Justia Insurance Law Opinion Summaries

A joint state and federal criminal investigation, "Operation Back Cracker," uncovered a scheme where Minnesota healthcare providers, primarily chiropractors, recruited car accident victims and fraudulently billed auto insurers for their treatment. In related civil settlements, some providers agreed not to bill certain insurance companies, including Illinois Farmers Insurance Company, for any treatment provided to their insureds. Plaintiffs, representing a class of insured individuals, sued Farmers, alleging that these no-bill agreements violated the Minnesota No-Fault Automobile Insurance Act.The United States District Court for the District of Minnesota granted summary judgment to the plaintiffs' injunctive class, enjoining Farmers from entering into or enforcing the no-bill agreements. The court found that these agreements effectively provided managed care services and set preestablished limitations on medical expense benefits, both of which are prohibited under the No-Fault Act. Farmers appealed the decision.The United States Court of Appeals for the Eighth Circuit reviewed the case and vacated the injunction. The court held that the no-bill agreements did not constitute managed care services as defined by the No-Fault Act because they excluded, rather than used, the providers under contract with Farmers. Additionally, the court found that the agreements did not place preestablished limitations on medical expense benefits since they did not limit reimbursement for reasonable expenses incurred by insureds. The court concluded that an insurer does not violate the No-Fault Act by enforcing a no-bill agreement against a provider, as long as it does not refuse to reimburse an insured who has incurred a qualifying expense. The case was remanded for further proceedings consistent with this opinion. View "Taqueria El Primo LLC v. IL Farmers Insurance Co." on Justia Law

In this case, the plaintiff, Shandor S. Badaruddin, was sanctioned by the Nineteenth Judicial District Court, Lincoln County, for his conduct as defense counsel in a criminal trial involving his client, Kip Hartman, who faced multiple felony charges related to securities and insurance fraud. The trial was conducted under strict time constraints due to the COVID-19 pandemic, and the court allocated equal time for both the prosecution and defense. Badaruddin was accused of mismanaging his allotted time, leading to a mistrial declaration by the District Court.The District Court found that Badaruddin had deliberately delayed the trial, which led to the mistrial. Consequently, the court imposed monetary sanctions amounting to $51,923.61 against Badaruddin for the costs associated with the trial. Badaruddin appealed the sanctions, arguing that he was not given adequate notice of the court's concerns and that his actions were not deliberate but rather a result of the challenging circumstances.The Supreme Court of the State of Montana reviewed the case and noted that the U.S. District Court had previously ruled that the mistrial declaration was erroneous. The U.S. District Court found that Badaruddin's actions did not constitute deliberate delay and that his efforts to manage the trial time were competent. The U.S. District Court's ruling was affirmed by the U.S. Court of Appeals for the Ninth Circuit, which held that Hartman could not be retried due to double jeopardy protections.Given the federal court's findings, the Supreme Court of Montana concluded that there was no basis for the sanctions under § 37-61-421, MCA, as there was no multiplication of proceedings. The court reversed the District Court's sanction order, determining that the costs incurred were not "excess costs" as defined by the statute. View "Badaruddin v. 19th Judicial District" on Justia Law

Kelsey Weyer applied for long-term disability benefits under a policy issued by Reliance Standard Life Insurance Company through her employer. Weyer suffers from multiple medical conditions, including chronic fatigue syndrome, Lyme disease, migraines, neurocognitive disorder, and others. The policy defines "Totally Disabled" differently for the first twenty-four months and thereafter. Initially, it means being unable to perform the duties of one's regular occupation, and after twenty-four months, it means being unable to perform any occupation. Reliance Standard initially approved Weyer’s claim and paid benefits for twenty-four months but later terminated them, arguing she could perform sedentary jobs and that her anxiety and depression contributed to her disability.The United States District Court for the District of Minnesota reviewed the case and ruled in favor of Weyer. The court found that the evidence did not support Reliance Standard’s claim that Weyer’s mental health issues contributed to her inability to work. It also held that Weyer was totally disabled under the policy’s "Any Occupation" standard, based on evidence from Weyer’s physicians and independent reviews.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court affirmed the district court’s decision, finding no clear error in its determination that Weyer was totally disabled and that her physical conditions alone rendered her unable to work. The appellate court also agreed that the mental health disorders did not contribute to her total disability under the policy’s terms. The court applied a "but-for" causation standard, concluding that Weyer’s physical conditions independently caused her total disability, thus the mental health limitation clause did not apply. The court affirmed the district court’s judgment in favor of Weyer. View "Weyer v. Reliance Standard Life Insurance Company" on Justia Law

