Justia Insurance Law Opinion Summaries

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

Plaintiffs, representing a class of drivers whose cars were totaled in accidents, alleged that their insurers, State Farm Mutual Automobile Insurance Company and State Farm Fire and Casualty Company, failed to pay the actual cash value of their vehicles. They contended that State Farm applied two unlawful discounts: a negotiation discount, which reduced the value based on typical buyer negotiations, and a condition discount, which adjusted for the car's condition compared to similar vehicles.The United States District Court for the Western District of Washington initially certified two classes: a negotiation class and a condition class. However, following the Ninth Circuit's decision in Lara v. First National Insurance Company of America, the district court decertified both classes and granted summary judgment in favor of State Farm, concluding that the plaintiffs failed to demonstrate injury.The United States Court of Appeals for the Ninth Circuit reviewed the case. The court reversed the district court's decertification of the negotiation class, holding that plaintiffs could prove injury on a class-wide basis by adding back the unlawful negotiation adjustment to determine the value each class member should have received. However, the court affirmed the decertification of the condition class, as determining injury required an individualized comparison of the unlawful condition adjustment and a hypothetical lawful adjustment.The Ninth Circuit also vacated the district court's summary judgment against the named plaintiffs, remanding the case for the district court to reassess whether the plaintiffs provided sufficient evidence of injury. The court clarified that plaintiffs could rely on the Autosource reports, minus the unlawful adjustments, as relevant evidence of injury. The court rejected State Farm's argument that Article III standing was a barrier to the plaintiffs' suit, affirming that the plaintiffs' claim of receiving less than owed under their insurance policies constituted a concrete injury. View "JAMA V. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY" on Justia Law

Christina Barrera, the office manager at PowerMed, was involved in a scheme to help unqualified individuals, mainly employees of AB InBev, fraudulently obtain disability benefits from the Social Security Administration (SSA) and private insurers. Patients paid PowerMed $21,600 for a "disability package" that included unnecessary medical tests and assistance in fraudulently applying for disability benefits. Barrera explained the scheme to patients, helped them complete paperwork, and coached them on how to appear disabled. An undercover officer's investigation led to Barrera's indictment and subsequent trial, where a jury found her guilty of conspiracy to defraud the SSA but acquitted her of health care fraud and theft of government funds.The United States District Court for the Eastern District of Missouri sentenced Barrera, ordering her to pay restitution to the SSA and private insurers. The presentence investigation report (PSR) recommended $339,407.80 in restitution to the SSA, but the Government argued for additional restitution to private insurers, totaling $203,907.62. The district court adopted the Government's figures, ordering Barrera to pay a total of $543,315.42 in restitution. After Barrera's sentencing, her co-conspirator Clarissa Pogue was sentenced but was not required to pay restitution to private insurers, leading Barrera to appeal.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court held that Barrera's criminal conduct included defrauding private insurers as part of the scheme to defraud the SSA, affirming the district court's decision to order restitution to private insurers. However, the court found errors in the calculation of restitution amounts for Prudential and MetLife, vacating those portions and remanding for further proceedings. The court rejected Barrera's argument regarding sentencing disparities with Pogue, emphasizing that the statutory direction to avoid unwarranted sentence disparities refers to national disparities, not differences among co-conspirators. The judgment was affirmed in part, vacated in part, and remanded. View "United States v. Barrera" on Justia Law

Cynthia Roberge, a State of Rhode Island employee, was involved in a car accident with an underinsured motorist while driving her personal vehicle during the course of her employment. She sought uninsured/underinsured motorist (UM/UIM) coverage under the State's insurance policy issued by Travelers Property Casualty Company of America. Travelers denied her claim, stating that she was not entitled to UM/UIM coverage because she was not driving a "covered auto" as defined by the policy.Roberge filed a lawsuit in Providence County Superior Court, asserting claims for breach of contract, declaratory judgment, and bad faith. Travelers removed the case to the United States District Court for the District of Rhode Island. The district court granted summary judgment in favor of Travelers, concluding that Roberge was not entitled to UM/UIM coverage under the policy's terms and that neither the Rhode Island Supreme Court's decision in Martinelli v. Travelers Insurance Companies nor the Rhode Island Uninsured Motorist Statute required such coverage.On appeal, the United States Court of Appeals for the First Circuit reviewed the case. The court noted that the policy's language clearly excluded Roberge from UM/UIM coverage because she was not driving a "covered auto." However, the court found that the case raised unresolved questions of Rhode Island insurance law, particularly regarding the applicability of the Martinelli exception and the requirements of the Rhode Island Uninsured Motorist Statute. The First Circuit decided to certify two questions to the Rhode Island Supreme Court: whether an employee must be considered a named insured under an employer's auto insurance policy when operating a personal vehicle in the scope of employment, and whether it violates Rhode Island law and public policy for an employer's policy to provide liability but not UM/UIM coverage to employees in such circumstances. The case was stayed pending the Rhode Island Supreme Court's response. View "Roberge v. Travelers Property Casualty Co. of America" on Justia Law

