Justia Insurance Law Opinion Summaries

Humana sued, alleging that Glaxo was obligated to reimburse Humana for expenses Humana had incurred treating its insureds’ injuries resulting from Glaxo’s drug, Avandia. Humana runs a Medicare Advantage plan. Its complaint asserts that, pursuant to the Medicare Act, Glaxo is in this instance a “primary payer” obligated to reimburse Humana as a “secondary payer.” The district court dismissed, agreeing with Glaxo that the Medicare Act did not provide Medicare Advantage organizations with a private cause of action to seek such reimbursement. The Third Circuit reversed and remanded. The Medicare Secondary Payer Act, in 42 U.S.C. 1395y(b)(3)(A), provides Humana with a private cause of action against Glaxo. Even if the provision is ambiguous, regulations issued by the Centers for Medicare and Medicaid Services make clear that the provision extends the private cause of action to MAOs. View "Humana Med. Plan Inc. v. GlaxoSmithKline LLC" on Justia Law

Title insurance purchasers, on behalf of themselves and similarly situated consumers, claimed that insurers collectively fixed title insurance rates in violation of the Sherman Act. Title insurers in Delaware are required to file their insurance rates with the state Department of Insurance, Del. Code tit. 18, 2504(a). Insurers may comply with the state’s rate filing requirements through a licensed rating organization. Defendants, title insurers, are members of and file their rates through the Delaware Title Insurance Rating Bureau, which is licensed by the DOI; the statutory scheme authorizes cooperative action. The district court dismissed, holding that the complaint is barred by the filed-rate doctrine (which precludes antitrust suits based on rates currently filed with federal or state agencies), lack of standing, and federal antitrust liability exemptions. The Third Circuit affirmed.

Title insurance purchasers, on behalf of themselves and similarly situated consumers, claimed that insurers collectively fixed title insurance rates in violation of the Sherman Act and the New Jersey Antitrust Act. In New Jersey, the Department of Banking and Insurance approves and regulates title insurance rates, N.J. Stat. Ann. 17:1C-19(a)(1). Insurers may collectively file rates for approval through a licensed rating organization, thereby authorizing cooperative action. The district court dismissed, holding that the complaint is barred by the filed-rate doctrine (which precludes antitrust suits based on rates currently filed with federal or state agencies), lack of standing, and federal and state antitrust liability exemptions. The Third Circuit affirmed.

While working as a dentist, Fleisher obtained long-term disability insurance coverage under separate policies. He obtained the North American policy by membership in a professional organization. The Standard policy is an employee benefit, governed by the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B) and provides for monthly benefits to a maximum of "$10,000 before reduction by Deductible Income," defined to include "[a]ny amount you receive or are eligible to receive because of your disability under another group insurance coverage," but to exclude benefits paid under "any individual disability insurance policy." In 2008, Fleisher became disabled and claimed benefits under both policies. Shortly after Fleisher began collecting under both policies, Standard reduced his monthly benefits from $10,000 to $8,500 based on its determination that the North American policy was another group insurance coverage, and that the $1,500 in benefits he receives under it is deductible income. The district court dismissed his ERISA suit. The Third Circuit affirmed, finding the decision supported by substantial evidence and not unreasonable.

The company and its affiliates filed for Chapter 11 bankruptcy and sought to resolve asbestos-related liability through the creation of a personal-injury trust under 11 U.S.C. 524(g). As part of its reorganization plan, it sought to transfer rights under insurance liability policies to the trust. The Insurers had provided liability policies to the debtors prior to bankruptcy and objected that the transfer violated the policies' anti-assignment provisions. The bankruptcy and district courts held that 11 U.S.C. 1123(a)(5)(B) preempts those provisions. The Third Circuit affirmed. Section 524 trusts are the only national statutory scheme available to resolve asbestos litigation through a quasi-administrative process. The plain language of 11 U.S.C. 1123(a) evinces clear intent for a preemptive scope that includes transfer of property to a 524 trust; that preemption reaches private contracts enforced by state common law.

