Justia Insurance Law Opinion Summaries

Princeton Excess and Surplus Lines Insurance Company (PESLIC) filed this declaratory judgment action. PESLIC issued two commercial liability insurance policies to the Clubs covering the time period relevant to the Models’ claims: Number 1RA3GL0000179–01, with a policy period of November 9, 2015, to November 9, 2016 (the 01 Policy); and Number 1RA3GL0000179–02, with a policy period of November 9, 2016, to November 9, 2017 (the 02 Policy). The policies have identical coverage provisions but contain slightly different exclusions. The parties dispute whether this exclusion renders illusory the Personal and Advertising Injury coverage provided in the 02 Policy. If it does not, then the Clubs have no coverage applicable to the Models’ claims; if it does, then they have coverage, as the district court held.   The Fifth Circuit reversed the district court’s summary judgment ruling. The court held PESLIC does not have a duty to defend or indemnify the Clubs in the underlying lawsuit because neither the 01 Policy nor the 02 Policy provides coverage for the claims alleged by the Models. The court explained that the text of the 02 Policy is not ambiguous, and Texas law “presumes that the party knows and accepts the contract terms.” Those terms disclose that the policy’s Personal and Advertising Injury coverage comprises a single category of coverage and further that the Exhibition and Related Marketing Exclusion removes much but by no means all, of that coverage. The 02 Policy is, therefore, not illusory, and the exclusion must be enforced, constraining the court to conclude there is no coverage for the Models’ underlying claims under the 02 Policy. View "Princeton Excess v. AHD Houston" on Justia Law

Plaintiff sued Travelers Indemnity Company of America, seeking a declaration that an insurance policy between Travelers and the City of Hermantown authorizes up to $2,000,000 in coverage for his tort claim against the city. The district court granted summary judgment for Plaintiff, and Travelers appeals.   The court concluded that the insurance policy limits the amount of Plaintiff’s recovery to $500,000 and therefore reversed the judgment. The court explained that under Minnesota law, a municipality is liable for its torts and those of its employees acting within the scope of their employment. But a municipality may obtain insurance coverage for damages “in excess of the limit of liability imposed by section 466.04,” and procurement of such insurance waives the statutory limit of liability. The court concluded that the insurance policy authorizes coverage up to only $500,000 for Plaintiff’s claim. The policy provides different limits for different types of liabilities. The policy provides a coverage limit of $2,000,000 for claims not subject to the statutory limit set forth in Minn. Stat. Section 466.04. But for claims subject to the statutory limit in Section 466.04, the endorsement expressly limits coverage to $500,000. The substance of this contractual arrangement is no different than if the parties agreed on two separate policies for the two different types of liability. Plaintiff’s claim for injuries arising from an automobile accident in Hermantown is subject to Minnesota’s $500,000 cap on municipal tort liability. View "James Prisk v. Travelers Indemnity Co. of America" on Justia Law

M.P.N. manufactures radiators in Philadelphia. Mercer worked at M.P.N. from 2015-2017. In 2019, Mercer sued., alleging that M.P.N. concealed blood test results showing that he had dangerously high levels of zinc and lead after he was exposed to lead and cadmium on the job. A physician advised M.P.N. to remove Mercer from work but M.P.N. ignored the advice. As a result, Mercer continued working at M.P.N. and suffered permanent, avoidable brain damage. The Pennsylvania Workers’ Compensation Act is the “exclusive” source of employer liability for suits relating to workplace injuries suffered by employees. Mercer argued that he could recover from M.P.N. under a “fraudulent misrepresentation” exception recognized by the Pennsylvania Supreme Court.Zenith Insurance sought a declaration that it was not contractually obligated to defend M.P.N., against a workplace liability lawsuit. In a partial summary judgment, the district court declared that Zenith has a duty to defend M.P.N. The Third Circuit dismissed an appeal. Because the district court did not rule on all of the claims before it, that order is not final and cannot be appealed under the usual source of jurisdiction, 28 U.S.C. 1291. Zenith argued the court could consider its challenge under 28 U.S.C. 1292(a)(1), which permits appeals from non-final orders that relate to injunctive relief but the Third Circuit rule is that purely declaratory orders are not injunctive and cannot be enforced by contempt. View "Zenith Insurance Co. v. Newell" on Justia Law

