Justia Insurance Law Opinion SummariesArticles Posted in U.S. 7th Circuit Court of Appeals
Kolbe & Kolbe Health & Welfare Benefit Plan v. Med. Coll. of WI
An employee benefits plan sued a medical college that provides patient care in clinics and hospitals and an affiliated children’s hospital, with which it had provider agreements, alleging ERISA violations and breach of contract under Wisconsin law. The suit was based on the plan’s determination that an employee’s child was not covered by the plan and the hospital’s denial of its subsequent request that the hospital refund about $1.7 million the plan had already paid on behalf of the child. The plan makes no mention of refunds. The district court dismissed and awarded attorneys’ fees to the hospital as a sanction for having filed frivolous claims. The Seventh Circuit affirmed dismissal of the ERISA claims but reversed dismissal of the breach of contract claim, rejecting the district court’s finding of preemption, and imposition of sanctions. On remand of the contract claim, the district court granted summary judgment in favor of the hospital. The Seventh Circuit affirmed, noting that the hospital, having been paid in full by the plan, has no possible claim against Medicaid, that the plan took 11 months to determine that the child was not a beneficiary, and that the hospital has not been unjustly enriched. View "Kolbe & Kolbe Health & Welfare Benefit Plan v. Med. Coll. of WI" on Justia Law
Hussey v. Milwaukee County
In 1971 Milwaukee County provided its employees with health insurance under an ordinance that stated that the “county shall participate in the payment of monthly premiums” and extended coverage to retirees. In 1993, the ordinance was amended to provide that “[t]he County shall pay the full monthly cost of providing such [health insurance] coverage to retired members” as “part of an employee’s vested benefit contract.” Upon her 1991 retirement, Hussey had paid no co‐payments or deductibles for her health care. Her benefit plan booklet explained that with 15 years of service: “the retiree may participate in the health plan in which he/she is currently enrolled on the same basis as … the active employee group. The County will make the full premium contribution.” Until 2012, the plan coordinated benefits so that expenditures not covered by Medicare were paid in full by the County. In 2012 the County increased deductibles, co‐payments, and co‐insurance charges and modified coordination of benefits so that retirees over age 65 would pay the same deductibles, co‐payments, and co‐insurance charges as active employees. Hussey filed a purported class action, alleging that the failure to provide cost‐free health insurance to retirees constituted an unconstitutional taking of property. The Seventh Circuit agreed with the district court that the County only promised retirees the ability to participate in the same health insurance plan as active employees on a “premium‐free” basis. View "Hussey v. Milwaukee County" on Justia Law
Netherlands Ins.. Co. v. Phusion Projects, Inc.
Phusion manufactures and distributes an alcoholic beverage called “Four Loko.” Its original formula contained energy stimulants, such as caffeine, guarana, taurine, and wormwood. Phusion purchased a commercial general liability insurance policy and a umbrella policy from members of the Liberty Mutual Group. The policies include identical provisions, excluding coverage for bodily injury or property damage when the insured may be held liable by reason of causing or contributing to intoxication. Plaintiffs sued Phusion in separate state court actions, alleging injuries caused by consumption of Four Loko. Two cases involved traffic accidents, one involved a shooting, another involved paranoid behavior resulting in accidental death, and a fifth claim involved a death from heart trouble. Phusion notified Liberty, which sought a declaratory judgment regarding the scope of coverage. The district court examined the underlying cases in the context of comparable automobile exclusions and ruled that four of the five cases fell within the Liquor Liability Exclusion. The Seventh Circuit affirmed. The Liquor Liability Exclusions in the policies are unambiguous and apply to Phusion. The allegations of simple negligence raised by the plaintiffs in the underlying complaints are not sufficiently independent from the allegations that Phusion caused or contributed to the intoxication of any person. View "Netherlands Ins.. Co. v. Phusion Projects, Inc." on Justia Law
Norem v. Lincoln Benefit Life Co.