B.R.S. Real Estate, Inc. owned a commercial property in West Warwick, Rhode Island, which suffered extensive water damage in 2018 due to frozen and burst pipes. B.R.S. filed an insurance claim under a policy issued by Certain Underwriters at Lloyd's, London. Disagreements arose over the amount of the loss, leading to an appraisal process involving party-appointed appraisers and a neutral umpire. The appraisal panel issued an award, which B.R.S. contested, arguing that the appraiser appointed by the insurers was biased and that the district court erred in granting summary judgment on its claim for withheld depreciation.The United States District Court for the District of Rhode Island initially denied the defendants' motion to confirm the appraisal award, citing the need for discovery. After discovery, the court granted summary judgment for the defendants, concluding that no reasonable jury could find the appraiser biased or the umpire incompetent. The court also found that B.R.S. had not met the policy conditions for receiving the withheld depreciation, as the property had not been repaired or replaced for the same use.The United States Court of Appeals for the First Circuit reviewed the case and affirmed the district court's judgment. The appellate court held that the district court correctly applied the summary judgment standard and that B.R.S. could not challenge the appraiser's impartiality post-decision based on information known before the appraisal. The court also found that the umpire was competent and that B.R.S. failed to provide evidence that the property was repaired or replaced for the same use, as required by the policy. Consequently, the court upheld the denial of the withheld depreciation and confirmed the appraisal award. View "B.R.S. Real Estate, Inc. v. Certain Underwriters at Lloyd's, London" on Justia Law

Nevada Health CO-OP, a health insurance provider, received two loans from the Centers for Medicare & Medicaid Services (CMS) under the Affordable Care Act’s CO-OP program. These loans included a start-up loan and a solvency loan. In 2015, Nevada Health faced financial difficulties and was placed into receivership by the Nevada Commissioner of Insurance. CMS subsequently terminated the loan agreement and began offsetting payments owed to Nevada Health against the start-up loan debt.The United States Court of Federal Claims reviewed the case and granted summary judgment in favor of the Nevada Commissioner of Insurance, acting as the receiver for Nevada Health. The court found that the government improperly withheld statutory payments owed to Nevada Health under the ACA. The court also held that the government could not invoke 31 U.S.C. § 3728 to withhold these payments in the future.The United States Court of Appeals for the Federal Circuit reviewed the case. The court affirmed the lower court’s judgment that the government improperly withheld payments owed to Nevada Health. The court held that the loan agreement subordinated the government’s claim to those of policyholders and basic operating expenses, thus precluding the government from asserting offset rights to jump ahead of these senior creditors. However, the appellate court vacated the portion of the lower court’s order that addressed the government’s ability to invoke 31 U.S.C. § 3728, ruling that the lower court exceeded its jurisdiction by addressing this issue, which was not raised by the parties. View "Richardson v. United States" on Justia Law

John’s Grill, Inc., a restaurant in San Francisco, suffered significant financial losses during the COVID-19 pandemic and sought compensation from its property insurer, Sentinel Insurance Company, Ltd. Sentinel denied the claim, stating that the losses did not fall under the policy’s “Limited Fungi, Bacteria or Virus Coverage” endorsement, which only covers virus-related losses if the virus results from specific causes like windstorms or water damage. John’s Grill argued that this limitation made the virus-related coverage illusory and unenforceable.The San Francisco City and County Superior Court sustained Sentinel’s demurrer, finding the policy language clear and enforceable. The court reasoned that the specified causes of loss could potentially cause virus damage, thus the coverage was not illusory. The Court of Appeal reversed, agreeing with John’s Grill that the specified cause of loss limitation rendered the virus coverage illusory, as the listed causes were not realistically related to virus transmission. The appellate court held that the policy’s promise of virus-related coverage was illusory and allowed John’s Grill’s claims to proceed.The Supreme Court of California reversed the Court of Appeal’s decision. The court held that the policy’s specified cause of loss limitation was clear and unambiguous, and thus enforceable. It concluded that John’s Grill did not have a reasonable expectation of coverage for pandemic-related losses under the policy. The court also determined that the illusory coverage doctrine, as articulated by John’s Grill, did not apply because the policy did offer a realistic prospect for virus-related coverage under certain conditions. The case was remanded for further proceedings consistent with this opinion. View "John's Grill, Inc. v. The Hartford Financial Services Group, Inc." on Justia Law