Justia Insurance Law Opinion SummariesArticles Posted in Insurance Law
Futterman v. Kaiser Foundation Health Plan, Inc.
The Plan is a nonprofit health care service plan subject to Health & Safety Code 1340, including the Parity Act, under which: “Every health care service plan contract . . . that provides hospital, medical, or surgical coverage shall provide coverage for the diagnosis and medically necessary treatment of severe mental illness of a person of any age, and of serious emotional disturbances of a child . . . under the same terms and conditions applied to other medical conditions.”Plaintiffs alleged that the Plan violates the Parity Act by “deterring members from obtaining one-on-one mental health therapy without making individualized determinations … encouraging ‘group’ therapy, without making individualized determinations" where similar practices are not followed in the treatment of physical health conditions. An Unruh Civil Rights Act claim alleged that the Plan intentionally discriminated against persons with mental disabilities or conditions. The court granted the Plan summary judgment.The court of appeal affirmed the rejection of one plaintiff’s individual claims; the Plan is not liable for the acts of its subsidiary by whom the plaintiff’s coverage was issued. The court otherwise reversed. On an Unfair Competition Law claim, the court failed to consider how the Plan’s conduct undermines its contractual promises of covered treatment in violation of the Parity Act. On the Unruh claim, triable issues of fact exist as to whether the plaintiffs were denied medically necessary treatment as a result of intentional discrimination. View "Futterman v. Kaiser Foundation Health Plan, Inc." on Justia Law
Posted in: California Courts of Appeal, Contracts, Health Law, Insurance Law
Perez v. Kaiser Foundation Health Plan, Inc.
Maria chose her family’s benefits during her 2014 orientation, using Coppola laptops. Coppola’s HR team was available to answer questions. The authorization agreement notifies enrollees that "clicking the SAVE button below ... will serve as my electronic signature of agreement to the ... Arbitration Agreement (above)," and “If you do not wish to accept the arbitration agreement above you must click on the CANCEL button below.”Andrea (Maria’s daughter) sued Kaiser, for its failure to timely diagnose her aggressive cancer. Kaiser petitioned to compel arbitration. Andrea argued Kaiser failed to comply with Health and Safety Code 1363.1’s specific requirements for disclosing arbitration agreements with healthcare service plans. Maria declared she was unaware of signing an arbitration agreement. Although Maria had a good understanding of English, she was not a native speaker and declared she could not read English well enough to understand she was agreeing to arbitration. Maria also stated she did not know how to operate the computer. The court granted Kaiser’s motion. The parties selected an arbitrator from a list. A disclosure statement listed the arbitrator’s prior and pending cases involving Kaiser. The arbitrator later sent notices informing the parties he had agreed to arbitrate additional Kaiser cases. The arbitrator concluded Kaiser was not liable for Andrea’s death.The court of appeal affirmed the denial of a motion to vacate. The arbitrator had an initial obligation to disclose he had pending cases involving Kaiser and was not obligated to disclose their outcome; the fact the arbitrator decided cases in Kaiser’s favor during the pendency of the Perezes’ arbitration would not raise doubt the arbitrator would be impartial. View "Perez v. Kaiser Foundation Health Plan, Inc." on Justia Law
Angell v. GEICO Advantage Ins
Plaintiffs sued Defendants GEICO Advantage Insurance Company and its related entities. Each Plaintiff possessed a vehicle that was subject to a private passenger auto insurance policy with a different Defendant (collectively, the “Policies”). Each Plaintiff’s vehicle was involved in an auto collision while insured under one of the Policies. Plaintiffs sought to represent a class of insureds claiming that GEICO failed to fully compensate them for the total loss of their vehicles under their respective insurance policies. The district court held that Plaintiffs had standing to sue on behalf of the proposed class and subsequently granted class certification. GEICO appealed both holdings. The Fifth Circuit affirmed. The court wrote it is clear that each Plaintiff individually satisfies the less stringent class certification approach. Indeed, there is no dispute that each Plaintiff alleges that he or she has suffered some injury; the disagreement between the parties concerns how those injuries relate to those of the class. Further, the court wrote it disagreed with the contention that Plaintiffs have alleged three separate injuries. GEICO’s failure to remit any of the three Purchasing Fees amounts to the same harm—a breach of the Policies. The court also concluded that the strategic value of these claims’ waiver is considerably greater than their inherent worth. It was accordingly within the district court’s discretion to rule that Plaintiffs are adequate class representatives. Moreover, the court wrote that GEICO’s arguments against class certification for this claim largely track its arguments opposing certification of Plaintiffs’ other claims. The district court’s analysis meets the requisite rigor when read in the broader context of its decision. View "Angell v. GEICO Advantage Ins" on Justia Law
Callahan v. Brant
