Justia Insurance Law Opinion Summaries

The Supreme Judicial Court affirmed the judgment of the superior court finding that the tortfeasor who injured Appellants in a motor vehicle accident was not an underinsured driver pursuant to Maine’s underinsured motorist (UM) statute, and therefore, there was no gap in coverage requiring State Farm Mutual Automobile Insurance Company to pay UM benefits under two policies issued to Appellants. The court held that because Appellants recovered far more from the tortfeasor’s insurers than the maximum amount of UM coverage provided by the State Farm policies, they surpassed the same recovery that would have been available had the tortfeasor been insured to the same extent. Therefore, there was no UM gap that State Farm was responsible to cover. View "Wallace v. State Farm Mutual Automobile Insurance Co." on Justia Law

The Second Circuit held that, when applied, Section 5‐335 of the New York General Obligations Law prohibited Aetna's reduction of plaintiff's disability benefits. In this case, neither the Employee Retirement Income Security Act's, 29 U.S.C. 1001 et seq., preemptive force nor the Plan's choice of law provision compelled a different conclusion; and the court rejected Aetna's forfeiture argument. Therefore, the district court erred in granting Aetna's motion for summary judgment and denying plaintiff's motion for summary judgment in regard to plaintiff's entitlement to the past and ongoing benefits that Aetna has withheld on the ground that they are duplicative of plaintiff's personal injury settlement. Accordingly, the court reversed in part and remanded. View "Arnone v. Aetna Life Ins. Co." on Justia Law

Plaintiff, who was injured while rendering roadside aid as a Good Samaritan, was “occupying” the insured vehicle for purposes of underinsured motorist (UM) coverage and was therefore entitled to recover under the terms of a GEICO Insurance Agency, Inc. policy.Plaintiff was a passenger in a Saab driven by Gregory Hurst when the two witnessed an automobile collision. Plaintiff exited the Saab and was attempting to render assistance when she was struck by another car. Plaintiff settled a claim against the driver of the vehicle that hit her but claimed that she was not fully compensated for her injuries. Consequently, Plaintiff filed a claim with GEICO (Defendant) seeking relief through Hurst’s GEICO policy that insured the Saab. Defendant denied the claim on the ground that Plaintiff was not “occupying” the insured vehicle at the time of her injuries. Plaintiff then filed this action. The trial justice agreed with Defendant, concluding that Plaintiff could not recover UM benefits under the terms of the GEICO policy. The Supreme Court vacated the judgment of the superior court, holding that Plaintiff was entitled to recover under the terms of the policy. View "Hudson v. GEICO Insurance Agency, Inc." on Justia Law

Where an insurance policy is restricted to liability for any bodily injury “caused, in whole or in part” by the “acts of omissions” of the named insured, the coverage applies to injury proximately caused by the named insured.The Appellate Division denied summary judgment in favor of the insurance company on the issue of coverage after interpreting this policy language as extending coverage broadly to any injury causally linked to the named insured. The court also concluded that an additional insured may collect for an injury caused solely by its own negligence even where the named insured bears no legal fault for the underlying harm. The Court of Appeals reversed, holding that the language “caused, in whole or in part” requires the insured to be the proximate cause of the injury giving rise to liability, not merely the “but for” cause. View "Burlington Insurance Co. v. New York City Transit Authority" on Justia Law

A provision of the mandatory form settlement document promulgated by the Director of the Division of Workers’ Compensation (“Director”) did not waive an injured employee’s statutory right under section 8-43-204(1), C.R.S. (2016), to reopen a settlement based on a mutual mistake of material fact. Petitioner Victor England was a truck driver for Amerigas Propane. He filed a workers’ compensation claim after sustaining a serious injury to his shoulder in December 2012 while making a delivery for Amerigas. England’s claim was governed by the Colorado Workers’ Compensation Act, which required that settlements between employer and employee must be written, signed by both sides, and approved by the Director or an administrative law judge (“ALJ”). Pursuant to section 8-43-204, the Director promulgated a form settlement agreement (“Form”), which the parties are required to use to settle all claims. In this case, the parties’ settlement agreement was consistent with the Form. England’s pain continued after the settlement agreement was signed and approved. In October 2013, he sought further medical evaluation, which revealed a previously undiagnosed stress fracture in the scapula (shoulder blade) of England’s injured shoulder. Up to this point, no one was aware that this fracture existed. England claims that if he had been aware of this fracture, he would not have settled his claim. England filed a motion to reopen the settlement on the ground that the newly discovered fracture justified reopening his workers’ compensation claim. An ALJ agreed, and the Industrial Claim Appeals Office (ICAO) affirmed. The court of appeals reversed, concluding that the Form waived England’s right to reopen. The Colorado Supreme Court held that because provisions of the form document must yield to statutory rights, the court of appeals erred in its conclusion. View "England v. Amerigas Propane" on Justia Law

Health insurers do not have a broad, unrestricted right of subrogation against third-party tortfeasors who cause injury to their insureds but, rather, are limited to reimbursement rights established by statute.In this personal injury case, the circuit court ruled that Haw. Rev. Stat. 663-10 and/or Haw. Rev. Stat. 431:13-103(a)(1) abrogated Hawai’i Medical Service Association’s (HMSA) contractual and common law rights in subrogation against a third-party tortfeasors responsible for injury to its insured. The Supreme Court affirmed, holding (1) a health insurer does not have equitable subrogation rights against a third-party tortfeasor in the context of personal injures; (2) a health insurer’s subrogation and reimbursement rights are limited by section 663-10 and section 431-13:103(a)(1); (3) any contractual provision that conflicts with section 663-10 is invalid; and (4) section 663-10 takes precedence over HMSA’s subrogation rights. View "Yukumoto v. Tawarahara" on Justia Law

