Justia Insurance Law Opinion Summaries

A Tennessee resident insured by State Farm had her vehicle declared a total loss after an accident. State Farm calculated the payout for her claim using a valuation method provided by Audatex, which included a “Typical Negotiation Adjustment” (TNA) that reduced the value based on the assumption that used cars typically sell for less than their advertised price. The plaintiff argued that this adjustment did not reflect actual market practices and unfairly reduced the payout, constituting a breach of contract and a violation of Tennessee law. She filed a class action on behalf of similarly situated State Farm policyholders in Tennessee who received payouts calculated with the TNA.After the plaintiff filed suit in Tennessee state court, State Farm removed the case to the United States District Court for the Western District of Tennessee. The district court denied State Farm’s initial summary judgment motion but enforced the policy’s appraisal provision, leading to an appraisal process in which the plaintiff ultimately received a higher payout. State Farm then argued that the plaintiff’s claims were moot or lacked standing because she had been paid the appraised value, but the district court rejected this argument, finding her claims for breach of contract and consequential damages survived. The district court certified a class of Tennessee policyholders who received payouts reduced by the TNA, finding the requirements of Federal Rule of Civil Procedure 23 were met.The United States Court of Appeals for the Sixth Circuit reviewed the class certification. The court held that the plaintiff had standing to pursue her claims and that the class satisfied the requirements of numerosity, commonality, typicality, adequacy, predominance, superiority, and ascertainability. The court distinguished its approach from other circuits, emphasizing that common questions about the propriety of the TNA predominated over individualized damages issues. The Sixth Circuit affirmed the district court’s order certifying the class and remanded for further proceedings. View "Clippinger v. State Farm Automobile Insurance Co." on Justia Law

In this case, Christopher C. Brown, through his company Tattooed Millionaire Entertainment (TME), owned a Memphis music studio and insured both the studio and its equipment with Hanover American Insurance Company. John Falls, a musician, leased Studio B and its equipment from Brown and also obtained insurance from Hanover for the equipment and lost business income. In 2015, the studio was damaged by arson, and both Brown and Falls submitted insurance claims. Hanover discovered Brown had forged receipts for equipment purchases and sued to recover advance payments and for a declaratory judgment of no further liability. Brown, Falls, and another lessee counter-sued for breach of contract. After a jury trial in the United States District Court for the Western District of Tennessee, Falls was awarded $2.5 million for equipment loss and $250,000 for business income, while Brown was found to have committed insurance fraud.Hanover moved to set aside the verdict under Rule 50(b), which the district court granted. On appeal, the United States Court of Appeals for the Sixth Circuit reversed, holding Hanover had forfeited its Rule 50(b) motion by failing to make a Rule 50(a) motion as to Falls, and ordered reinstatement of the jury verdict. Subsequent proceedings included a federal interpleader action and a parallel state court action between Falls and TME. The district court enjoined the state action, but the Sixth Circuit reversed the injunction.In the present appeal, the United States Court of Appeals for the Sixth Circuit affirmed the district court’s allocation of the insurance payout, holding that Hanover was precluded by res judicata from challenging Falls’s recovery on grounds that could have been raised earlier. The court found the district court’s error in interpreting the wrong lease was harmless and upheld the allocation of funds based on the value of Falls’s leasehold interest. The court also held that Tennessee public policy barred Brown from recovering his allocated share due to his insurance fraud. The district court’s judgment was affirmed. View "Hanover American Insurance Co. v. Tattooed Millionaire Entertainment" on Justia Law

Two hospitals in Tennessee, Saint Francis Hospital and Saint Francis Hospital-Bartlett, sued Cigna Health and Life Insurance Company, claiming that Cigna routinely underpaid them for emergency services provided to Cigna members. The hospitals, which are out-of-network providers for Cigna, argued that Cigna had a quasi-contractual obligation to pay the reasonable value of their services based on federal and state laws requiring hospitals to treat emergency patients and insurers to cover emergency care.The United States District Court for the Western District of Tennessee dismissed the hospitals' claims. The court found that the hospitals' complaint did not meet the pleading standards of Rule 8, that Tennessee common law did not support their claims, and that the Employee Retirement Income Security Act (ERISA) preempted their claims.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court's dismissal. The Sixth Circuit held that neither federal law (specifically the Affordable Care Act) nor Tennessee law imposed a duty on Cigna to pay the full value of out-of-network emergency services. The court noted that the ACA's requirement for insurers to provide "coverage" for emergency services did not mean that insurers had to pay the full cost. The court also found that Tennessee common law did not support the hospitals' claims for quantum meruit and unjust enrichment, as there was no contractual or statutory duty for Cigna to pay the full value of the services.The Sixth Circuit concluded that the hospitals' claims failed because they could not establish that Cigna had a legal obligation to pay more than what was stipulated in its contracts with its members. The court did not address the ERISA preemption issue, as the dismissal was affirmed on other grounds. View "AMISUB (SFH), Inc. v. Cigna Health & Life Ins. Co." on Justia Law