The Supreme Court affirmed the judgment of the district court granting summary judgment in favor of Plaintiffs' insurer and its agent in this negligence action brought by Plaintiffs seeking to recover damages after their home was destroyed in a fire, holding that the district court did not err.Insureds purchased a homeowners insurance policy from Insurer through a licensed insurance producer (Agent). Insureds later filed a complaint alleging that Agent negligently advised them on the estimated replacement value of their home and negligently misrepresented the adequacy of their policy limits in the event of a total loss. Insureds also alleged that Insurer was liable under a theory of respondent superior. The district court granted summary judgment for Insurer and Agent. The Supreme Court affirmed, holding that Insureds' claims failed as a matter of law and that the district court did not err in granting summary judgment. View "Callahan v. Brant" on Justia Law
New York Life Ins. Co. v. Mitchell
The federal district court in Washington State certified a question of law to the Washington Supreme Court. Washington law required group life insurance policies to have an incontestability clause providing that “the validity of the policy shall not be contested, except for nonpayment of premiums, after it has been in force for two years from its date of issue.” The certified question in this case asked whether an insurer could invalidate a life insurance policy after this two-year period on grounds that the policies were void ab initio or never “in force.” New York Life Insurance (NY Life) issued two life insurance policies to Lorenzo Mitchell, naming his nephew, Simon Mitchell, as the sole beneficiary. Lorenzo died more than two years after the policies were issued, and Simon sought to collect on the policies. NY Life became aware that Lorenzo had Down syndrome and lived with significant intellectual disabilities. These facts raised questions about the circumstances under which the policies were issued. NY Life sued Simon in federal district court seeking declaratory relief that the policies were void ab initio under three possible theories: imposter fraud, incapacity, and lack of an insurable interest. The Washington Supreme Court concluded NY Life’s first and third claims were not barred by that provision. “In contrast, lack of capacity does not, on its own, render an insurance contract void; it renders it at most voidable. Because a voidable contract is not void ab initio, we hold the incontestability provision bars NY Life’s second claim.” View "New York Life Ins. Co. v. Mitchell" on Justia Law
Posted in: Civil Procedure, Contracts, Insurance Law, Washington Supreme Court
Schleicher & Stebbins Hotels, LLC, et al. v. Starr Surplus Lines Insurance Co., et al.
In an interlocutory appeal, multiple hotel operators challenged a superior court’s orders in a suit against defendants, multiple insurance underwriters, all relating to the denial of coverage during the COVID-19 world health pandemic. Plaintiffs owned and operated twenty-three hotels: four in New Hampshire, eighteen in Massachusetts, and one in New Jersey. Plaintiffs purchased $600 million of insurance coverage from defendants for the policy period from November 1, 2019 to November 1, 2020. With the exception of certain addenda, the relevant language of the policies was identical, stating in part that it “insures against risks of direct physical loss of or damage to property described herein . . . except as hereinafter excluded.” For periods of time, pursuant to governors’ orders, hotels in each of the three states were permitted to provide lodging only to vulnerable populations and to essential workers. These essential workers included healthcare workers, the COVID-19 essential workforce, and other workers responding to the COVID-19 public health emergency. Beginning in June 2020, plaintiffs’ hotels were permitted to reopen with a number of restrictions on their business operations. Plaintiffs, through their insurance broker, provided notice to defendants they were submitting claims in connection with losses stemming from COVID-19. Plaintiffs sued when these claims denied, arguing that the potential presence of the virus triggered business loss provisions in their respective policies. To this, the New Hampshire Supreme Court disagreed, finding that “[w]hile the presence of the virus might affect how people interact with one another, and interact with the property, it does not render the property useless or uninhabitable, nor distinctly and demonstrably altered.” View "Schleicher & Stebbins Hotels, LLC, et al. v. Starr Surplus Lines Insurance Co., et al." on Justia Law
Posted in: Business Law, Contracts, Health Law, Insurance Law, New Hampshire Supreme Court
Windermere Oaks v. Allied World
Allied World Specialty Insurance Company issued a WaterPlus Package Insurance Policy to the Windermere Oaks Water Supply Corporation. That policy includes coverage for Public Officials and Management Liability. But it also includes various exclusions from coverage. At issue in this appeal is the exclusion of contractual liability. The Fifth Circuit affirmed the district court’s judgment granting summary judgment in favor of the insured. The court held that a claim for breach of fiduciary duty is not a claim for breach of contract and is, therefore, not subject to exclusion from coverage under a contractual liability exclusion. The court explained that under the Texas Prompt Payment of Claims Act, Tex. Ins. Code Section 542.060, an insurer’s breach of the duty to defend constitutes a per se violation View "Windermere Oaks v. Allied World" on Justia Law
Nodak Ins. Co. v. Farm Family Casualty Ins. Co., et al.