Only two sections of the Michigan no-fault act mention healthcare providers, MCL 500.3157 and MCL 500.3158, and neither of those sections confers on a healthcare provider a right to sue for reimbursement of the costs of providing medical care to an injured person. Although MCL 500.3112 allows no-fault insurers to directly pay PIP benefits to a healthcare provider for expenses incurred by an insured, MCL 500.3112 does not entitle a healthcare provider to bring a direct action against an insurer for payment of PIP benefits. Covenant Medical Center, Inc., brought suit against State Farm Mutual Automobile Insurance Company to recover payment under the no-fault act for medical services provided to State Farm’s insured, Jack Stockford, following an automobile accident in which Stockford was injured. State Farm denied payment. In the meantime, Stockford had filed suit against State Farm for no-fault benefits, including personal protection insurance (PIP) benefits. Without Covenant’s knowledge, Stockford and State Farm settled Stockford’s claim for $59,000 shortly before Covenant initiated its action against State Farm. As part of the settlement, Stockford released State Farm from liability for all allowable no-fault expenses and any claims accrued through January 10, 2013. State Farm moved for summary judgment under MCR 2.116(C)(7) (dismissal due to release) and MCR 2.116(C)(8) (failure to state a claim). The trial court granted State Farm’s motion under MCR 2.116(C)(7), explaining that Covenant’s claim was dependent on State Farm’s obligation to pay no-fault benefits to Stockford, an obligation that was extinguished by the settlement between Stockford and State Farm. View "Covenant Medical Center, Inc. v. State Farm Mutual Automobile Ins. Co." on Justia Law

In 2004, George and Thelma Nickola, were injured in a car accident. The driver of the other car was insured with a no-fault insurance policy provided the minimum liability coverage allowed by law: $20,000 per person, up to $40,000 per accident. The Nickolas’ (acting through their attorney) wrote to their insurer, defendant MIC General Insurance Company, explaining that the no-fault liability insurance policy was insufficient to cover the Nickolas' injuries. The letter also advised MIC that the Nickolas were claiming UIM benefits under their automobile policy. The Nickolas’ policy provided for UIM limits of $100,000 per person, up to $300,000 per accident, and they sought payment of UIM benefits in the amount of $160,000; $80,000 for each insured. An adjuster for defendant MIC denied the claim, asserting that the Nickolas could not establish a threshold injury for noneconomic tort recovery. The matter was ultimately ordered to arbitration, the outcome of which resulted in an award of $80,000 for George’s injuries and $33,000 for Thelma’s. The award specified that the amounts were “inclusive of interest, if any, as an element of damage from the date of injury to the date of suit, but not inclusive of other interest, fees or costs that may otherwise be allowable.” The trial court affirmed the arbitration awards but declined to award penalty interest under the UTPA, finding that penalty interest did not apply because the UIM claim was “reasonably in dispute” for purposes of MCL 500.2006(4). The Court of Appeals affirmed the trial court, holding that the “reasonably in dispute” language applied to plaintiff’s UIM claim because a UIM claim “essentially” places the insured in the shoes of a third-party claimant. The Michigan Supreme Court held that an insured making a claim under his or her own insurance policy for UIM benefits cannot be considered a “third party tort claimant” under MCL 500.2006(4). The Court reversed the Court of Appeals denying plaintiff penalty interest under the UTPA, and remanded this case back to the trial court for further proceedings. View "Estate of Nickola v MIC General Ins. Co." on Justia Law

Leticia Salinas injured her back while working for Bridgeview Estates (“Employer”). After receiving medical treatment for roughly six weeks, her workers’ compensation benefits were temporarily denied by Old Republic Insurance Company. Nearly two years later, Salinas filed a claim for reimbursement for medical costs and all future medical care. The Idaho Industrial Commission concluded that Salinas failed to prove that she was entitled to payment of compensation. Notwithstanding that conclusion, the Commission awarded Salinas attorney’s fees. The Employer appealed the award. The Supreme Court concluded the Commission erred in awarding attorney’s fees, and vacated the judgment. View "Salinas v. Bridgeview Estates" on Justia Law

Plaintiff, the executrix of the estate of the decedent, brought a declaratory judgment action seeking a declaration that the estate was entitled to underinsured motorist coverage under a policy issued by Quincy Mutual policy. The motion justice determined that the decedent was “occupying” his owned-but-not-insured motorcycle at the time of his fatal injury, and therefore, an exclusion of the policy applied. Plaintiff appealed, arguing that summary judgment was inappropriate because the decedent was separated from his motorcycle at the time of his death and, therefore, was not occupying the motorcycle as that term was defined in the Quincy Mutual policy. The Supreme Court reversed, holding that a genuine issue of material fact existed as to what impact caused the decedent’s fatal injuries and the time or distance between them, precluding summary judgment. View "Jackson v. Quincy Mutual Fire Insurance Co." on Justia Law