Justia Insurance Law Opinion Summaries

BlueCross BlueShield of Tennessee (BlueCross) is an insurer and fiduciary for an ERISA-governed group health insurance plan. A plan member in New Hampshire sought coverage for fertility treatments, which BlueCross denied as the plan did not cover such treatments. The Commissioner of the New Hampshire Insurance Department initiated an enforcement action against BlueCross, alleging that the denial violated New Hampshire law, which mandates coverage for fertility treatments. BlueCross sought to enjoin the state regulatory action, arguing it conflicted with its fiduciary duties under ERISA.The United States District Court for the Eastern District of Tennessee denied BlueCross's request for relief and granted summary judgment to the Commissioner. The court found that the Commissioner’s enforcement action was against BlueCross in its capacity as an insurer, not as a fiduciary, and thus was permissible under ERISA’s saving clause, which allows state insurance regulations to apply to insurers.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court’s decision. The Sixth Circuit held that the Commissioner’s action was indeed against BlueCross as an insurer, aiming to enforce New Hampshire’s insurance laws. The court noted that ERISA’s saving clause permits such state actions and that BlueCross could not use its fiduciary duties under ERISA to evade state insurance regulations. The court also referenced the Supreme Court’s decision in UNUM Life Insurance Co. of America v. Ward, which established that state insurance regulations are not preempted by ERISA when applied to insurers. Thus, the Sixth Circuit concluded that ERISA did not shield BlueCross from the New Hampshire regulatory action. View "BlueCross BlueShield of Tennessee v. Nicolopoulos" on Justia Law

Two former police officers, Mark Zukowski and Joshua Ruggiero, were injured in the line of duty and subsequently awarded both accidental disability retirement (ADR) benefits and workers' compensation benefits under Maryland's Workers' Compensation Act. The ADR benefits exceeded the workers' compensation benefits, resulting in an offset that left the officers with only a small portion of the workers' compensation benefits. The officers' attorney sought fees based on the total workers' compensation award before the offset was applied.The Maryland Workers' Compensation Commission awarded attorney's fees based on the reduced amount of workers' compensation benefits after applying the statutory offset. The Circuit Court for Anne Arundel County affirmed the Commission's decision, holding that attorney's fees should be calculated after the offset.The Supreme Court of Maryland reviewed the case and affirmed the lower courts' decisions. The Court held that the terms "benefits" and "compensation" are interchangeable in this context, meaning that attorney's fees should be calculated based on the amount of compensation actually payable to the claimant after applying the statutory offset. The Court emphasized that the attorney's fees are a lien on the compensation awarded, which is defined as the money payable to the injured employee. Therefore, the offset must be applied before calculating the attorney's fees. The Court also rejected the argument that this interpretation was unconstitutional, stating that the attorney voluntarily agreed to the fee arrangement and was aware of the statutory provisions governing attorney's fees. View "Zukowski v. Anne Arundel Cnty." on Justia Law

Martin Montano Jr., an employee of Casas Custom Floor Care, LLC, was involved in a fatal car accident while driving his mother's truck to correct his timesheet at the company's main yard. Michael Cravens, the surviving spouse of the deceased, sued Montano and Casas, alleging negligence and vicarious liability. Cincinnati Indemnity Company, which insured Casas, issued a reservation of rights letter to Montano, disputing its obligation to defend or insure him under the policy.The Superior Court in Pima County granted summary judgment in favor of Cravens, ruling that Montano was using the vehicle "in connection with" Casas's business at the time of the accident, thus obligating Cincinnati to indemnify Montano. The court also upheld the enforceability of a Morris Agreement between Montano and Cravens, which stipulated Montano's liability and assigned his rights under the policy to Cravens. The court of appeals affirmed the superior court's rulings on both coverage and the agreement.The Supreme Court of Arizona reviewed the case and held that an employee operates a non-owned auto "in connection with your business" when using the vehicle while engaged in the employer's business. This does not include a routine commute. The court also held that a contingent Morris agreement is enforceable if it meets the substantive requirements to ensure against fraud, collusion, unfairness, or unreasonableness. The court vacated the court of appeals' coverage ruling, affirmed the ruling on the Morris Agreement, reversed the superior court's judgment, and remanded for further proceedings consistent with its opinion. View "CRAVENS v MONTANO" on Justia Law