In this case, a private insurance company, TIG Insurance Company, sought to enforce two judgments against the Republic of Argentina. The dispute centers on whether Argentina, as the successor to a state-owned Argentine company, Caja Nacional de Ahorro y Seguro, is liable under reinsurance contracts that Caja entered into with TIG in 1979. TIG alleged that Caja failed to pay as promised under these contracts, leading to arbitral awards and subsequent judgments in TIG's favor.The United States District Court for the District of Columbia initially ruled in favor of Argentina, finding that Argentina's property was immune from execution under the Foreign Sovereign Immunities Act (FSIA) because it was not used for commercial activity at the time the writ would issue. The court also held that the Illinois district court lacked jurisdiction over Argentina for the 2018 judgment and that TIG needed to amend the 2001 judgment in Illinois to name Argentina before seeking enforcement in D.C. TIG appealed these decisions.The United States Court of Appeals for the District of Columbia Circuit reviewed the case and concluded that two FSIA exceptions—the arbitration and waiver exceptions—might apply. The court held that an agreement could be "made by" a sovereign if it legally binds that sovereign to arbitrate, even if the sovereign was not an original signatory. The court also found that implied waiver does not require evidence of subjective intent but can be based on objective actions, such as agreeing to arbitration or a choice-of-law clause. The court vacated the district court's decisions and remanded for further analysis and factfinding on these issues.The appellate court affirmed the denial of TIG's request for jurisdictional discovery and precluded TIG from advancing an alter ego theory or arguing that Argentina failed to raise its immunity in a responsive pleading. The case was remanded for further proceedings consistent with the appellate court's instructions. View "TIG Insurance Company v. Republic of Argentina" on Justia Law

The plaintiffs, EB Holdings II, Inc. and QXH II, Inc., sought coverage from their insurers for legal fees and expenses incurred in defending against a lawsuit alleging fraudulent inducement in the purchase of notes backed by their long-term debt. The insurers denied coverage, claiming the plaintiffs made material misrepresentations in their insurance renewal application by failing to disclose significant long-term debt.The United States District Court for the District of Nevada granted summary judgment in favor of the insurers, concluding that Nevada law governed the affirmative defense of material misrepresentation. The court found that the plaintiffs had indeed made a material misrepresentation by not disclosing their long-term debt, thus barring coverage under the insurance policies.The United States Court of Appeals for the Ninth Circuit reviewed the case and reversed the district court's decision. The appellate court held that the district court erred in its choice-of-law analysis. The Ninth Circuit determined that Texas law, not Nevada law, should govern the affirmative defense of material misrepresentation. The court reasoned that the substantial relationship test set forth in the Restatement (Second) of Conflict of Laws § 188 pointed to Texas law, given that the underwriting process largely occurred through agents based in Texas and the plaintiffs were headquartered there.Applying Texas law, the Ninth Circuit found that there were material disputes of fact regarding the elements of the affirmative defense, including the plaintiffs' intent to deceive and whether the insurers provided timely notice of their refusal to be bound by the policy. Consequently, the court reversed the summary judgment and remanded the case to the district court for further proceedings. View "EB HOLDINGS II, INC. V. ILLINOIS NATIONAL INSURANCE COMPANY" on Justia Law

Christa Taylor purchased an automobile insurance policy from Root Insurance Company. After her vehicle was damaged in a hailstorm, Root determined it to be a total loss and paid Taylor the vehicle's actual cash value of $22,750. However, Root did not include an amount representing the sales tax in this payment. Taylor argued that the policy required Root to pay the applicable sales tax in addition to the actual cash value and filed a putative class action for breach of contract and violation of the Texas Prompt Payment of Claims Act (TPPCA).The United States District Court for the Western District of Texas reviewed the case. Root moved to dismiss Taylor's claims under Federal Rule of Civil Procedure 12(b)(6). The magistrate judge recommended granting Root's motion and denying Taylor's request for leave to amend her complaint. The district court conducted a de novo review, agreed with the magistrate judge, and dismissed the suit. Taylor then appealed the decision.The United States Court of Appeals for the Fifth Circuit reviewed the case de novo. The court held that the insurance policy's language required Root to pay only the "applicable sales tax," and since a total-loss settlement is not considered a sale under Texas law, no sales tax was applicable. The court also noted that actual cash value does not include taxes and fees payable to purchase a replacement vehicle under Texas law. Consequently, Root did not breach the policy, nor did it violate the TPPCA. The court affirmed the district court's dismissal of Taylor's claims. View "Taylor v. Root Insurance" on Justia Law

Covil Corporation, through its receiver, sued Pennsylvania National Mutual Insurance Company for breaching their insurance contract by not contributing to a settlement in an asbestos case. David Rollins had sued Covil and others, alleging negligent asbestos exposure caused his mesothelioma. Penn National insured Covil during part of the exposure period. Covil settled the case and sought $50,000 from Penn National, which the insurer refused to pay.The circuit court granted summary judgment for Covil, requiring Penn National to indemnify Covil for the settlement. The court rejected Penn National's arguments about untimely notice, premature summary judgment, and policy exclusions. The court of appeals affirmed the decision.The South Carolina Supreme Court reviewed the case and affirmed the court of appeals' decision with modifications. The court held that the notice-prejudice rule did not apply because the underlying plaintiff, Rollins, had already been fully compensated. The court also found that Covil's untimely notice was not a material breach of the insurance contract, as Covil's interests were adequately protected by other insurers' counsel. Additionally, the court ruled that Penn National did not waive its right to timely notice by attending mediation.The court further held that the policy's "Products Hazard" and "Completed Operations Hazard" exclusions did not apply. The Products Hazard exclusion was inapplicable because Covil's liability was based on installation, not supplying asbestos. The Completed Operations Hazard exclusion did not apply because Rollins's exposure occurred before Covil's work was completed. Thus, the court affirmed the lower court's summary judgment in favor of Covil. View "Covil Corporation v. Pennsylvania National Mutual Casualty Insurance Company" on Justia Law