Fire-Dex, a manufacturer of personal protective equipment for firefighters, faced lawsuits from firefighters and their spouses alleging exposure to carcinogens from Fire-Dex's products. These lawsuits were consolidated in multidistrict litigation in South Carolina. Fire-Dex had general commercial liability insurance policies with Admiral Insurance Company and requested Admiral to defend and indemnify it against the lawsuits. Admiral refused, leading to a declaratory judgment action in federal court in Ohio, where the district court declined to exercise jurisdiction.The United States District Court for the Northern District of Ohio initially had diversity jurisdiction over Admiral's declaratory judgment action but chose to abstain from exercising it, a decision affirmed by the Sixth Circuit. Subsequently, Fire-Dex filed a lawsuit in Ohio state court seeking a declaration that Admiral must defend and indemnify it, along with compensatory and punitive damages for breach of contract and bad faith. Admiral removed the case to federal court and filed counterclaims for declaratory judgment. Fire-Dex moved to remand the case to state court.The United States Court of Appeals for the Sixth Circuit reviewed the district court's decision to remand the declaratory claims and stay the damages claims. The Sixth Circuit held that the district court erred in abstaining from the declaratory claims under Thibodaux abstention, as the case did not involve unsettled questions of state law intimately involved with state sovereignty. The court also found that abstaining from the declaratory claims was an abuse of discretion because the declaratory and damages claims were closely intertwined, and no traditional abstention doctrine applied to the damages claims. The Sixth Circuit vacated the district court's order and remanded for further proceedings. View "Fire-Dex, LLC v. Admiral Insurance Co." on Justia Law

Brandi Goodwin, a part-time nursing assistant at Fisher Titus Hospital, contracted COVID-19 in December 2020, leading to symptoms such as shortness of breath and chest pain. She filed for short-term disability benefits, which Unum Life Insurance Company approved and extended until June 2021. However, when Goodwin applied for long-term disability benefits, Unum denied her claim, citing a pre-existing condition (vertigo) and normal test results that did not support her continued complaints.The United States District Court for the Southern District of Ohio upheld Unum's denial of long-term disability benefits. Goodwin then appealed the decision, arguing that Unum's denial was procedurally and substantively unreasonable.The United States Court of Appeals for the Sixth Circuit reviewed the case de novo. The court assessed whether Unum's decision-making process was procedurally sound and whether the decision was supported by substantial evidence. The court found that Unum considered all relevant evidence, including new medical opinions and test results, and provided rational reasons for changing its benefits determination from short-term to long-term. The court also noted that Unum's reliance on file reviewers over treating physicians was not unreasonable and that Goodwin did not provide concrete evidence of bias affecting Unum's decision.The Sixth Circuit concluded that Unum's decision to deny Goodwin long-term disability benefits was both procedurally and substantively reasonable. Therefore, the court affirmed the district court's judgment in favor of Unum. View "Goodwin v. Unum Life Ins. Co. of Am." on Justia Law

BlueCross BlueShield of Tennessee (BlueCross) is an insurer and fiduciary for an ERISA-governed group health insurance plan. A plan member in New Hampshire sought coverage for fertility treatments, which BlueCross denied as the plan did not cover such treatments. The Commissioner of the New Hampshire Insurance Department initiated an enforcement action against BlueCross, alleging that the denial violated New Hampshire law, which mandates coverage for fertility treatments. BlueCross sought to enjoin the state regulatory action, arguing it conflicted with its fiduciary duties under ERISA.The United States District Court for the Eastern District of Tennessee denied BlueCross's request for relief and granted summary judgment to the Commissioner. The court found that the Commissioner’s enforcement action was against BlueCross in its capacity as an insurer, not as a fiduciary, and thus was permissible under ERISA’s saving clause, which allows state insurance regulations to apply to insurers.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court’s decision. The Sixth Circuit held that the Commissioner’s action was indeed against BlueCross as an insurer, aiming to enforce New Hampshire’s insurance laws. The court noted that ERISA’s saving clause permits such state actions and that BlueCross could not use its fiduciary duties under ERISA to evade state insurance regulations. The court also referenced the Supreme Court’s decision in UNUM Life Insurance Co. of America v. Ward, which established that state insurance regulations are not preempted by ERISA when applied to insurers. Thus, the Sixth Circuit concluded that ERISA did not shield BlueCross from the New Hampshire regulatory action. View "BlueCross BlueShield of Tennessee v. Nicolopoulos" on Justia Law

