Justia Insurance Law Opinion SummariesArticles Posted in U.S. Court of Appeals for the Seventh Circuit
Kennedy v. Lilly Extended Disability Plan
Seventh Circuit affirms award of permanent disability benefits for fibromyalgia.Kennedy was hired by Lilly in 1982 and became an executive director in Lilly’s human resources division, with a monthly salary of $25,011. In 2008, she quit work because of disabling symptoms of fibromyalgia. She was approved for monthly benefits of $18,972 under the company’s Extended Disability Benefits plan. Three and a half years later her benefits were terminated. Kennedy sued under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001. The Seventh Circuit affirmed summary judgment in favor of Kennedy, with an award of $537,843.81 in past benefits and prejudgment interest and reinstatement of benefits. The court characterized Lilly’s evidence as “a hodgepodge” and noted that Lilly did not indicate what kind of work Kennedy would be able to perform. Kennedy’s general internist testified that she is permanently disabled, basing this opinion on his diagnoses of her nonarticular rheumatism (musculoskeletal aches and pains not traceable to joints), fibromyalgia, sleep disorder, depression, irritable bowel syndrome, restless leg syndrome, and her symptoms of pain and fatigue. Her rheumatologist concurred. The court noted the company’s conflict of interest, being both the initial adjudicator of an employee’s benefits claim and the payor of those benefits. View "Kennedy v. Lilly Extended Disability Plan" on Justia Law
Title Industry Assurance Co., R.R.G. v. First American Title Insurance Co.
In 2008, Chicago Abstract was sued in state court by a title insurance company and financial firms. Chicago Abstract tendered these lawsuits to its “errors and omissions” liability insurer, TIAC. TIAC could defend without reservation; defend while reserving its rights; seek a declaratory judgment concerning the scope of coverage; or decline to defend. Under Illinois law, when a liability insurer unjustifiably refuses to defend, the insurer is estopped from later asserting policy defenses to coverage. TIAC declined to defend. Years passed without further communications between TIAC and its insured. In 2014, a state court plaintiff filed an amended complaint. An attorney appointed by TIAC made an appearance in that case. TIAC then sought a declaration that coverage was unavailable based on policy exclusions. Chicago Abstract did not defend; the company had been involuntarily dissolved. Plaintiffs from the state-court litigation against Chicago Abstract appeared in the federal case as defendants. The Seventh Circuit affirmed judgment in favor of those defendants. The undisputed facts show that TIAC breached its duty to defend in the underlying litigation and is estopped from asserting “at this very late stage” any policy defenses to coverage that might have been available if TIAC had made a different choice when the complaints were first tendered. View "Title Industry Assurance Co., R.R.G. v. First American Title Insurance Co." on Justia Law
Prather v. Sun Life Financial Insurance Co.
Prather, age 31, tore his Achilles tendon. His surgery to repair the injury was uneventful. He returned to work. Four days later he collapsed, went into cardiopulmonary arrest, and died as a result of a blood clot in the injured leg that had traveled to a lung. Prather’s widow applied for benefits under his Sun Life group insurance policy (29 U.S.C. 1132(a)(1)), which limited coverage to “bodily injuries ... that result directly from an accident and independently of all other causes.” Sun Life refused to pay. The Seventh Circuit ruled in favor of Prather’s widow, noting that deep vein thrombosis and pulmonary embolism are risks of surgery, but that even with conservative treatment, such as immobilization of the affected limb, the insured had an enhanced risk of a blood clot. The forensic pathologist who conducted a post-mortem examination of Prather did not attribute his death to the surgery. Prather’s widow then sought attorneys’ fees of $37,170 under ERISA, 29 U.S.C. 1132(g)(1). The Seventh Circuit awarded $30,380, stating that there is no doubt of Sun Life’s culpability or of its ability to pay without jeopardizing its existence; the award of attorneys’ fees is likely to give other insurance companies in comparable cases pause; and a comparison of the relative merits of the contending parties clearly favors the plaintiff. View "Prather v. Sun Life Financial Insurance Co." on Justia Law
Madison Mutual Insurance Co. v. Diamond State Insurance Co.
