Justia Insurance Law Opinion Summaries

Tony Kourianos worked as a coal miner for more than 27 years before filing a claim for benefits under the Black Lung Benefits Act (“BLBA”). His claim was reviewed through a three-tiered administrative process. Ultimately, the Benefits Review Board (“BRB”) found that he was entitled to benefits. The BRB also found that Kourianos’s last employer, Hidden Splendor Resources, Inc., was the “responsible operator” liable for paying those benefits. Hidden Splendor’s insurer, Rockwood Casualty Insurance Company, petitioned the Tent Circuit Court of Appeal for review of the BRB’s decision: (1) challenging the administrative law judge’s (“ALJ”) decision prohibiting Hidden Splendor from withdrawing its responsible operator stipulation; and (2) contending the BRB incorrectly found that Kourianos was totally disabled and entitled to benefits. Finding no abuse of discretion in the BRB decision, the Tenth Circuit denied Rockwood's petition. View "Rockwood Casualty Insurance v. Director, OWCP" on Justia Law

Timothy Hinton died from injuries sustained in a fall from a tree stand. At the time of his fall, Timothy was wearing a fall-arrest system which included a full-body harness, tether and tree strap. Timothy had purchased the tree stand and fall-arrest system from The Sportsman’s Guide, Inc. (“TSG”), in 2009. C&S Global Imports, Inc. (“C&S”) had manufactured the items and marketed them to TSG. Pekin Insurance Company insured C&S at the time of Timothy’s injury and death. After filing their third amended complaint, the Hintons filed a motion for partial summary judgment against Pekin, claiming Pekin waived its defenses to coverage or should have been estopped from asserting any coverage defenses. Among other arguments, the Hintons maintained that Pekin failed to defend C&S, did not file a declaratory-judgment action and allowed a default judgment against C&S. The circuit court denied the Hintons’ motion. Pekin then moved for summary judgment, arguing the insurance policy excluded coverage for tree or deer stands and related equipment. The circuit court granted Pekin’s motion and entered a final judgment dismissing Pekin from the suit. The Hintons appealed both of the circuit court’s rulings. After review, the Mississippi Supreme Court affirmed the order denying partial summary judgment to the Hintons, the order granting summary judgment to Pekin and the final judgment dismissing Pekin from the suit. View "Hinton v. Pekin Insurance Company" on Justia Law

In this case involving the proper method of applying a personal injury protection (PIP) insurance policy deductible to a medical provider’s bill for hospital emergency services and care, the Supreme Court approved the Fifth District Court of Appeal’s decision, holding that the deductible should be subtracted from the total charges prior to application of the reimbursement limitation in Fla. Stat. 627.736(5)(a)1.b.While this case was pending in the Court, the Fourth District Court of Appeal issued an opinion in State Farm Mutual Automobile Insurance Co. v. Care Wellness Center, LLC (Care Wellness), 240 So. 3d 22 (Fla. 4th DCA 2018), holding that the deductible should be applied after charges are reduced under any fee schedule found in section 627.736. The Supreme Court approved the Fifth District’s decision in the instant case and disapproved the Fourth District’s decision in Care Wellness, holding that, under Fla. Stat. 627.739(2), the deductible should be applied to the total medical charges prior to reduction under the reimbursement limitation. View "Progressive Select Insurance Co. v. Florida Hospital Medical Center" on Justia Law

In 2002, Charles Herron, who was under the influence of alcohol and not old enough to legally possess or consume it, was involved in a single-vehicle accident in Bethel, Alaska A 15-year-old passenger in Herron’s vehicle, Angelina Trailov, was injured. Herron was insured by Allstate Insurance Company. Allstate filed a complaint for declaratory relief in the U.S. District Court in anticipation of Herron confessing judgment in the accident-related personal injury suit. Allstate requested a declaration that “its good faith attempt to settle Trailov and Mary Kenick's (Trailov's mother) claims satisfied its obligation to its insured, and a further declaration that Allstate [wa]s not obligated to pay any portion of the confessed judgment that exceed[ed] the limit of the bodily injury coverage afforded Herron under the [p]olicy.” Due to Herron’s April confession of judgment and assignment of claims, Allstate amended its federal complaint for declaratory relief. The only material addition was the statement that Herron had confessed judgment and assigned his rights against Allstate. The issue this case presented for the Alaska Supreme Court's review centered on the preclusive effect of that declaratory judgment in favor of the insurance company against its insured in federal court in a subsequent state court proceeding. The superior court concluded that the declaratory judgment had no preclusive effect on a negligent adjustment action brought in state court by the insured’s assignees against the insurance company and its claims adjuster. The state action proceeded to an 11-day jury trial ending with a multi-million dollar verdict against the insurance company and its claims adjuster. The declaratory judgment determined that the insurance company and the adjuster acted reasonably when they offered policy limits to settle the underlying claim against the insured. Because the insurance company’s and adjustor’s reasonableness in adjusting the insurance claim was a necessary element of a negligent adjustment tort, the Supreme Court held that the assignees of the insured were precluded from relitigating this issue. The superior court therefore erred in denying the insurance company’s and claims adjuster’s motions for summary judgment. View "Allstate Insurance Company v. Kenick" on Justia Law