In 1994, Norem purchased a “Flexible Premium Variable Life Insurance Policy” from Lincoln Benefit. With variable life insurance, part of the premium is allocated to the insurer’s investment funds, called subaccounts. Policyholders may move their investments within the subaccounts and the death benefit, which is guaranteed not to fall below a certain amount. With variable universal life, the policyholder may easily invest and alter insurance coverage. The policy is comprised of the policy value, which represents the investment component, and its net amount at risk, which represents the insurance component. Norem purchased his policy because he wanted both life insurance and an investment vehicle for the proceeds from the sale of his ownership of a medical business. The policy has a “cost of insurance” (COI) charge deducted monthly from the policy. The policy explains how the COI rate is calculated. Norem filed a putative class action on behalf of himself and other similarly situated policyholders, claiming that Lincoln Benefit breached the terms of its policies in its method of calculating the COI rate.Before deciding on class certification, the district court granted summary judgment to Lincoln Benefit, concluding that its calculation of COI rates did not breach the contract. The Seventh Circuit affirmed. View "Norem v. Lincoln Benefit Life Co." on Justia Law
NECA-IBEW Rockford Local Union 364 Health & Welfare Fund v. A&A Drug Co.
The NECA-IBEW Health and Welfare Fund provides health benefits to members of a local union of electrical workers. The Fund negotiated a Local Agreement with Sav-Rx, a provider of prescription-drug benefits, under which Sav-Rx reimburses pharmacies for dispensing medication and then invoices the Fund for some of its costs. The Local Agreement does not call for arbitration. A few months later, Sav-Rx negotiated a different agreement with the national organization of the IBEW, with which the local is affiliated. The National Agreement offers locals reduced charges and more services than the Local Agreement and contains a mandatory arbitration clause. Local unions and funds could opt into the National Agreement, but the Fund's trustees never voted on the matter. Over the next eight years the Fund accepted from Sav-Rx services provided by the National Agreement. The Fund sued Sav-Rx for invoicing the Fund at rates not authorized by either the Local or National Agreement. The district court dismissed, finding that Fund had accepted the benefits of the National Agreement and was bound to it; Sav-Rx established that the Fund knew it was accepting benefits under the National Agreement. The Seventh Circuit affirmed. View "NECA-IBEW Rockford Local Union 364 Health & Welfare Fund v. A&A Drug Co." on Justia Law
Posted in: Arbitration & Mediation, Contracts, Insurance Law, Labor & Employment Law, U.S. 7th Circuit Court of Appeals
Killian v. Concert Health Plan
After discovering that she had lung cancer that had spread to her brain, Killian underwent aggressive treatment on the advice of her doctor. The treatment was unsuccessful and she died. Her husband submitted medical bills for the cost of the treatments to her health insurance company. The company denied coverage on most of the expenses because the provider was not covered by the insurance plan network. The husband filed suit, seeking benefits for incurred medical expenses, relief for breach of fiduciary duty, and statutory damages for failure to produce plan documents. The district court dismissed denial-of-benefits and breach-of-fiduciary-duty claims, but awarded minimal statutory damages against the plan administrator. In 2012, the Seventh Circuit affirmed the dismissals, rejecting an argument that the plan documents were in conflict, but remanded for recalculation of the statutory damages award. On rehearing, en banc, the Seventh Circuit affirmed the denial of benefits and statutory penalties holdings, but reversed on the breach of fiduciary duty claim. The instructions given in plan documents were deficient and a reasonable trier of fact could rule in favor of Killian, based on telephone conversations in which Killian attempt to determine whether the physicians who were about to perform surgery were within the network. View "Killian v. Concert Health Plan" on Justia Law
Schilke v. Am. Sec. Ins. Co.
In a proposed class action, Schilke alleged that Wachovia, her lender and holder of a mortgage on her home, fraudulently placed insurance on her property when her homeowner’s policy lapsed. Wachovia secured the replacement coverage from ASI and charged her for it, as specifically permitted by her loan agreement. The premium was more than twice what she had paid for her own policy and included a commission to Wachovia’s insurance-agency affiliate, also as permitted under the loan agreement. Schilke calls the commission a “kickback” and asserted statutory and common-law claims, most sounding in fraud or contract. The district court dismissed based on federal preemption and the filed-rate doctrine. The Seventh Circuit affirmed. The loan agreement and related disclosures and notices conclusively show that there was no deception at work. Wachovia fully disclosed that lender-placed insurance could be significantly more expensive than her own policy and could include a fee or other compensation to the bank and its insurance-agency affiliate. Maintaining property insurance was Schilke’s contractual obligation and she failed to fulfill it. . View "Schilke v. Am. Sec. Ins. Co." on Justia Law
Posted in: Banking, Class Action, Insurance Law, Real Estate & Property Law, U.S. 7th Circuit Court of Appeals
Nat’l Cas. Co. v. White Mountains Reinsurance Co.