In 1999, the Dribbens purchased a home from the Favres on 42 acres in a four‐parcel development near Saint Louis, Missouri. Davidson represented the Favres in that purchase. Davidson was also one of the developers and owned one parcel. The development has a 30‐acre artificial lake; the dam creating that lake is located on the Dribbens parcel. In a 2006 lawsuit, the Dribbens alleged that Davidson failed to disclose that the original owners/developers had never obtained a permit from the Illinois Department of Natural Resources, which amounted to fraudulent concealment and consumer fraud. Davidson tendered the suit to Diamond State, which had issued her professional liability errors and omissions policy. In 2011, the Dribbens filed a second suit, alleging a pattern of harassment, intimidation, and interference with the Dribbens’ property rights by the Davidsons. Davidson tendered the 2011 lawsuit to Madison Mutual, which had provided her homeowner’s insurance and umbrella coverage. Diamond State refused to supply a defense to the 2011 litigation. Madison Mutual sought a declaratory judgment that Diamond State has breached its duty to defend in the 2011 suit and had a duty to reimburse Madison Mutual. The Seventh Circuit affirmed summary judgment in favor of Diamond State. The 2011 suit does not potentially assert a claim that is plausibly within the Diamond State professional liability coverage. View "Madison Mutual Insurance Co. v. Diamond State Insurance Co." on Justia Law
Telamon Corporation v. Charter Oak Fire Insurance Co
Berry worked for Telamon from 2005-2011, under Consulting Agreements between Telamon and Berry’s one-woman company. Berry’s responsibilities expanded beyond those described in the Agreements. She became Telamon’s senior regional manager. She oversaw Telamon’s AT&T Asset Recovery Program, to remove old telecommunications equipment from AT&T sites and sell it to salvagers. Berry removed the equipment and sold it, but kept the proﬁts. The company discovered the scheme in 2011; it had suffered $5.2 million in losses. Berry was convicted of wire fraud and tax evasion; she was sentenced to 60 months’ imprisonment and ordered to pay $3,440,885 in restitution. Telamon sought compensation under its Travelers crime insurance policy and its Charter Oak general commercial insurance policy. Travelers denied coverage because Berry was not, legally, an employee; Charter denied coverage because she was, functionally, an employee. Telamon sued, alleging bad faith, then unsuccessfully sought permission to add claims based on older policies. The request came a year after the deadline for amending pleadings. Telamon ﬁled suit in state court, raising essentially the same claims. The insurers again removed; the district court dismissed the suit as an impermissible attempt to split claims. The Seventh Circuit affirmed both decisions, noting that none of the four ways of establishing bad faith under Indiana law exist in this case. View "Telamon Corporation v. Charter Oak Fire Insurance Co" on Justia Law
Allied Property & Casualty Insurance Co. v. Metro North Condominium Association
A subcontractor, CSC, installed the windows defectively at Metro's Chicago condominium. The building sustained significant water damage following a 2006 storm. The unit owners incurred personal-property damage. In 2009 Metro sued the developer, which was insolvent; in 2013 it added a claim against CSC for breach of the implied warranty of habitability. Metro and CSC reached a settlement. Metro dismissed its state court lawsuit; CSC assigned to Metro CSC’s rights to up to $700,000 of insurance coverage from Allied, arising out of the claims asserted against CSC in the lawsuit. The only pending claim against CSC in that lawsuit was for breach of the implied warranty of habitability. The settlement specified that it was not intended to compensate for the cost of repairing or replacing CSC’s defectively installed windows, but rather for the resultant damage to the remaining parts of the condominium and to the unit owners’ personal property. Allied obtained a declaratory judgment that it was not liable under CSC’s standard commercial general liability policy. The Seventh Circuit affirmed. The measure of damages for a breach of the implied warranty of habitability is the cost of repairing the “defective conditions,” here the defectively installed windows. Illinois courts have concluded that CGL policies like Allied’s do not cover the cost of repairing the insured’s defectively completed work; the Allied policy specifically excludes the cost of repairing CSC’s defective work. View "Allied Property & Casualty Insurance Co. v. Metro North Condominium Association" on Justia Law
Indianapolis Airport Authority v. Travelers Property Casualty Co.
The Indianapolis Airport Authority sued Travelers Property Casualty over Travelers’ partial denial of a claim for coverage arising from an airport construction accident that occurred in 2007. On motions for summary judgment, the district court interpreted the insurance contract in favor of Travelers on several issues, narrowing the Authority’s case to a claim for unreimbursed inspection costs associated with the incident. Two weeks before trial was set to begin on that claim, the district court entered an evidentiary order that effectively precluded the Authority from proving that sole remaining claim by restricting the testimony of two “hybrid fact/expert” witnesses, leaving the Authority with no designated damages expert. The Seventh Circuit affirmed in part and reversed in part the district court’s summary judgment order, and vacated the evidentiary order. The court upheld the district court’s construction of the General Coverage Provision and agreed that the Authority has no compensable soft cost claim because of the deductible, but stated that, if the Authority can demonstrate with competent evidence that it incurred expenses to reduce soft costs for which Travelers otherwise would have been liable, it may recover those expenses under the “expenses to reduce the amount of loss” provision, subject to policy limits. View "Indianapolis Airport Authority v. Travelers Property Casualty Co." on Justia Law
Equal Employment Opportunity Commission v. Flambeau, Inc.
