Justia Insurance Law Opinion Summaries

Articles Posted in U.S. 10th Circuit Court of Appeals
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The issue on appeal to the Tenth Circuit was whether Plaintiff Altheia Allen was disabled when her employer SouthCrest Hospital allegedly failed to accommodate her disability and terminated her employment. Because the Tenth Circuit concluded after review of the trial court record that Plaintiff failed to demonstrate a genuine issue of material fact concerning her alleged disability, the Court affirmed the district court's grant of summary judgment in favor of SouthCrest.

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Okmulgee Inn Venture, LLC (Okmulgee) leased space to a nightclub-bar and was a named insured on a liquor liability insurance policy. Okmulgee’s insurer, Mount Vernon Fire Insurance Company (Mt. Vernon), assumed a duty to defend Okmulgee against suits seeking damages for injuries covered by the policy. In 2006, three bar patrons sustained gunshot wounds during a fight at the nightclub and sued Okmulgee, alleging, among other things, that Okmulgee failed to ensure the safety of the bar’s patrons, properly train the bar's staff, or investigate the bar’s operator. The only specific allegations pertaining to alcohol were that two of the three victims were under-age but were admitted to the bar and served alcohol. Mt. Vernon refused to defend Okmulgee in these suits. Mt. Vernon asserted there was no coverage under the policy, and thus no duty to defend or indemnify, because the allegations did not indicate the injuries were caused by the selling, serving, or furnishing of alcoholic beverages. Mt. Vernon then initiated this declaratory judgment action to determine its obligations. On cross motions for summary judgment, the district court ruled in favor of Mt. Vernon. Okmulgee insisted Mt. Vernon owed it a duty to defend because the facts showed that coverage was provided by the policy. Because the victims had yet to establish Okmulgee’s liability for any claims, the Tenth Circuit concluded after its review that the question of Mt. Vernon’s duty of indemnification was not ripe for adjudication. Mt. Vernon is obligated to defend its insured, and Okmulgee was entitled to summary judgment on the duty-of-defense issue.

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Plaintiff Joseph Zbegner appealed a district court order dismissing without prejudice his claims against Allied Property and Casualty Insurance Co. (Allied) as not ripe for adjudication. Plaintiff was in an automobile accident in Boulder, Colorado in 2007. At that time he had an automobile insurance policy with Allied, which included underinsured motorist (UIM) coverage. In his complaint against Allied, Plaintiff alleged that he suffered severe injuries as a result of the accident and sustained damages exceeding $150,000. He claimed the driver of the other car was the person at fault in the accident, but was underinsured. Allstate paid Plaintiff $351.74 for property damage and offered him $2,145.00 to settle his injury claim. Plaintiff did not accept Allstate’s offer and did not resolve his claim against the driver. After Allied declined his claim, Plaintiff filed this action. Allied moved to dismiss Plaintiff's claim, asserting it could not know the amount due Plaintiff for UIM benefits until he had resolved his claim against Allstate, the driver's insurer. Because his claims were contingent on a future event, Allied contended they were not ripe for adjudication. The district court granted Allied’s motion, and dismissed Plaintiff's claims without prejudice. On appeal to the Tenth Circuit, Plaintiff contended the district court misconstrued Colorado law in its ripeness analysis. After careful review, the Tenth Circuit concluded the district court was correct in its analysis of Colorado law, and that Plaintiff's claim was not yet ripe for review.

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Plaintiff-Appellant Eugene S. appealed a district court's denial of his motion to strike and its entry of summary judgment in favor of Defendant-Appellee Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). Plaintiff sought coverage for his son A.S.'s residential treatment costs from his employer's ERISA benefits insurer. Horizon's delegated plan administrator originally denied the claim. Having exhausted his administrative appeals, Plaintiff filed suit in district court challenging the denial of benefits. The parties filed cross-motions for summary judgment, but Horizon also filed a declaration that included the terms of Horizon's delegation of authority to the plan administrator to administer mental health claims in a Vendor Services Agreement. Plaintiff moved to strike that declaration as procedurally barred. The district court denied the motion and granted Horizon summary judgment, finding that neither Horizon nor its plan administrator acted in an arbitrary or capricious manner in denying the contested claim. Upon review, the Tenth Circuit found substantial evidence in the record that A.S. did not meet the criteria for residential treatment benefits under the plan, and as such, the plan administrator did not act in an arbitrary or capricious manner in denying Plaintiff's claim. The Court affirmed the district court's judgment.

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Plaintiff John Ensey was employed by both Defendant Ozzie’s Pipeline Padder, Inc. (Ozzie’s) and Rockford Corporation when he was severely injured. He sued Ozzie’s but was denied relief on the ground that Ozzie’s was protected by the exclusive-remedy provision of the New Mexico Workers’ Compensation Act. Plaintiff appealed, contending that Ozzie’s could not invoke the exclusivity provision because it failed to show that it contributed to paying for the workers’ compensation policy obtained by co-employer Rockford. Upon review, the Tenth Circuit concluded that under New Mexico law Ozzie’s was protected by the exclusivity provision because its contract with Rockford required Rockford to obtain workers’ compensation insurance for Plaintiff, and Plaintiff failed to produce evidence to overcome the inference that Ozzie’s therefore contributed to paying the insurance premium. Accordingly, the Court affirmed the district court's judgment that denied him relief.