Wehr Constructors, Inc. (Wehr) entered into a contract with St. Claire Medical Center (St. Claire) to build an addition to the hospital. Wehr's performance was allegedly deficient, leading to significant construction defects. St. Claire terminated the contract and sought damages from Wehr's performance-bond carrier, Travelers Casualty and Surety Company (Travelers Surety). Travelers Surety then involved Wehr in the litigation. Wehr sought defense coverage from its insurers: Phoenix Insurance Company (Phoenix), St. Paul Surplus Lines Insurance Company (St. Paul), and Travelers Property Casualty Company of America (Travelers Property).The United States District Court for the Eastern District of Kentucky ruled that none of Wehr’s insurers had a duty to defend Wehr in the lawsuit initiated by St. Claire. The court held that Phoenix’s duty to defend was not triggered because St. Claire did not assert claims directly against Wehr. It also found that St. Paul had no duty to defend because Wehr did not specifically agree to perform as a construction manager, a requirement under the St. Paul policy. Although Wehr did not seek summary judgment against Travelers Property, the court noted that Travelers Property also had no duty to defend for the same reasons as Phoenix.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court affirmed the district court’s decision regarding St. Paul, agreeing that Wehr did not specifically agree to serve as a construction manager. However, it reversed the decision regarding Phoenix, holding that Phoenix had a duty to defend Wehr because the damages alleged by St. Claire potentially fell within the policy coverage, and Wehr was a party to the suit. The court vacated the decision regarding Travelers Property and remanded for further proceedings to determine whether Travelers Property had a duty to defend, given the ambiguity in the district court’s ruling and the stipulation by the parties. View "Phoenix Insurance Co. v. Wehr Constructors, Inc." on Justia Law

US Framing International LLC entered into a subcontract with Continental Building Company for framing services on two student-housing projects. Disputes arose, leading US Framing to leave the Knoxville project. Continental then filed an insurance claim alleging US Framing's breach of the subcontract. US Framing sued Continental and its officers, claiming insurance fraud under Tennessee law. The district court dismissed the case, stating US Framing failed to plead any injury directly caused by the alleged fraudulent insurance claim.The United States District Court for the Eastern District of Tennessee initially reviewed the case. The court granted Continental's motion to dismiss, concluding that US Framing did not demonstrate any direct injury resulting from Continental's insurance claim. US Framing then appealed the decision.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court affirmed the district court's dismissal, holding that US Framing did not plausibly allege any economic damages directly resulting from Continental's alleged insurance fraud. The court also determined that US Framing could not recover attorney's fees or statutory penalties, as it did not establish itself as a prevailing party entitled to such relief. The court's decision was based on the interpretation of Tennessee law, which requires a direct causal link between the alleged fraud and the claimed damages. View "US Framing International LLC v. Continental Building Co." on Justia Law

Karl Tobien, a door-to-door salesman, was attacked by a dog while working in Ohio. He filed two federal lawsuits: one against the homeowners in the Southern District of Ohio, which was dismissed by agreement, and another against Nationwide General Insurance Company in the Eastern District of Kentucky. Tobien claimed Nationwide violated Kentucky’s Unfair Claims Settlement Practices Act, acted in bad faith, and sought punitive damages after the company denied his insurance claim.The United States District Court for the Eastern District of Kentucky dismissed Tobien’s lawsuit for improper venue, concluding that most relevant events occurred in Ohio. Tobien appealed, arguing that the Eastern District of Kentucky was a proper venue and that the district court should have transferred the case to the Southern District of Ohio instead of dismissing it.The United States Court of Appeals for the Sixth Circuit reviewed the case de novo and upheld the district court’s decision. The court determined that Tobien failed to show that a substantial part of the events giving rise to his claims occurred in the Eastern District of Kentucky. The court also found that transferring the case to the Southern District of Ohio would not be in the interest of justice, as Ohio law would apply and Tobien’s claims would fail under Ohio law. Consequently, the Sixth Circuit affirmed the district court’s dismissal of Tobien’s lawsuit. View "Tobien v. Nationwide Gen. Ins. Co." on Justia Law

As a nurse at the University of Louisville Hospital, Milby was covered by a long-term disability insurance policy. In 2011, Milby sought and received disability benefits for 17 months. During a subsequent eligibility review, the plan engaged MCMC, a third-party reviewer. MCMC opined that the “opinions of [Milby’s treating physicians] are not supported by the available medical documentation” and that she could perform sustained full-time work without restrictions as of 2/22/2013. Neither MCMC nor its agent was licensed to practice medicine in Kentucky. The plan terminated Milby’s benefits effective February 2013. Milby’s suit against her disability insurance provider remains pending. She also filed suit alleging negligence per se against MCMC for practicing medicine in Kentucky without appropriate licenses. MCMC removed the case to federal court, claiming complete preemption under the Employee Retirement Income Security Act (ERISA). The trial court denied Milby’s motion for remand to state court and dismissed. The Sixth Circuit affirmed. The state-law claim fits in the category of claims that are completely preempted by ERISA: it is in essence about the denial of benefits under an ERISA plan and the defendant does not owe an independent duty to the plaintiff because the defendants were not practicing medicine under the specified Kentucky law. View "Milby v. MCMC, LLC" on Justia Law