Flambeau adopted an employee wellness program, requiring its employees, as a condition of receiving employer-subsidized health insurance, to fill out a medical questionnaire and to undergo biometric testing. One employee did not meet those requirements in time for the 2012 benefit year;, he and his family were briefly without health insurance. He filed a complaint with the Equal Employment Opportunity Commission, which filed suit, arguing that Flambeau’s requirement violated the Americans with Disabilities Act (ADA) ban on involuntary medical examinations, 42 U.S.C. 12112(d)(4). The district court dismissed; the Seventh Circuit affirmed. The court declined to address whether wellness programs are exempt from the limits on medical examinations because the ADA does not “restrict … [an] organization … administering the terms of a bona fide benefit plan that are based on underwriting risks, classifying risks, or administering such risks that are based on or not inconsistent with State law” or the EEOC argument that this insurance safe harbor does not apply to wellness programs. The court held that the relief the EEOC sought is either unavailable or moot. The employee resigned before suit was filed. He did not incur damages as a result of Flambeau’s policy and is not entitled to punitive damages. Flambeau abandoned its wellness program requirements for reasons unrelated to the litigation. View "Equal Employment Opportunity Commission v. Flambeau, Inc." on Justia Law
Geiger v. Aetna Life Insurance Co.
Geiger, an account executive, received Aetna group disability insurance coverage. In 2009, Geiger stopped working and obtained short term disability precipitated by lumbar back pain and a 2007 L5S1 discectomy and bilateral ankle pain caused by avascular necrosis of the talar bones. In 2010, Geiger had several ankle surgeries. Aetna determined that Geiger was disabled from her occupation and approved long-term disability benefits, citing “required walking and driving for this occupation.” Geiger received $4,012 per month, 50% of her predisability earnings. Upon her approval for Social Security disability benefits, the amount was reduced to $784. After 24 months, the Plan requires a claimant to be unable to work at any reasonable occupation. In 2012, Aetna’s physician examined Geiger and found her capable of sedentary work. Under surveillance, Geiger was observed driving and visiting stores. The Plan terminated her benefits. In 2013, Aetna reinstated Geiger’s benefits. In 2014, under surveillance, Geiger was seen climbing into and driving an SUV, shopping, and carrying a bag. Aetna again terminated her benefits, citing the surveillance, prior independent peer reviews, a comprehensive clinical review, and occupational information. Geiger filed suit, citing her lack of medical improvement, her worsening medical condition, and the impact of severe pain on her ability to work. The court granted Aetna summary judgment. The Seventh Circuit affirmed, finding that Aetna minimized any conflict of interest stemming from its roles as administrator and insurer; presented sufficient evidence supporting its decision; and properly considered Geiger’s impairment and pain and the surveillance video. View "Geiger v. Aetna Life Insurance Co." on Justia Law
M.G. Skinner and Associates v. Norman-Spencer Agency, Inc
WCPP is a risk purchasing group for commercial property insurance. MGSA, an insurance broker, acts as WCPP’s program administrator, representing more than 600 properties. In 2011, MGSA sought renewal coverage for the WCPP properties. MGSA contracted with MC, which engaged NCAIG, which had previous insurance‐placement experience with Ward and his company JRSO. The chain of brokers for the WCPP renewal was: from MGSA, to MC, to NCAIG, to Ward and JRSO. In reality, Ward had created a fictitious policy for WCPP that was not actually backed by a legitimate insurer. Ward was convicted of wire fraud, sentenced to 10 years in prison, and ordered to pay restitution. One of the property groups in the WCPP program, Myan, had a history of losses, so MC had split it off from the main WCPP group for placement directly with JRSO for insurance. The Myan coverage used Norman-Spencer as program administrator, at the recommendation of NCAIG. Norman‐Spencer was paid $25,000 and issued policies for Myan’s coverage. Norman-Spencer wanted, but never obtained, additional contracts from WCPP. Norman-Spencer discovered an order issued against Ward and JRSO that could implicate Ward’s ability to bind coverage and, when Norman asked for a copy of Ward’s reinsurance agreement, Ward delayed for over a month and produced an agreement that contained irregularities. Norman‐Spencer did not inform WCPP or MGSA about these problems. None of the proposals or pricing information for WCPP came through Norman‐Spencer. MC and NCAIG received a commission from the WCPP premium; Norman‐Spencer did not. After Ward’s fraud was discovered, MGSA and WCPP sued Norman-Spencer. The Seventh Circuit affirmed summary judgment in favor of Norman-Spencer, concluding that Norman-Spencer owed no duty of care to either company. View "M.G. Skinner and Associates v. Norman-Spencer Agency, Inc" on Justia Law