This appeal required the Pennsylvania Supreme Court to determine whether a “household vehicle exclusion” contained in a motor vehicle insurance policy violated Section 1738 of the Motor Vehicle Financial Responsibility Law (“MVFRL”), 75 Pa.C.S. 1738, because the exclusion impermissibly acted as a de facto waiver of stacked uninsured and underinsured motorist (“UM” and “UIM,” respectively) coverages. In 2012, Appellant Brian Gallagher was riding his motorcycle when William Stouffer ran a stop sign in his pickup truck, colliding with Gallagher’s motorcycle, causing Gallagher to suffer severe injuries. At the time of the accident, Gallagher had two insurance policies with GEICO; one included $50,000 of UIM coverage, insured only Gallagher’s motorcycle; the second insured Gallagher’s two automobiles and provided for $100,000 of UIM coverage for each vehicle. Gallagher opted and paid for stacked UM and UIM coverage when purchasing both policies. Stouffer’s insurance coverage was insufficient to compensate Gallagher in full. Consequently, Gallagher filed claims with GEICO seeking stacked UIM benefits under both of his GEICO policies. GEICO paid Gallagher the $50,000 policy limits of UIM coverage available under the Motorcycle Policy, it denied his claim for stacked UIM benefits under the Automobile Policy. GEICO based its decision on a household vehicle exclusion found in an amendment to the Automobile Policy. The exclusion states as follows: “This coverage does not apply to bodily injury while occupying or from being struck by a vehicle owned or leased by you or a relative that is not insured for Underinsured Motorists Coverage under this policy.” According to Gallagher, by denying him stacked UIM coverage based upon the household vehicle exclusion, GEICO was depriving him of the stacked UIM coverage for which he paid. The Pennsylvania Supreme Court held the household vehicle exclusion violated the MVFRL, and vacated the Superior Court’s judgment, reversed the trial court’s order granting summary judgment in favor of GEICO, and remanded to the trial court for further proceedings. View "Gallagher v. GEICO" on Justia Law

Defendant Metropolitan Property and Casualty Insurance Company (Metropolitan), appealed a superior court order partially granting and partially denying its summary judgment motion as well as a cross-motion filed by plaintiff Joseph Santos. Santos held a personal excess liability policy with Metropolitan that included excess underinsured motorist (UIM) coverage. After Metropolitan denied a claim made by Santos for excess UIM benefits after Santos was hurt in a motorcycle accident, he brought this declaratory judgment action. The trial court ruled that Metropolitan was liable to Santos for excess UIM benefits. Metropolitan argued the trial court erred in so holding because Santos’s policy required, as a precondition to receiving excess UIM benefits, that he carry a certain amount of underlying insurance coverage, and Santos did not do so. Santos argued his lack of sufficient underlying coverage allowed Metropolitan to reduce its excess UIM liability but not escape it altogether. Finding no error in the superior court's judgment, the New Hampshire Supreme Court affirmed partial summary judgment. View "Santos v. Metropolitan Property & Casualty Ins. Co." on Justia Law

Dennis Woolman, former president of The Clemens Coal Company, challenged a district court’s determination that Liberty Mutual Fire Insurance Company didn’t breach a duty to him by failing to procure for Clemens Coal an insurance policy with a black-lung disease endorsement. Clemens Coal operated a surface coal mine until it filed for bankruptcy in 1997. Woolman served as Clemens Coal’s last president before it went bankrupt. Federal law required Clemens Coal to maintain worker’s compensation insurance with a special endorsement covering miners’ black-lung disease benefits. Woolman didn’t personally procure insurance for Clemens Coal but instead delegated that responsibility to an outside consultant. The policy the consultant ultimately purchased for the company did not contain a black-lung-claim endorsement, and it expressly excluded coverage for federal occupational disease claims, such as those arising under the Black Lung Benefits Act (the Act). In 2012, a former Clemens Coal employee, Clayton Spencer, filed a claim with the United States Department of Labor (DOL) against Clemens Coal for benefits under the Act. After some investigation, the DOL advised Woolman that Clemens Coal was uninsured for black-lung-benefits claims as of July 25, 1997 (the last date of Spencer’s employment) and that, without such coverage, Woolman, as Clemens Coal’s president, could be held personally liable. Woolman promptly tendered the claim to Liberty Mutual for a legal defense. Liberty Mutual responded with a reservation-of-rights letter, stating that it hadn’t yet determined coverage for Spencer’s claim but that it would provide a defense during its investigation. Then in a follow-up letter, Liberty Mutual clarified that it would defend Clemens Coal as a company (not Woolman personally) and advised Woolman to retain his own counsel. Liberty Mutual eventually concluded that the insurance policy didn’t cover the black-lung claim, and sued Clemens Coal and Woolman for a declaration to that effect. In his suit, Woolman also challenged the district court’s rejection of his argument that Liberty Mutual should have been estopped from denying black-lung-disease coverage, insisting that he relied on Liberty Mutual to provide such coverage. Having considered the totality of the circumstances, the Tenth Circuit Court of Appeals concluded the district court didn’t err in declining Woolman’s extraordinary request to expand the coverages in the Liberty Mutual policy. “Liberty Mutual never represented it would procure the coverage that Woolman now seeks, and the policy itself clearly excludes such coverage. No other compelling consideration justifies rewriting the agreement— twenty years later—to Woolman’s liking.” View "Liberty Mutual Fire Insurance v. Woolman" on Justia Law