Haylee Hinton was injured in a car accident caused by another motorist running a red light. She initially sought compensation from her employer’s workers’ compensation insurer and later settled with the motorist’s insurance carrier. Hinton then filed a claim for underinsured motorist benefits with Midwest Family Mutual Insurance, her underinsured motorist coverage provider, and submitted the claim to arbitration as permitted by Utah law.Midwest sought a declaratory judgment from the district court to limit the categories of damages Hinton could recover in arbitration, citing Utah Code section 31A-22-305.3(4)(c)(i), which excludes benefits paid or payable under the Workers’ Compensation Act from underinsured motorist coverage. The district court interpreted the statute to mean that past and future medical expenses and two-thirds of lost wages were payable under workers’ compensation and ruled that Hinton could not recover these categories of damages from Midwest.Hinton petitioned for interlocutory review, arguing that the district court lacked jurisdiction and misinterpreted the statute. The Utah Supreme Court found that the district court had jurisdiction but misinterpreted the statute. The court concluded that “payable” means benefits that can or may be paid to a specific claimant in a particular case, not just categories of damages generally available under workers’ compensation. The court vacated the district court’s order and remanded the matter for further proceedings to determine what benefits remain payable to Hinton under the Workers’ Compensation Act. View "Hinton v. Midwest Family Mutual Insurance" on Justia Law

Joe David Hudson was injured while working for Joplin Regional Stockyards, Inc. (JRS) in 2002. In 2005, Hudson, JRS, and JRS' insurer, Star Insurance Company, entered into a settlement agreement where Hudson received an $80,000 lump sum. The settlement left future medical expenses for Hudson's left ankle open. In 2011, Hudson had a below-the-knee amputation, which Star refused to cover. Hudson filed the settlement in circuit court in 2013, and the court rendered judgment in accordance with the settlement. Hudson later filed an equitable garnishment action, leading Star to pay $92,000 for his medical bills. In 2015, Star agreed to reimburse Hudson up to $610,311.75 for future medical expenses. In 2016, Hudson and JRS entered into a subordination agreement, acknowledging all payments due under the judgment had been received.In 2022, Hudson filed a motion to revive the judgment, which JRS opposed, arguing the judgment had been satisfied and the Division of Workers' Compensation had not determined the future medical care provision. JRS also filed a motion for relief from the judgment, claiming it was void due to lack of due process. The Circuit Court of Jasper County sustained Hudson's motion to revive the judgment and overruled JRS' motion for relief.The Supreme Court of Missouri reviewed the case and determined that JRS had standing to appeal. The court found that the circuit court erred in reviving the judgment because JRS had satisfied the judgment by paying the $80,000 lump sum. The court reversed the circuit court's order sustaining Hudson's motion to revive the judgment and overruled Hudson's motion to revive the judgment. Hudson's motion for damages for a frivolous appeal was also overruled. View "Hudson v. Joplin Regional Stockyards, Inc." on Justia Law

Glenn O. Hawbaker, Inc. (GOH) engaged in a scheme to underpay its employees by misappropriating fringe benefits owed under the Pennsylvania Prevailing Wage Act (PWA) and the Davis-Bacon Act (DBA). This led to two class-action lawsuits against GOH. GOH sought coverage under its insurance policy with Twin City Fire Insurance Company (Twin City), which denied coverage and sought a declaratory judgment that it had no duty to provide coverage. GOH and its Board of Directors counterclaimed, alleging breach of contract and seeking a declaration that certain claims in the class actions were covered under the policy.The United States District Court for the Middle District of Pennsylvania dismissed GOH's counterclaims, concluding that the claims were not covered under the policy due to a policy exclusion for claims related to "Wage and Hour Violations." The court also granted Twin City's motion for judgment on the pleadings, affirming that Twin City had no duty to defend or indemnify GOH for the class-action claims.The United States Court of Appeals for the Third Circuit reviewed the case and affirmed the District Court's judgment. The Third Circuit agreed that the claims in question were not covered under the policy because they were related to wage and hour violations, which were explicitly excluded from coverage. The court emphasized that the exclusion applied broadly to any claims "based upon, arising from, or in any way related to" wage and hour violations, and found that the factual allegations in the class actions were indeed related to such violations. Thus, Twin City had no duty to defend or indemnify GOH under the terms of the policy. View "Twin City Fire Insurance Co. v. Glenn O. Hawbake, Inc." on Justia Law

In this case, the plaintiff, MVT Services, LLC (MVT), purchased a workers’ compensation and employers’ liability policy (WC/EL Policy) from Great West Casualty Company (Great West) for coverage from January 1, 2013, to January 1, 2014. MVT also entered into a Staff Leasing Agreement with OEP Holdings, LLC (OEP) and purchased a non-subscriber insurance policy from Crum & Forster Specialty Insurance Company (C&F). On August 13, 2013, MVT terminated its Texas coverage under the WC/EL Policy, effective September 16, 2013. On September 15, 2013, a day before the termination, MVT’s semi-tractor trailer crashed, killing driver Lawrence Parada. Parada’s widow filed a lawsuit against MVT. Great West denied coverage, leading MVT to seek defense under the C&F Policy.The United States District Court for the District of New Mexico found that Great West breached its duty to defend MVT, causing MVT to incur damages. The court awarded MVT damages and attorney fees. Great West appealed, arguing that the district court erred in finding that the Parada lawsuit would have resolved within the policy limit and that the breach did not proximately cause the damages.The United States Court of Appeals for the Tenth Circuit reviewed the case. The court held that the district court did not clearly err in its factual findings that MVT would have invoked the Exclusive Remedy defense and that the gross negligence claim would have resolved within the policy limit. The court also found that the district court did not err in awarding damages for the $250,000 retention under the C&F Policy, the $250,000 MVT contributed to the settlement, and $41,476.84 in attorney fees. The court affirmed the district court’s award of attorney fees, concluding that Great West failed to show the district court committed legal error or clearly erred in its fact findings. The Tenth Circuit affirmed the district court’s judgment. View "MVT Services v. Great West Casualty Company" on Justia Law