The Supreme Court affirmed the judgment of the court of appeals reversing the opinion of the Workers' Compensation Board affirming the administrative law judge's (ALJ) conclusion that medical providers did not have to submit their medical billing statements until after a determination of liability, holding that the statute is unambiguous.At issue was whether P&P Construction, Inc. and, by extension, the company's insurer, Kentucky Employers Mutual Insurance (KEMI), was responsible for payment of medical billings statements submitted outside of the forty-five-day period set forth in Ky. Rev. Stat. 342.020(4). The ALJ and Board determined that medical providers do not have to submit their billings until after a determination of liability. The court of appeals reversed, holding that medical providers are required to submit their billings within forty-five days of service, regardless of whether a determination of liability has been made, and therefore, employers and their insurance carriers are not responsible for payment of billings submitted after the forty-five day period. The Supreme Court, holding that under the unambiguous language of the statute, medical service providers must submit their billings within forty-five days of treatment, and such requirement applies both pre- and post-award. View "Farley v. P&P Construction, Inc." on Justia Law

United Behavioral Health (“UBH”) appeals from the district court’s judgment finding it liable to classes of Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001 et seq. (“ERISA”) Plaintiffs under 29 U.S.C. Sections 1132(a)(1)(B) and (a)(3), as well as several pre- and posttrial orders, including class certification, summary judgment, and a remedies order. UBH contends on appeal that Plaintiffs lack Article III standing and that the district court erred at class certification and trial in several respect.   The Ninth Circuit reversed in part. The panel held that Plaintiffs had Article III standing to bring their claims. Plaintiffs sufficiently alleged a concrete injury as to their fiduciary duty claim because UBH’s alleged violation presented a material risk of harm to plaintiffs’ interest in their contractual benefits. Plaintiffs also alleged a concrete injury as to the denial of benefits claim. Further, plaintiffs alleged a particularized injury as to both claims because UBH’s Level of Care Guidelines and Coverage Determination Guidelines for making medical necessity or coverage determinations materially affected each Plaintiff. And Plaintiffs’ alleged injuries were “fairly traceable” to UBH’s conduct. The panel held that the district court did not err in certifying the three classes to pursue the fiduciary duty claim, but the panel reversed the district court’s certification of the denial of benefits classes. The panel held that, on the merits, the district court erred to the extent it determined that the ERISA plans required the Guidelines to be coextensive with generally accepted standards of care. View "DAVID WIT, ET AL V. UNITED BEHAVIORAL HEALTH" on Justia Law

K.C. Hopps, Ltd., sued its insurer, The Cincinnati Insurance Company, seeking coverage for lost business income incurred during the COVID-19 pandemic. Cincinnati moved for summary judgment based on K.C. Hopps’s inability to show physical loss or damage, which the district court denied. After the jury returned a verdict for Cincinnati, K.C. Hopps renewed its motion for judgment as a matter of law and moved for a new trial. The district court denied both motions.   The Second Appellate District affirmed. The court explained that K.C. Hopps alleged that COVID-19 particles were present at its properties. The court wrote that has repeatedly rejected similar claims for COVID-19-related business interruptions because the insured did not sufficiently allege physical loss or damage. The court explained that even if K.C. Hopps could show actual contamination of its properties, any possible contamination was not the cause of its lost business income. K.C. Hopps did not limit its operations because COVID-19 particles were found at its properties—it did so because of the shutdown orders. K.C. Hopps remained open until government orders limited its operations. And even if its premises weren’t contaminated, K.C. Hopps “would have been subject to the exact same restrictions.” View "K.C. Hopps, Ltd. v. The Cincinnati Insurance Co." on Justia Law