Participants in an employer-sponsored 401(k) plan brought suit under the Employment Retirement Income Security Act of 1974, 29 U.S.C. 1001, and the Investment Company Act of 1940, 15 U.S.C. 80a-1, claiming excessive fees on annuity insurance contracts offered to plan participants. The district court dismissed the ICA claims because only those maintaining an ownership interest in the funds could sue under the derivative suit provision and the participants are no longer investors in the funds in question. As to the ERISA claims, the court dismissed because participants failed to make a pre-suit demand upon the plan trustees to take appropriate action and failed to join the trustees as parties. The Third Circuit affirmed with regards to the ICA claims, but vacated on the ERISA counts, holding that the statute does not require pre-suit demand or joinder of trustees.

Plaintiff, a maintenance director, had a stroke and began leave under the Family and Medical Leave Act, 29 U.S.C. 612(a)(1) in January 2008. He received disability benefits from Unum. The doctor cleared him to return to work starting on May 1, with conditions that he not work more than four hours per day or lift loads in excess of 20 pounds. The administrator notified plaintiff that part-time work was not available. The doctor cleared him to work full-time, but did not change the lifting restriction. On April 20, the employer terminated plaintiff's employment and notified him that he would not be rehired with lifting restrictions. Until July 2008, when the restrictions were lifted, he received benefits from Unum. The district court rejected claims under the Americans with Disabilities Act, the Pennsylvania Human Relations Act, and the FMLA. The Third Circuit affirmed. The FMLA does not require an employer to provide reasonable accommodation to facilitate return to an equivalent position following leave. Entitlement to restoration requires that the employee be able to perform essential job functions without accommodation. Having represented to Unum that he was disabled, plaintiff was estopped from claiming that he was able to perform all essential functions.

In 2005, the Secretary of Labor filed suit for breach of fiduciary duty, alleging that defendants had established a health benefit plan that was a multi-employer welfare arrangement governed by the Employee Retirement Income Security Act. Defendants had retained, as compensation, a substantial portion of payments made by businesses to enroll their employees. The complaint alleged improper diversion of funds and that defendants were required by ERISA to use the assets only for the defraying reasonable plan expenses for the benefit of plan participants. The district court ruled in favor of defendants. The Third Circuit vacated, characterizing the scheme appearing to be "an aggressively marketed, but inadequately funded health benefit plan masquerading as an ERISA-exempt plan in order to evade the solvency controls imposed by state insurance regulation."

The insured was driving his pickup truck when he was injured after swerving to avoid a cardboard box lying in the middle of his lane. Allstate stipulated that an unidentified vehicle dropped the box, but rejected a claim for uninsured motorist benefits and sought a declaratory judgment. The insured responded with counterclaims for breach of contract and insurance bad faith under 42 Pa. Cons. Stat.8371. The district court entered judgment for Allstate, finding that the injuries did not "arise out of ownership, maintenance or use of an uninsured auto." The Third Circuit reversed, rejecting an argument that the harm was caused by a box, not a vehicle. Physical contact with an uninsured vehicle is not required for an accident to "arise out of" the use of an uninsured vehicle. Accepting for purposes of appeal that an unidentified vehicle that dropped the box was an uninsured vehicle, there is a sufficient causal connection. The court noted that the insurance law is to be liberally construed in order to afford the greatest possible coverage to injured claimants.

After defendant was in a serious automobile accident, a benefit plan administered by plaintiff paid $66,866 for his medical expenses. Defendant then recovered $110,000 from third parties, with the assistance of counsel. Plaintiff, which had not sought to enforce its subrogation rights, demanded reimbursement of the entire $66,866 it had paid without allowance for legal costs, which had reduced defendant's net recovery to less than the amount it demanded. Plaintiff sued for "appropriate equitable relief" pursuant to the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(3) B). The district court ordered plaintiff to pay the entire. $66,866. The Third Circuit vacated, holding that defendant may assert equitable limitations, such as unjust enrichment, on plaintiff's equitable claim.