Kevin Klabon, a technician for CMI Legacy, LLC, was injured in a car accident while driving a company van. The accident was caused by Rodrigo Canchola-Rodriguez, an underinsured driver. Klabon received workers' compensation benefits from CMI's carrier, Pinnacol Assurance, and settled with Canchola-Rodriguez's insurer for $25,000. He then sought additional underinsured motorist (UIM) benefits from CMI's commercial auto insurer, Travelers Property Casualty Company of America, which valued his claim at $78,766 but paid only $45,766.68.Klabon sued Travelers in state court for unreasonable denial and delay of UIM benefits, alleging bad faith and breach of contract. Travelers removed the case to federal court and moved for summary judgment, arguing that Klabon's receipt of workers' compensation benefits barred his UIM claim under Colorado's Workers' Compensation Act (WCA). The United States Magistrate Judge certified the question to the Colorado Supreme Court, given conflicting precedents and significant public policy implications.The Colorado Supreme Court concluded that an employee injured by a third-party tortfeasor and who receives workers' compensation benefits is not barred from suing their employer's UIM insurer. The court held that the WCA's exclusivity provisions immunize only employers and their workers' compensation carriers, not separate UIM insurers. The court also determined that a suit to recover UIM benefits does not constitute a suit against the employer or co-employee and thus is not barred by the WCA. The court answered the certified question in the negative, allowing Klabon to pursue his claim against Travelers. View "Klabon v. Travelers Property Casualty Company of America" on Justia Law

Plaintiffs M.S. and L.S. sought insurance coverage for mental health treatments for their child, C.S., under a health benefits plan provided by M.S.'s employer, Microsoft Corporation. The plan, administered by Premera Blue Cross, is subject to ERISA and the Parity Act. Premera denied the claim, stating the treatment was not medically necessary. Plaintiffs pursued internal and external appeals, which upheld the denial. Plaintiffs then sued in federal district court, alleging improper denial of benefits under ERISA, failure to produce documents in violation of ERISA’s disclosure requirements, and a Parity Act violation for applying disparate treatment limitations to mental health claims.The United States District Court for the District of Utah granted summary judgment to Defendants on the denial-of-benefits claim but ruled in favor of Plaintiffs on the Parity Act and ERISA disclosure claims. The court found that Defendants violated the Parity Act by using additional criteria for mental health claims and failed to disclose certain documents required under ERISA. The court awarded statutory penalties and attorneys’ fees to Plaintiffs.The United States Court of Appeals for the Tenth Circuit reviewed the case. The court vacated the district court’s grant of summary judgment on the Parity Act claim, finding that Plaintiffs lacked standing to bring the claim. The court reversed the district court’s ruling that Defendants violated ERISA by not disclosing the Skilled Nursing InterQual Criteria but affirmed the ruling regarding the failure to disclose the Administrative Services Agreement (ASA). The court upheld the statutory penalty for the ASA disclosure violation and affirmed the award of attorneys’ fees and costs to Plaintiffs. View "M.S. v. Premera Blue Cross" on Justia Law

Plaintiffs Marla Knudsen and William Dutra, representing a class of similarly situated individuals, filed a class action lawsuit under the Employee Retirement Income Security Act (ERISA) against MetLife Group, Inc. They alleged that MetLife, as the administrator and fiduciary of the MetLife Options & Choices Plan, misappropriated $65 million in drug rebates from 2016 to 2021. Plaintiffs claimed this misappropriation led to higher out-of-pocket costs for Plan participants, including increased insurance premiums.The United States District Court for the District of New Jersey dismissed the case for lack of standing. The court concluded that the plaintiffs did not demonstrate a concrete and individualized injury. It reasoned that the plaintiffs had no legal right to the general pool of Plan assets and had not shown that they did not receive their promised benefits. The court found the plaintiffs' claims that they paid excessive out-of-pocket costs to be speculative and lacking factual support.The United States Court of Appeals for the Third Circuit affirmed the District Court's dismissal. The Third Circuit held that the plaintiffs failed to establish an injury-in-fact, as their allegations of increased out-of-pocket costs were speculative and not supported by concrete facts. The court noted that the plaintiffs did not provide specific allegations showing how the misappropriated drug rebates directly caused their increased costs. The court emphasized that financial harm must be actual or imminent, not conjectural or hypothetical, to satisfy Article III standing requirements. Consequently, the plaintiffs lacked standing to pursue their ERISA claims. View "Knudsen v. MetLife Group Inc" on Justia Law