Steidl and Whitlock were convicted of 1987 murders, largely based on testimony by two supposed eyewitnesses. Long after the convictions, an investigation revealed that much of the testimony was perjured and that exculpatory evidence had been withheld. The revelations led to the release of the men and dismissal of all charges. Steidl had spent almost 17 years in prison; Whitlock had spent close to 21 years. They sued. By 2013, both had settled with all defendants. Because the defendants were public officials and public entities, disputes arose over responsibility for defense costs. National Casualty sought a declaratory judgment that it was not liable for the defense of former State’s Attorney, McFatridge, or Edgar County, agreeing to pay their costs under a reservation of rights until the issue was resolved. The Seventh Circuit ruled in favor of National Casualty. In another case McFatridge sought a state court order that the Illinois Attorney General approve his reasonable expenses and fees; the Illinois Supreme Court rejected the claim. In a third case, National Casualty sought a declaratory judgment that another insurer was liable for costs it had advanced. The Seventh Circuit affirmed that the other company is liable. It would be inequitable for that company to benefit from National’s attempt to do the right thing, especially since it did not do the right thing and contribute to the defense costs under a reservation of rights. View "Nat'l Cas. Co. v. White Mountains Reinsurance Co." on Justia Law
Posted in: Civil Rights, Criminal Law, Insurance Law, Legal Ethics, Professional Malpractice & Ethics, U.S. 7th Circuit Court of Appeals
Nat’l Union Fire Ins. Co. v. Mead Johnson & Co., LLC
Mead Johnson, purchased a primary Commercial General Liability policy from National Union, with a limit of $2 million for liability for “personal and advertising injury” and an excess liability policy from Lexington, with a limit of $25 million. Mead’s main product, Enfamil infant formula, is sold worldwide. Mead’s competitor, PBM, sued Mead for false advertising and consumer fraud and Mead sued PBM for trade dress infringement. PBM claimed that Mead had falsely asserted that PBM’s generic formula lacked key fats that promote brain and eye development. The suit sought $500 million in damages for product disparagement, a tort that the policies cover as a form of “advertising injury.” Mead did not notify the insurers of the suit until December 2009, after the suit ended in the $13.5 million verdict against Mead. Mead wanted its insurers to pay that judgment, plus a $15 million settlement that it made to resolve the class action suit. The insurers obtained declaratory judgments that they were not required to pay. The Seventh Circuit reversed the summary judgment in favor of the insurers in the suit relating to the PBM litigation, but affirmed the judgment in favor of National Union in the suit arising from the class action against Mead. View "Nat'l Union Fire Ins. Co. v. Mead Johnson & Co., LLC" on Justia Law
Posted in: Consumer Law, Injury Law, Insurance Law, Products Liability, U.S. 7th Circuit Court of Appeals
Southland Mgmt. Corp. v. RSUI Indem. Co.
The Gulfport Mississippi apartment complex was damaged in Hurricane Katrina. Its insurer, RSUI paid actual-cash-value proceeds. The parties began negotiating for additional replacement-cost proceeds. During negotiations, the named-insured contracted to sell the property in its unrepaired state to Edgewood and notified RSUI of its intention to assign the claim for replacement-cost proceeds. RSUI responded that if the property was sold before repair, there could be no recovery of replacement-cost proceeds. The sale closed. The seller and Edgewood sought a declaration that the insurer was obligated to pay the claim with a related breach-of-contract action. Edgewood repaired the property. The litigation continued for years until it became clear that there had been no assignment. The district court dismissed the claims. The Seventh Circuit affirmed in part and reversed in part. Absent an assignment, Edgewood lacks standing; the seller still owns the claim and remains a proper plaintiff. The seller had an insurable interest when the policy issued and at the time of the loss; the sale of the property in its unrepaired state did not extinguish its right to recover. Although the policy specifies that replacement-cost proceeds will not be paid until the property is repaired, it does not require that the insured complete the repairs itself. View "Southland Mgmt. Corp. v. RSUI Indem. Co." on Justia Law