Justia Insurance Law Opinion Summaries

The Office of Personnel Management (OPM) administers retirement benefits for civilian employees of the U.S. government. OPM typically pays retirement benefits to retirees themselves. But when a retiree’s benefits are subject to division pursuant to a divorce decree, OPM divides them between the retiree and his or her former spouse according to the terms of the decree. The Federal Law Enforcement Officers Association (Association) brought this action against OPM in district court, claiming that OPM’s method of apportioning one type of retirement benefit, the Annuity Supplement, violates the Administrative Procedure Act. OPM moved to dismiss the complaint on jurisdictional grounds.   The district court acknowledged that federal employees’ claims for retirement benefits are generally routed through that system of review, but held that the Association’s claims fell within an exception allowing pre-enforcement challenges to agency rules to proceed in district court. Exercising jurisdiction, the district court dismissed one of the Association’s counts for failure to state a legally cognizable claim and, after the administrative record was filed, granted summary judgment to OPM as to the others.   The DC Circuit vacated the district court’s orders and remanded with instructions to dismiss for lack of jurisdiction. The court held that the CSRA’s system of review—which channels disputes about FERS retirement benefits through an administrative process, subject to direct review in the Federal Circuit—precludes district court review of the Association’s claims. View "Federal Law Enforcement Officers Association v. Kiran Ahuja" on Justia Law

Plaintiff is a former federal employee and participant in a health-insurance plan (“Plan”) that is governed by the Federal Employees Health Benefits Act (“FEHBA”). The Plan stems from a contract between the federal Office of Personnel Management (“OPM”) and Blue Cross Blue Shield Association and certain of its affiliates (together, “Blue Cross”). Blue Cross administers the Plan under OPM’s supervision. Plaintiff suffered from cancer, and she asked Blue Cross whether the Plan would cover the proton therapy that her physicians recommended. Blue Cross told her the Plan did not cover that treatment. So Plaintiff chose to receive a different type of radiation treatment, one that the Plan did cover. The second-choice treatment eliminated cancer, but it also caused devastating side effects. Plaintiff then sued OPM and Blue Cross, claiming that the Plan actually does cover proton therapy. As against OPM, she seeks the “benefits” that she wanted but did not receive, as well as an injunction directing OPM to compel Blue Cross to reform its internal processes by, among other things, covering proton therapy in the Plan going forward. As against Blue Cross, she seeks monetary damages under Texas common law. The district court dismissed Plaintiff’s suit.   The Fifth Circuit affirmed. The court held that neither the advance process nor the proton-therapy guideline poses an immediate threat of injury, so injunctive relief is therefore unavailable. Further, the court found that FEHBA preempts Plaintiff’s common-law claims against Blue Cross. Accordingly, the court held that no relief is available under the relevant statutory and regulatory regime. View "Gonzalez v. Blue Cross Blue Shield" on Justia Law

Plaintiffs, current and former employees of RingCentral, participated in RingCentral’s employee welfare benefits plan. The plan participated in the “Tech Benefits Program” administered by Sequoia Benefits and Insurance Services, LLC, a management and insurance brokerage company. The Tech Benefits Program was a MEWA that pooled assets from employer-sponsored plans into a trust fund for the purpose of obtaining insurance benefits for employees at large-group rates. Plaintiffs filed this putative class action on behalf of the RingCentral plan and other Tech Benefits Program participants, asserting that Sequoia owed fiduciary duties to the plan under ERISA because Sequoia allegedly exercised control over plan assets through its operation of the Tech Benefits Program. Plaintiffs alleged that Sequoia violated its fiduciary duties by receiving and retaining commission payments from insurers, which Plaintiffs regarded as kickbacks, and by negotiating allegedly excessive administrative fees with insurers, leading to higher commissions for Sequoia.   The Ninth Circuit affirmed the district court’s dismissal for lack of Article III standing. The court held that Plaintiffs failed to establish Article III standing as to either of their two theories of injury. The panel held, as to the out-of-pocket-injury theory, Plaintiffs failed to establish the injury in fact required for Article III standing because their allegations did not demonstrate that they paid higher contributions because of Sequoia’s allegedly wrongful conduct. And Plaintiffs failed to plead the third element, that their injury would likely be redressed by judicial relief. View "RACHAEL WINSOR, ET AL V. SEQUOIA BENEFITS & INSURANCE, ET AL" on Justia Law

