Justia Insurance Law Opinion Summaries

Plaintiffs were catastrophically injured in automobile accidents. All sustained traumatic brain injuries and are now mentally impaired. State Farm initially paid no-fault insurance benefits for the cost of attendant care services rendered at home, but reduced the rates on the basis of market surveys of the cost of the services. State Farm refused to raise the rates because it could not verify whether plaintiffs had received the type of care that would justify paying higher rates. Plaintiffs refused to submit documentation regarding the nature and extent of the care they were receiving. Plaintiffs sued. The district court awarded plaintiffs monetary sanctions, instead of default judgment, in response to State Farm’s violation of discovery orders. A jury rendered a verdict in State Farm’s Favor. The Sixth Circuit dismissed appeal regarding the discovery sanctions, for lack of jurisdiction, but otherwise affirmed.

Plaintiff filed a class-action lawsuit against the insurance company, claiming breach of contract because the company began interpreting the "actual charges" provision of his cancer-insurance policy to mean the charges that the medical provider accepts as full payment from the primary insurer and the insured. Plaintiff claims that the policy entitles him to be paid the higher "list prices" that appear on his hospital bills before the primary insurer negotiates a lower rate. The company made payments to the insured, not directly to hospitals. The district court certified the class and issued a preliminary injunction, requiring the company to pay plaintiff according to his interpretation. Meanwhile, an Arkansas state court certified a nearly identical class, and the Arkansas Supreme Court affirmed a settlement in that action. The Sixth Circuit vacated class certification, based on the intervening Arkansas case. The court dismissed appeal of the injunction for lack of jurisdiction because was not a decision on the merits.

Plaintiffs sought insurance coverage for settlement and defense costs related to thousands of asbestos-exposure products-liability lawsuits that began in 1981. Many of the underlying asbestos claims arose from exposure to products manufactured by Reardon, a corporation that sold its assets and liabilities to plaintiff and became a division of plaintiff's business in 1966. The policies did not expressly identify Reardon or its later incarnation as "Named Insureds," but provided coverage for asbestos claims related to the Reardon products, and each has paid pursuant to the policies' aggregate limits for "Products Hazard" claims. The insurance companies, collectively, have paid more than $100 millions plaintiffs sought more than $125 million in additional coverage, arguing that the Products Hazard caps did not apply to the Reardon claims. The district court granted summary judgment to the insurance companies. The Sixth Circuit affirmed, finding that the policy language supported application of the cap,

Hit by a vehicle in 2004, plaintiff had medical bills of $82,036 that were paid in full by Medicare. The owner of the vehicle settled with plaintiff for $125,000. Medicare sought reimbursement of $62,338 under 42 U.S.C. 13955y(b)(2)(B)(i)., which plaintiff paid under protest. An ALJ rejected plaintiff's argument that an unknown motorist was responsible for 90 percent of the damage so that only 10 percent of the settlement was for medical expenses and the rest was for pain and suffering. The Medicare Appeals Council, district court, and Sixth Circuit affirmed, noting that plaintiff presented no evidence of hardship.

Two members of a program advertised as providing healthcare discounts to consumers sued, seeking to represent a class of 30,850. They claimed violations of the Ohio Consumer Sales Practices Act as well as Ohio’s common law prohibition against unjust enrichment in that healthcare providers listed in the discount network that had never heard of the program, and that newspaper advertisements, designed to look like news stories were deceptive. The district court exercised jurisdiction under the Class Action Fairness Act of 2005, 28 U.S.C. 1332(d), which grants jurisdiction over class actions in which the amount in controversy exceeds $5 million and the parties are minimally diverse. The district court dismissed. The Sixth Circuit affirmed. The consumer-protection laws of many states, not just of Ohio, govern the claims and there are many factual variations among the claims, making a class action neither efficient nor workable nor above all consistent with the requirements of Rule 23 of the Federal Rules of Civil Procedure.

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660â61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

The district court certified a class action and a proposed class in an action under the Employee Retirement Income Security Act, 29 U.S.C. 1001. The suit claimed that Blue Cross breached its fiduciary duty by imposing and failing to disclose an other-than-group subsidy and that the OTG subsidy violated Mich. Comp. Laws 550.1211(2). The state insurance commissioner took the position that state law allows the assessment and that revenue it generates funds Medigap coverage. The Sixth Circuit reversed, holding that the class action is not the superior method of adjudication (Federal Rule of Civil Procedure 23(b)(3)) and prosecuting separate actions does not present the risk of inconsistent adjudications (FRCP 23(b)(1)(A)). ERISA fiduciary status is a crucial threshold factual issue specific to every class member, requiring the court to make individualized determinations. Resolution of the legality of the subsidy before that determination would also mitigate the state's concerns about stopping collection of the fee. Potential awards at stake would not preclude individual class members from seeking relief and there was no evidence that individual litigation would create a risk of inconsistent adjudications that would establish incompatible standards of conduct for the defendant.

Plaintiff, employed by a company contracted to do grounds maintenance, was injured while mowing grass at an Army base. A deteriorating steam pipe fell, striking him in the head. The district court granted summary judgment to the United States, reasoning that under the Kentucky Workers' Compensation Law, the United States was an up-the-ladder contractor, or statutory employer, so that plaintiff's only remedy was the workers' compensation benefits he received from his direct employer. The Sixth Circuit affirmed, holding that the U.S. government is a "person" entitled to the up-the-ladder defense and that the waiver of immunity under the Federal Torts Claims Act, 28 U.S.C. 1346, provides for claims in the same manner and to the same extent as a private individual. The government "secured the payment of compensation" by hiring a contractor and, therefore, cannot be treated as an employer that did not secure benefits. The work performed by plaintiff was a "regular and recurrent" part of work at the facility and the government was entitled to contractor immunity.

The trust was created by the Chapter 11 bankruptcy plan of a corporation that, from 1965 to 1981, manufactured and sold automotive products containing asbestos. Numerous suits were filed concerning those products. Coverage through one primary insurer has been exhausted; two primary insurers are defending. The trust holds an umbrella insurance policy issued by defendant, which contends that it is not required to defend the claims. The district court agreed and dismissed the trust's complaint. The Sixth Circuit affirmed. Although the umbrella policy schedule of primary carriers only lists the policy that has been exhausted, the umbrella policy applies, by its unambiguous terms, the umbrella policy applies only where an occurrence is not covered by the underlying insurance listed in the schedule, "or any other underlying insurance collectible by the insured."