A jury convicted former United States Postal Service employee Robert Hamilton of three counts of making a false or fraudulent statement for the purpose of obtaining compensation under the California workers' compensation law. On appeal, Hamilton argued: (1) because, as a federal employee, his workers' compensation benefits were provided under the Federal Employment Compensation Act, the doctrine of federal preemption barred him from being prosecuted under California law for any offense alleging fraud in obtaining federal workers' compensation benefits under FECA; and (2) regardless of whether the prosecution was preempted, his conviction was supported by insufficient evidence under Insurance Code section 1871.4 (a)(1) because that statute applied only to false or fraudulent statements made for the purpose of obtaining compensation afforded under the California workers' compensation law, which was not applicable to him as a federal employee. On the issue of federal preemption, the Court of Appeal concluded that Hamilton did not meet his burden to establish that the State's prosecution of him was preempted. With respect to the sufficiency of the evidence, the Court agreed with the State's concession that insufficient evidence supported Hamilton's convictions because he did not receive compensation under the California workers' compensation law. The Court declined to exercise discretion to modify the judgment to impose convictions on a lesser included offense. Accordingly, the judgment was reversed. View "California v. Hamilton" on Justia Law

Ace American Insurance Company ("Ace"), an intervenor in the action below, appeals from the Baldwin Circuit Court's dismissal of the action filed by Ace's insured, Willie James Westbrook, against Rouse's Enterprises, LLC, d/b/a Rouses Markets ("Rouses Markets"). In August 2016, Westbrook sued Rouses Markets seeking to recover damages for injuries he sustained as the result of the allegedly negligent operation of a pallet jack by a Rouses Markets' employee while Westbrook was delivering goods to the Rouses Markets' location in Spanish Fort during the course of his employment with Cardinal Logistics Management Corporation ("Cardinal"). The Alabama Supreme Court has stated previously that, "'since dismissal with prejudice is a drastic sanction, it is to be applied only in extreme situations' and that, as a result, 'appellate courts will carefully scrutinize such orders and occasionally will find it necessary to set them aside.'" The Court could not say that the circumstances presented by this case presented an extreme situation in which dismissal of Ace's claim for want of prosecution was warranted. Accordingly, it reversed the judgment of the trial court dismissing Ace's claim and remanded the case for further proceedings. View "Ace American Insurance Company v. Rouse's Enterprises, LLC, d/b/a Rouses Markets" on Justia Law

In 2002, in Texas, Dr. Phillips performed a laparoscopic hysterectomy on Bramlett, a 36-year-old mother. While hospitalized, Bramlett suffered internal bleeding and died. Her family filed a wrongful death lawsuit against the hospital and Dr. Phillips, who held a $200,000 professional liability insurance policy with MedPro. He notified MedPro of the lawsuit. In 2003, the hospital settled with the Bramletts for approximately $2.3 million. The Bramletts wrote to Dr. Phillips’s attorney, Davidson, with a $200,000 Stowers demand; under Texas law, if an insurer rejects a plaintiff's demand that is within the insured’s policy limit and that a reasonably prudent insurer would accept, the insurer will later be liable for any amount awarded over the policy limit. MedPro twice refused to settle. The family won a $14 million verdict. The Supreme Court of Texas capped Dr. Phillips’s liability. The family sued MedPro, which settled. MedPro was insured by AISLIC, which declined to cover MedPro’s settlement. The district court granted AISLIC summary judgment, concluding that coverage was excluded because MedPro should have foreseen the family’s claim. An exclusion precluded coverage for “any claim arising out of any Wrongful Act” which occurred prior to June 30, 2005, if before that date MedPro “knew or could have reasonably foreseen that such Wrongful Act could lead to a claim.” The Seventh Circuit reversed in part, finding genuine issues of material fact regarding whether MedPro’s failure to settle was a Wrongful Act and whether MedPro could have foreseen a "claim" before the malpractice trial. View "Medical Protective Co. of Fort Wayne, Indiana v. American International Specialty Lines Insurance Co." on Justia Law