewed the case de novo. The court held that ERISA does not explicitly address the issue of a beneficiary who murders the insured, and thus, either Tennessee law or federal common law must apply. The court found that both Tennessee’s slayer statute and federal common law would disqualify Guy from receiving the insurance proceeds. The court affirmed the district court’s decision, concluding that Guy’s actions disqualified him from benefiting from his mother’s insurance plans under both state and federal law. View "Standard Insurance Co. v. Guy" on Justia Law

In 2013, Johnny Ray Penegar, Jr. was diagnosed with mesothelioma, and Medicare partially covered his treatment costs. He filed a workers' compensation claim against his employer, UPS, and its insurer, Liberty Mutual. After his death, his wife, Carra Jane Penegar, continued the claim and added a death benefits claim. The North Carolina Industrial Commission (NCIC) ruled in her favor, ordering Liberty Mutual to cover all medical expenses related to the mesothelioma and reimburse any third parties, including Medicare. The NCIC's decision was affirmed by the North Carolina Court of Appeals and the Supreme Court of North Carolina denied further review. In 2020, Penegar and Liberty Mutual settled, with Liberty Mutual agreeing to pay $18,500 and to handle any Medicare liens.Penegar filed a class action lawsuit in the Western District of North Carolina under the Medicare Secondary Payer Act (MSP Act), alleging that Liberty Mutual failed to reimburse Medicare, leading to a collection letter from the Centers for Medicare and Medicaid Services (CMS) demanding $18,500. Liberty Mutual moved to dismiss, arguing Penegar lacked standing and that the settlement precluded her claims. The district court agreed, finding Penegar lacked standing and dismissed the case.The United States Court of Appeals for the Fourth Circuit reviewed the case and affirmed the district court's decision. The court held that Penegar did not suffer a cognizable injury in fact at the time she filed the lawsuit. The NCIC had ordered Liberty Mutual to reimburse Medicare directly, not Penegar, distinguishing her case from Netro v. Greater Baltimore Medical Center, Inc. Additionally, the CMS letter only posed a risk of future harm, which is insufficient for standing in a damages suit. Finally, any out-of-pocket expenses Penegar incurred were already compensated by Liberty Mutual before she filed the lawsuit, negating her claim of monetary injury. View "Penegar v. Liberty Mutual Insurance Co." on Justia Law