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This appeal stemmed from an explosion that severely injured Robbie Griffin at a worksite in Stephens County, Oklahoma. At the time of the explosion, Mr. Griffin was working as an independent contractor for S&W Transports, Inc. Through a settlement agreement, S&W agreed to pay Mr. Griffin for his injuries. The issue before the Court was which of S&W’s insurers had a duty provide coverage for that payment. Mid-Continent Casualty Company covered S&W under a general commercial insurance policy. Union Insurance Company covered S&W under a commercial umbrella insurance policy. Mid-Continent and Union agreed that if Mr. Griffin caused, in whole or in part, his injuries, Mid-Continent must provide coverage. If not, Union provided coverage. Both companies moved for summary judgment in the district court. The court held that Mr. Griffin caused his injuries under Oklahoma insurance law and granted summary judgment for Union. Mid-Continent appealed. Because, after its review, the Tenth Circuit agreed that Mr. Griffin caused, at least in part, his injuries, the Court affirmed the district court's judgment in favor of Union.

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The issue before the Tenth Circuit in this case centered on whether property damage caused by a subcontractor's faulty workmanship is an "ocurrence" for purposes of a commercial general liability (CGL) insurance policy. The issue arose from the appeals of Plaintiffs-Appellants Greystone Construction, Inc., The Branan Company, and American Family Mutual Insurance Company (American) who all appealed the district court’s grant of summary judgment in favor of Defendant National Fire & Marine Insurance Company (National). Greystone was the general contractor that employed multiple subcontractors to build a house in Colorado. As is common along Colorado’s front range, the house was built on soils containing expansive clays. Over time, soil expansion caused the foundation to shift, resulting in extensive damage to the home’s living areas. The homeowners sued Greystone for damages, alleging defective construction by the subcontractors who installed the foundation. Greystone was insured under CGL policies provided by two insurers. American provided policies for 2001 to 2003, and National provided policies for 2003 to 2006. The American and National policy periods did not overlap. Greystone tendered a claim to American and then National. National denied it owed Greystone any defense. In district court, the builders and American sought to recover a portion of their defense costs from National. Upon review, the Tenth Circuit concluded that damage arising from a poor workmanship may fall under a CGL policy’s initial grant of coverage, even though recovery may still be precluded by a business-risk exclusion or another provision of the policy. The case was remanded to the district court for further proceedings.

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Plaintiff Steven Lucas filed suit against Liberty Life Assurance Company of Boston (Liberty Life), asserting that the company violated the Employee Retirement Income Security Act of 1974 (ERISA) when it denied his claim for long term disability benefits. Finding that the denial of benefits was not arbitrary and capricious, the district court entered judgment in favor of Liberty Life. Plaintiff appealed the district court's decision. Plaintiff was an employee of the Coca-Cola Company. Liberty Life both administered and insured Coca-Cola's long-term disability benefits plan. Under the plan, it has discretionary authority to determine eligibility for benefits. Plaintiff suffered a work-related injury requiring spinal surgery and, after a short period back on the job, stopped working. He filed a claim for long-term disability benefits in August 2005. In September 2007, Liberty Life terminated Plaintiff's benefits after determining that he was not eligible for continued benefits under the "any occupation" provision: while he might not be capable of performing his own occupation, he was capable of performing some occupation comparable to his former position. Plaintiff filed an administrative appeal with Liberty Life, but the company upheld the denial of benefits. Upon review, the Tenth Circuit concluded that Liberty Life's decision was supported by substantial evidence, and that Plaintiff failed to show that it was arbitrary and capricious. Accordingly, the Court affirmed the district court's decision.

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Defendant-Appellant Alan Tukes appealed his federal conviction for bank robbery, arguing that the government’s evidence was insufficient to prove that the bank was insured by the Federal Deposit Insurance Corporation (“FDIC”) at the time of the crime. At trial, a prosecutor asked the bank’s branch manager: “Now, the Compass Bank, is that a bank that is federally insured by the [FDIC]?” She responded: “Yes, it is.” When asked whether the bank “has” any documentation proving its insured status, she replied: “Yes. We have a certificate.” When asked whether the certificate “hangs” in the branch, the manager replied in the affirmative. The district court admitted the certificate, dated November 8, 1993, into evidence. The government offered no additional evidence of the bank’s insured status. At summation, Defendant argued that the government had not proven that the bank was FDIC insured at the time of the robbery. The jury returned a guilty verdict. Viewing the evidence in the light most favorable to the government, the Tenth Circuit concluded "it is clear that a rational juror could have concluded beyond a reasonable doubt that the bank was insured at the time of the robbery." The Court affirmed Defendant's conviction.

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Eric Walters was a federal employee covered by a Standard Option health insurance plan (the Plan) administered by Blue Cross Blue Shield of Kansas City (Blue Cross). In November 2007 he went to Weight Loss Healthcare Centers of America, Inc. (Weight Loss) to inquire about surgical treatment for obesity. Because Weight Loss had no contractual arrangement with Blue Cross as either a preferred provider or a participating provider, Walters would expect to pay more than if he used a provider that had a contract. Nevertheless, Walters had outpatient laparoscopic surgery at Weight Loss to help him better control his weight. Although Walters obtained preauthorization from Blue Cross for the surgery, there was no indication in the record that he requested or received information about his out-of-pocket costs. Weight Loss billed Blue Cross for the procedure. The Blue Cross Plan paid $2,300 according to the Planâs benefit for out-of-network providers. Weight Loss appealed the payment to the federal Office of Personnel Management (OPM), which held that Blue Crossâs interpretation of Waltersâs Plan was correct and it had paid the proper amount. The district court affirmed OPMâs decision. Upon review, the Tenth Circuit determined that OPM reasonably interpreted the Plan language. However, the Court reversed the district courtâs decision because OPM neither (1) reviewed the evidence that would show whether Blue Cross had correctly calculated the Plan allowance, nor (2) explained why such review was unnecessary.