A severe thunderstorm caused significant damage to Norwood Hospital, owned by Medical Properties Trust, Inc. (MPT) and leased to Steward Health Care System LLC (Steward). The storm led to extensive flooding in the hospital's basements and rainwater accumulation on the rooftop courtyard and parapet roofs, which then seeped into the building, causing further damage. MPT and Steward sought coverage from their insurers, Zurich American Insurance Company (Zurich) and American Guarantee and Liability Insurance Company (AGLIC), respectively. Both policies had high overall coverage limits but lower sublimits for flood damage. The insurers argued that all the damage was due to "Flood" as defined in the policies, which included "surface waters," and thus subject to the lower sublimits.The United States District Court for the District of Massachusetts granted partial summary judgment to the insurers, interpreting "surface waters" to include rainwater accumulated on the roofs. The court allowed an interlocutory appeal, recognizing the substantial ground for difference of opinion on this legal issue. The United States Court of Appeals for the First Circuit then certified the question to the Supreme Judicial Court of Massachusetts, asking whether rainwater accumulating on a building's rooftop courtyard or parapet roof constitutes "surface waters" under Massachusetts law.The Supreme Judicial Court of Massachusetts concluded that the term "surface waters" is ambiguous in this context. The court noted the lack of a clear definition in the policies and the divided case law on the issue. Given this ambiguity, the court ruled in favor of the insureds, determining that rainwater accumulating on the rooftop courtyard and parapet roofs does not unambiguously constitute "surface waters" under the policies. Therefore, the damage from such water infiltration is not subject to the flood sublimits. View "Zurich American Insurance Company v. Medical Properties Trust, Inc." on Justia Law

Plaintiff Katherine Rosenberg-Wohl procured a homeowners insurance policy from State Farm Fire and Casualty Company, which covered various risks including fire. After her neighbor fell on her staircase, she discovered the stairs needed replacement and filed a claim with State Farm. The insurer denied her claim, citing policy exclusions. Rosenberg-Wohl then filed two lawsuits: one for breach of contract and another under the Unfair Competition Law (UCL), seeking declaratory and injunctive relief regarding State Farm’s general claims-handling practices.The San Francisco City and County Superior Court sustained State Farm’s demurrer, concluding that the one-year limitations period in the insurance policy applied to all of Rosenberg-Wohl’s claims, including her UCL claim. The court reasoned that her claims were essentially “on the policy” because they were grounded in the denial of her insurance claim. The Court of Appeal affirmed this decision, with a majority agreeing that the one-year limitations period applied, while a dissenting justice argued that the UCL’s four-year limitations period should govern.The Supreme Court of California reviewed the case and concluded that the one-year limitations period in section 2071 of the Insurance Code and the insurance policy did not apply to Rosenberg-Wohl’s UCL cause of action. The court determined that her lawsuit was not a “suit or action on [the] policy for the recovery of any claim” because she sought only declaratory and injunctive relief, not a financial recovery under the policy. The court emphasized that the UCL’s four-year statute of limitations governed her claim. Consequently, the Supreme Court reversed the judgment of the Court of Appeal and remanded the matter for further proceedings consistent with its opinion. View "Rosenberg-Wohl v. State Farm Fire & Casualty Co." on Justia Law

Kalvin Earl Richardson purchased a house in St. Louis County, Missouri, through a Post Third Sale Offering, a process for selling tax-delinquent properties that have not been sold in three consecutive annual tax-collection auctions. Richardson then applied for homeowner insurance from Nationwide Mutual Insurance Company, stating on the application that the property was not purchased at a public auction. After a fire damaged the house, Nationwide refused to pay the claim, asserting that Richardson had misrepresented the purchase method. Nationwide sued, claiming the policy was void due to this misrepresentation.The United States District Court for the Eastern District of Missouri granted summary judgment in favor of Nationwide. The court ruled that the Post Third Sale Offering constituted a public auction and that Richardson's contrary statement on the insurance application was a material misrepresentation, rendering the insurance policy void ab initio.The United States Court of Appeals for the Eighth Circuit reviewed the case de novo. The appellate court found that the term "public auction" was not clearly defined in Nationwide's insurance application and that the Post Third Sale Offering did not meet the ordinary understanding of a public auction, which typically involves competitive bidding. The court noted that Missouri statutes and case law emphasize competition among bidders as a key element of a public auction, which was absent in the Post Third Sale Offering. Consequently, the court held that Nationwide did not meet its burden to prove that Richardson's representation was false in fact. The Eighth Circuit reversed the district court's summary judgment and remanded the case for further proceedings. View "Nationwide Mutual Insurance Company v. Richardson" on Justia Law