Appellant American Federation of State, County and Municipal Employees, Council 3 (“Appellant”) filed suit against the State of Maryland alleging that the State breached a statutorily formed contract with current state employees to provide them with certain prescription drug benefits upon retirement. The district court agreed that Maryland law created a contract, it held that the contract was unilateral in nature and that the promised benefits do not vest until an employee retires with sufficient years of service. The district court determined that the current employees represented by Appellant had no vested contractual right to the retirement prescription drug benefits and dismissed the complaint.   The Fourth Circuit affirmed. However, the court did so because it found that the statutory language does not create a contract with state employees. The court explained that in reviewing the language of the statutes at issue, it concluded that they do not create a contract binding upon the State. While Section 2-508 does “entitle” retirees to a subsidy, it does not include any unmistakable contract language. Rather, it only “entitles” a retiree to the “same State subsidy allowed a State employee.” The court explained that nothing in Sections 2-508 or 2-509.1 leaves the court with an unmistakably “clear indication that the legislature intended to bind itself contractually.” Therefore, “all doubts must be resolved in favor of the continuance of the power” of the state legislature to modify or repeal enactments of a previous legislature. View "AFSCME Maryland Council 3 v. State of Maryland" on Justia Law

Appellants– the former secretary-treasurer and president, respectively, of a District Lodge of the International Association of Machinists – appealed the district court’s denial of their motion for a preliminary injunction. They sued the international union, its president, and its general secretary-treasurer. The controversy concerns the suspensions of Appellants’ and the international union’s imposition of a trusteeship on their District Lodge. Appellants’ first amended complaint alleged one count under Title I and five counts under Title III of the Labor-Management Reporting and Disclosure Act (the “LMRDA”). They sought equitable relief along with compensatory and punitive damages. A month after they filed their first amended complaint, they filed a motion for a preliminary injunction. The district court denied the motion. It held that Appellants had not shown a likelihood of success on the merits. It also held that the other factors did not favor them.   The DC Circuit affirmed. The court held that Appellants’ request under Title III to end the trusteeship is moot. A case becomes moot when a party obtains the relief they sought. Here, the disputed trusteeship has been lifted. Further, the court explained that Appellants seek to invalidate an officer election. It is impossible to reinstate Appellant as secretary-treasurer or allow the District Lodge to elect new members to other positions unless the court invalidates the officer election that just occurred. Thus, the court rejected the Title I claim. View "Ian Scott-Anderman, et al. v. Robert Martinez, et al." on Justia Law

Respondent Stephany Connelly was a passenger in a vehicle driven by co-worker Freya Trezona during the course and scope of their employment when Trezona negligently caused the accident, injuring Connelly. Because workers’ compensation benefits did not fully redress Connelly’s injuries, she made a claim for bodily injury and uninsured motorist (UM) benefits with her own insurance carrier and with Trezona’s carrier. Both companies denied the claim, contending Connelly’s sole remedy lay with the South Carolina Workers’ Compensation Act. Connelly filed suit seeking a declaration that both policies provided coverage. The parties agreed the dispute turned on the interpretation of the phrase “legally entitled to recover” found in the UM statute. The trial court ruled in favor of Connelly, and the court of appeals concurred the phrase was legally ambiguous. The South Carolina Supreme Court found the phrase unambiguous: the amount a plaintiff is “legally entitled to recover” under a UM provision of an insurance policy is the amount for which the plaintiff has secured a judgment against the at-fault defendant. Because the Act prevents Connelly from ever becoming “legally entitled to recover” from Trezona under the facts of this case, the Court reversed the trial court. View "Connelly v. Main Street America Group" on Justia Law

Reliance Standard Life Insurance Company denied Plaintiff’s claim for long-term disability benefits after concluding that she was not “Totally Disabled” as defined by her disability insurance plan. Plaintiff brought an under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. Section 1132(a)(1)(B), arguing that the denial of benefits violated that Act. After conducting a bench trial under Federal Rule of Civil Procedure 52, the district court awarded judgment to Plaintiff. Reliance appealed, arguing that courts in the Fourth Circuit are required to resolve ERISA denial-of-benefits cases via summary judgment and that the district court erred in dispensing with this case through a bench trial. Reliance also argued that this Court must review the district court’s legal conclusions.   The Fourth Circuit affirmed. The court first held that because the plan at issue here did not require objective proof of disability, the court rejected Reliance’s contention that Plaintiff’s claim fails for the lack of such evidence. Further, the court wrote that the record supports the district court’s determination that Plaintiff’s disability was not limited to a “specific locale.” Accordingly, the court agreed that Plaintiff was “totally disabled” under the terms of the plan. View "Anita Tekmen v. Reliance Standard Life Ins." on Justia Law

