Justia Insurance Law Opinion Summaries

In 2003, the Trust sought group accident and life insurance policies as a benefit for its union members. Consistent with the Trust's request, the broker's RFP specifically sought a policy where the "Trust is the owner of the policy and also [a] beneficiary." Defendant's proposal contained only a summary of proposed terms, expressly cautioned that it was not a contract, and omitted reference to the Trust’s desired beneficiary provision. The policy drafts sent to the Trust did not contain the beneficiary provision the Trust wanted and stated that payment of the required premium after delivery of the policies would constitute acceptance. The Trust's chairman signed and paid the first premium in 2003 In May, 2004, the Trust made a claim on the group life policy. Defendant responded that the terms of the policy required it to pay the full benefit to the decedent's beneficiaries. The Trust terminated the policy, stopped paying premiums, and filed suit seeking a declaratory judgment and rescission of the contract. The district court dismissed the Trust's claims and entered judgment for defendant for $95,059.99 in unpaid premiums. The Seventh Circuit affirmed, finding that the parties had an enforceable contract.

Defendant is a captive insurer owned by plaintiff plans across the nation. In 2003 healthcare providers filed class action suits in Florida against all of those plans. Twelve plans, which had errors-and-omissions insurance from defendant, asked it to assume the defense and indemnify. Defendant declined, and the plans demanded arbitration. Acting under the Federal Arbitration Act, 9 U.S.C. 5, the district court held that the arbitrators could determine whether arbitration of a class action or consolidated arbitration were authorized by contract and appointed a third arbitrator. The court dismissed the appeal of the court's first ruling for lack of jurisdiction and affirmed the appointment. If defendant wanted a judge to decide whether the plans' demands should be arbitrated jointly or separately, it should have refused to appoint an arbitrator. Both sides appointed arbitrators, however, and the proceeding got under way. Nothing in the Federal Arbitration Act authorizes anticipatory review of the arbitrators' anticipated decisions on procedural questions.

On June 17, 2006, wife applied for a $500,000 life insurance policy. She paid $100 and signed a conditional receipt agreement for immediate coverage, subject to conditions that "on the Effective Date the Proposed Insured(s) is (are) insurable exactly as applied for under the Company’s printed underwriting rules for the plan, amount and premium rate class applied for; ... (C) the Proposed Insured(s) has/have completed all examinations and/or tests requested by the Company." On June 28, wife was examined and submitted specimens. Her cholesterol level and urine sample raised concerns. The company sought medical records from her physician and a second urine specimen. On July 22, 2006, wife was diagnosed with a brain tumor. On August 9, the company declared wife uninsurable based on her brain surgery. About a year later, she died. Husband claimed that the request for the second urine specimen was communicated in a untimely and ineffective fashion. The district court entered summary judgment for the insurance company on claims of breach of contract, estoppel, bad faith, and negligence. The Seventh Circuit affirmed, finding no evidence of purposeful misconduct; if there was no contract, any duty of good faith did not come into play.

Plaintiffs' insurance policy indemnifies them against liability under several federal environmental protection laws or the state-law equivalents. They attempted to invoke their policy for up to $10 million in coverage following an explosion on one of their vessels that resulted in an oil spill in the Chicago Sanitary and Ship Canal. The district court granted the insurer judgment on the pleadings that: it owed $5,000,000 per vessel, per incident and had fully honored the policy with respect to one vessel; it owed no coverage for either two others for in rem liability. It granted the insureds summary judgment on their breach of contract claim, finding that the insurer owed $5,000,000 in coverage for a vessel, was obligated to pay defense costs up to that amount, and had breached its contract by not doing so. It denied summary judgment on a claim of breach of the duty of good faith and fair dealing. The Seventh Circuit affirmed.

The company, an egg producer, was charged in class action suits with conspiring to fix the price of eggs, in violation of section 1 of the Sherman Act. and requested that its liability insurers defend. The company argued that the complaints sought damages for what its policies call "personal and advertising injury," defined as injury. arising out of a list of torts that includes use of another's advertising idea in your advertisement. The insurer refused and the district court granted summary judgment in favor of the insurer. The Seventh Circuit affirmed, noting that the antitrust complaints make no mention of the company's theory that consumers might believe that advertised "free-roaming" chicken management policies are an attempt to justify prices.