Farm Family Casualty Insurance Company (“Farm Family”) appealed after the district court granted summary judgment to Nodak Insurance Company (“Nodak”) and denied, in part, summary judgment to Farm Family. This case arose from an April 6, 2019 motor vehicle accident. Samuel Hamilton was the son of Bruce and Diana Hamilton. At the time of the April 2019 accident at issue, Samuel was a resident of North Dakota, and his parents were residents of Montana. Before the accident, Farm Family issued an automobile insurance policy to Bruce and Diana with an effective policy period of October 19, 2018 to April 19, 2019. The policy insured a 2011 pickup truck. After moving to Montana, the Hamiltons obtained an insurance policy from Mountain West Farm Bureau Mutual Insurance Company (“Mountain West”) that also insured the 2011 pickup truck with a term running from December 2, 2018 to June 2, 2019. In April 2019, Samuel was driving the insured 2011 pickup truck in Williams County, North Dakota. Samuel reportedly ran a stop sign while intoxicated and struck another vehicle; H.W. was seriously injured and A.M. was killed. Nodak insured the vehicle H.W. and A M. occupied at the time of the accident. Nodak filed suit seeking a declaration Farm Family’s automobile policy was in effect at the time of the April 2019 accident, Farm Family’s policy could not be retroactively cancelled, and the vehicle driven by the insureds’ son was not an “underinsured motor vehicle” under North Dakota law. The North Dakota Supreme Court concluded the automobile policy Farm Family issued to its insureds had not “ceased” under the policy language and remained in effect at the time of the April 2019 motor vehicle accident. View "Nodak Ins. Co. v. Farm Family Casualty Ins. Co., et al." on Justia Law
Dua v. Stillwater Insurance Company
In this insurance coverage action, Defendant Stillwater Insurance Company (Stillwater) contends that an animal liability exclusion in the insured’s homeowner’s insurance policy (the policy) precludes any duty to defend because the third parties sued the insured for injuries they and their dogs sustained when their dogs were bitten by two pit bulls on a public street. The insurer determined that the exclusion applied because the underlying complaint alleged that the pit bulls lived at the insured’s home and, therefore, it had no obligation to indemnify an excluded claim. The insured denied any ownership or control of the pit bulls, which were owned by her boyfriend, who did not live at her home. The insurer did not conduct any further investigation. Plaintiff argued that the trial court erred in granting summary judgment in favor of Stillwater on her claims based on Stillwater’s refusal to defend Plaintiff in the third-party lawsuit. The Second Circuit reversed. The court concluded that the trial court erred in granting summary judgment to Stillwater because there is evidence that Stillwater breached its duty to defend. The court also reversed the trial court’s grant of summary judgment in favor of Stillwater on Plaintiff’s claim for breach of the duty of good faith and fair dealing. The court explained that even if the insured was correct and the pit bulls were not under her ownership, the third party still might have raised a claim potentially covered by the policy. An insurer can be excused from the duty to defend only if the third-party complaint can by no conceivable theory raise an issue within the policy’s coverage. View "Dua v. Stillwater Insurance Company" on Justia Law
Posted in: California Courts of Appeal, Contracts, Insurance Law
Astellas US Holding, Inc. v. Federal Insurance Co.
The 2005 Medicare amendment, launching prescription drug coverage, raised concerns that patient assistance plans could violate the Anti-Kickback Statute, 42 U.S.C. 1320a-7b, and the False Claims Act, 31 U.S.C. 3729, by effectively rewarding doctors and patients for choosing particular drugs. Astellas subsequently launched Xtandi, used to treat metastatic prostate cancer. Priced at $7,800 per month, Xtandi prescriptions were covered by Medicare up to about $6,000 per month. Astellas made contributions to two patient assistance plans. An Astellas marketing executive encouraged both plans to create special funds to provide co-pay assistance for only androgen receptor inhibitors like Xtandi and a few other medications. Astellas donated to the new funds but stopped after contributing about $27 million. Astellas continued contributing to broader prostate cancer funds.The Department of Justice began investigating; the Astellas marketing executive acknowledged that he had “hoped” and “expected” that the contributions would produce financial benefits for Astellas but that Astellas had made no efforts to calculate “a return on investment.” Astellas settled with the government for $100 million--$50 million for “restitution” to the government. Astellas sought indemnification from liability insurers, including Federal, which denied coverage.The Seventh Circuit affirmed summary judgment for Astellas. Under Illinois law, a party may not obtain liability insurance for genuine restitution it owes the victim of its intentional wrongdoing, but a party may obtain insurance for compensatory damages. In cases of ambiguity, Illinois favors settlements and freedom of contract. Federal wrote its insurance policy to try to extend coverage to the limit of what Illinois law would allow. Federal did not carry its burden of showing that the portion of the settlement payment for which Astellas seeks coverage is uninsurable restitution. View "Astellas US Holding, Inc. v. Federal Insurance Co." on Justia Law