This action was brought by plaintiff Nancy Holm, administratrix of the estate of her husband, Christopher Friedauer, who died in 2015 after falling at his workplace, Holmdel Nurseries, LLC. As a longtime employee of the family-owned business, Christopher had been covered by workers’ compensation insurance, but he was no longer covered after he became a member of the LLC in 2012. Plaintiff claimed that defendant Daniel Purdy, who served as the insurance broker for Holmdel Nurseries from 2002 to 2015, failed to provide to the LLC the notice mandated by N.J.S.A. 34:15-36, and that Christopher was unaware that he no longer had workers’ compensation coverage in his new role as an LLC member. She alleged that as a result of defendant’s negligence and breach of fiduciary duty, Friedauer’s dependents were deprived of a workers’ compensation death benefit to which they would have been entitled under N.J.S.A. 34:15-13 had he been covered by workers’ compensation insurance at the time of his death. Defendant asserted that Friedauer’s father, Robert Friedauer, the LLC’s managing member for insurance issues, instructed defendant in 2002 that Holmdel Nurseries did not want to purchase workers’ compensation coverage for its LLC members because of the cost of that coverage. At the close of a jury trial, the trial court granted defendant’s motion for an involuntary dismissal pursuant to Rule 4:37-2(b) and his motion for judgment at trial pursuant to Rule 4:40-1. Informed by the New Jersey Legislature’s expression of public policy in N.J.S.A. 34:15-36, the New Jersey Supreme Court concurred with the Appellate Division that defendant had a duty to advise the LLC members, at the time of the workers’ compensation policy’s purchase or renewal, that an LLC member actively performing services on the LLC’s behalf was eligible for workers’ compensation coverage, but that the LLC must elect to purchase such coverage in order to obtain it. Consistent with N.J.S.A. 34:15-36, however, the Supreme Court held that defendant could not be held liable for breach of that duty unless the damages alleged were caused by defendant’s willful, wanton or grossly negligent act of commission or omission. The Supreme Court disagreed with the trial court’s assessment of the evidence presented by plaintiff on the question of proximate cause. Accordingly, the Court concurred that the trial court erred when it granted defendant’s motion to dismiss and his motion for judgment at trial, and affirmed as modified the Appellate Division’s judgment. The case was thus remanded to the trial court for further proceedings. View "Holm v. Purdy" on Justia Law

Supreme Court affirmed in part and reversed in part three orders issued by two separate judges presiding over two separate but related cases in the circuit court, holding that remand was required.Specifically, the Supreme Court held that the circuit court (1) did not err in denying Praetorian Insurance Company's motion to intervene in Plaintiff's wrongful death action against its insured, Air Cargo Carriers, LLC for lack of standing to assert Air Cargo's right to workers' compensation immunity; (2) erred in denying Praetorian's motion for summary judgment as to count one of its declaratory judgment complaint; and (3) correctly dismissed count two of Praetorian's declaratory judgment complaint on the grounds that Praetorian lacked standing. View "Praetorian Insurance Co. v. Chau" on Justia Law

The Travelers Indemnity Company appeals the judgment entered after the superior court denied Travelers’ petition for a writ of administrative mandate challenging the Insurance Commissioner’s decision that certain agreements relating to workers’ compensation insurance policies issued to Adir International, LLC were unenforceable. Travelers contended that Adir’s lawsuit in the trial court, which included a request for a declaratory judgment the agreements were void, barred the Commissioner, under the doctrine of exclusive concurrent jurisdiction, from exercising jurisdiction while that lawsuit was pending. Travelers also appealed the post-judgment order granting Adir’s motion for attorney fees, contending attorney fees were not authorized.   The Second Appellate Division affirmed the order and judgment denying Travelers’s petition. The court explained that the exclusive concurrent jurisdiction doctrine does not apply in this context to proceedings pending before the trial court and an administrative agency; and, in any event, it was reasonable and consistent with the primary jurisdiction doctrine for the trial court to defer to the Commissioner’s determination of the validity of the agreement at issue. In addition, because Adir’s administrative claim fell within the agreement’s attorney fee provision, the court affirmed the post-judgment order awarding Adir attorney fees. View "The Travelers Indemnity Co. v. Lara" on Justia Law