Plaintiff and appellant Rhonda S. is the conservator, appointed pursuant to section 5350 of the Lanterman-Petris Short Act (LPS), of her adult son David S. Plaintiff sued Defendants and respondents Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals for a declaration of their obligations, under LPS and the terms of David’s health plan, to transport and accept for “assessment and evaluation” (each as defined in LPS) conservatees like David upon their conservators’ demand. The trial court sustained Kaiser’s demurrer.
The Second Appellate District affirmed. The court explained that it rejects Plaintiff’s implication that an LPS conservatee is per se suffering from an “Emergency Medical Condition” at all times following the judicial determination of grave disability. The purposes of LPS conservatorship include providing treatment to the conservatee. (Section 5350.1.) To assume a conservatee’s condition remains static following the conservatorship order is to assume treatment is always ineffectual. We are offered no basis for such an assumption. For a mental health condition to be an “Emergency Medical Condition” under the plan, “acute symptoms of sufficient severity” must result in an “immediate” specified danger or mental health disorder-induced disability. Second, even if conservatees were in a state of perpetual “Emergency Medical Condition” within the meaning of the plan, Plaintiff’s requested declaration would eliminate the coverage requirement that a “reasonable person would have believed that the medical condition was an Emergency Medical Condition which required ambulance services.” View "Rhonda S. v. Kaiser Foundation Health Plan" on Justia Law

The First Circuit vacated the judgment of the district court in favor of Philadelphia Indemnity Insurance Company in this action seeking a declaration that BAS Holding Corporation breached a condition of the parties' insurance contract, holding that the district court's findings providing grounds for summary judgment were insupportable.After an arsonist destroyed a building owned by BAS and purportedly insured against loss by Philadelphia, the insurer sought an examination under oath (EUO) of George Carney, BAS's president and owner. Philadelphia then denied coverage on the grounds that BAS refused to provide Carney for an EUO, in violation of its obligations under the relevant insurance policy. Philadelphia then brought this action. The district court granted summary judgment for Philadelphia on the ground that BAS failed to cooperate by refusing to submit to the EUO. The First Circuit vacated the judgment, holding that where the evidence unequivocally showed the BAS never willfully and inexcusably refused to provide Carney for the EUO, and therefore summary judgment was improper. View "Philadelphia Indemnity Insurance Co. v. BAS Holding Corp." on Justia Law

The First Circuit affirmed the judgment of the district court granting United States Liability Insurance Group's (USLI) motion to dismiss this lawsuit brought by Nahant Preservation Trust, Inc. to secure insurance coverage in connection with defense costs and indemnification arising from a state court action brought by Northeastern University, holding that there was no error.Northeastern sued Nahant in state court seeking a declaratory judgment regarding its rights concerning certain land. Nahant, which carried liability insurance through USLI, did not notify USLI of the suit until it wrote to USLI seeking coverage for defense costs. USLI refused to provide coverage on the grounds that Nahant had provided untimely notice of the claim. Thereafter Nahant sued USLI seeking, among other things, a declaratory judgment regarding USLI's duty to defend and indemnify. The First circuit granted USLI's motion to dismiss, concluding that the "exclusion agreement" signed by the parties excluded coverage. The First Circuit affirmed, holding that the district court properly accepted USLI's plausible reading of the exclusion amendment. View "Nahant Preservation Trust, Inc. v. Mount Vernon Fire Insurance Co." on Justia Law

Allstate Insurance Company and several of its affiliates (collectively, Allstate) brought qui tam actions on behalf of the State of California alleging insurance fraud under the California Insurance Frauds Prevention Act (IFPA) (and the Unfair Competition Law (UCL) against three medical corporations, a medical management company and its parent company, four physicians, and Sattar Mir, an individual. The trial court found the complaints failed to state causes of action under the IFPA and the UCL because they were not pled with requisite specificity, the business models alleged were lawful, and one of the actions was time-barred.   The Second Appellate District reversed the orders sustaining the demurrers and judgments of dismissal. The court explained that the trial court found the complaints failed to state causes of action under the IFPA and the UCL because they were not pled with requisite specificity, the business models alleged were lawful, and one of the actions was time-barred. The court concluded that the operative complaints adequately plead causes of action under both statutes. View "P. ex rel. Allstate Ins. Co. v. Discovery Radiology etc." on Justia Law