The class action alleges that the company committed fraud by charging for uninsured or underinsured motorist coverage that is worthless in light of policy restrictions. The district court remanded to state court based on the representative plaintiff's argument that the amount in controversy was less than $5,000,000. The Seventh Circuit reversed, calculating the cost if the company were to stop charging a premium or change the terms so that policyholders receive indemnity more frequently, and the availability of punitive damages in Illinois, and concluding that it is not "legally impossible" that policyholders would recover the jurisdictional amount.

After being diagnosed with fibromyalgia, chronic pain, anxiety, and depression, plaintiff was awarded long-term disability benefits under an employee benefit plan issued and administered by defendant. Benefits were discontinued a little more than 24 months later, when defendant determined that plaintiff had received all to which she was entitled under the plan’s self-reported symptoms limitation. Because plaintiff had retroactively received social security benefits, defendant also sought to recoup equivalent overpayments as provided by the plan. On rehearing, the Seventh Circuit reversed the district court ruling in favor of defendant. The application of the self-reported symptoms clause was unreasonable under ERISA, 29 U.S.C. 1001; the disabling illness, fibromyalgia, is not primarily based on self-reported symptoms, but rather can be based on the verifiable evidence of its manifestations. The Social Security Act, 42 U.S.C. 407(a), does not preclude recovery of any overpayment that resulted from receipt of social security benefits.

Before his death, the orthodontist designated his sons as beneficiaries of a pension plan he had established for his business. Because the Employee Retirement Income Security Act, 29 U.S.C. 1001. The Plan moved for summary judgment.guarantees surviving spouses certain benefits, his wife signed a written consent form. After her husband died, wife claimed her consent was invalid because it was not witnessed, as required by ERISA. The pension plan denied her claim for benefits. The district court upheld that decision, invoking the substantial-compliance doctrine. The Seventh Circuit affirmed, but held that the substantial-compliance doctrine did not apply because ERISA is not silent on the issue of witnessing. The plan was within its discretion to deny the claim. Although no witness signed the consent form as a witness, it is clear that the orthodontist, then the plan representative, witnessed his wife's written consent to the waiver, as required by ERISA.

In attempting to enroll his infant daughter, a covered employee failed to complete parts of the form indicating whether the child resided with employee, was dependent upon employee for more than 50 percent support and maintenance, and whether the child qualified to be claimed as a tax exemption on employee's federal tax return. The plan made several inquiries before sending a notice that coverage was denied. The employee did not appeal. The plan sued under the Employee Retirement Income Security Act , 29 U.S.C. 1001, to recover $472,357.84 paid to the medical college and $1,199,538.58 paid to the hospital on behalf of the child. The district court dismissed. The Seventh Circuit affirmed dismissal of the ERISA claim. The plan reserves the right to recover against "covered persons" if it has paid them or any other party on their behalf. Neither the treating entities nor the child are covered persons. Because the plan is not implicated, state law claims were not preempted; the court reversed dismissal of those claims. Plaintiffs' position was not unreasonable; the district court abused its discretion in awarding attorney fees.

When plaintiffs left their jobs, they did not receive notices describing how to extend their health insurance coverage within the period prescribed by statute (COBRA notices). Responding to solicitation from a lawyer, they became named plaintiffs in a proposed class action seeking damages from and statutory penalties against their former employer. The district court declined to certify the class and, on consideration of the individual claims, denied the request for statutory penalties and one of the plaintiffs' requests for damages. The Seventh Circuit affirmed. The district court properly denied class certification because it found the proposed class counsel inadequate to represent the class, based on observations about counsel's diligence, respect for judicial resources, and promptness. Denial of statutory penalties under 29 U.S.C. 1132 was appropriate; there was no evidence of an administrator's bad faith (such as misrepresentations or willful delay in response to requests for information) or gross negligence. The district court was within its discretion in denying damages as compensation for expenses, where there was no evidence to indicate that the expenses were incurred as a result of the failure to provide timely notice of COBRA rights.