Justia Insurance Law Opinion Summaries

Following heavy snowfall in Pine Bluff, Arkansas, the roofs of several chicken houses at ten poultry farms collapsed. Norfolk & Dedham Mutual Fire Insurance Company, which insured the farms, sued Rogers Manufacturing Corporation, the manufacturer of the roof trusses used in the chicken houses, claiming strict product liability, negligence, and breach of warranties. Rogers moved to dismiss the complaint under Federal Rule of Civil Procedure 12(b)(6), arguing that Norfolk’s claims were barred by the Arkansas statute of repose.The United States District Court for the Eastern District of Arkansas agreed with Rogers and dismissed the complaint. Norfolk appealed the dismissal, arguing that the statute of repose did not apply to Rogers because the roof trusses were standardized goods, not custom-designed for the farms.The United States Court of Appeals for the Eighth Circuit reviewed the district court’s dismissal de novo, accepting the allegations in the complaint as true and drawing all reasonable inferences in Norfolk’s favor. The court found that Norfolk’s complaint plausibly supported an inference that the roof trusses were standardized goods, which would not be covered by the Arkansas statute of repose. The court emphasized that at this early stage, the complaint should not be dismissed if it allows for a reasonable inference of liability.The Eighth Circuit reversed the district court’s dismissal of the complaint and remanded the case for further proceedings, noting that the facts and legal arguments could be further developed as the case progresses. View "Norfolk & Dedham Mutual Fire Insurance Company v. Rogers Manufacturing Corporation" on Justia Law

In 2007, Dennis Collins, Suzanne Collins, David Butler, and Lucia Bott purchased long-term care insurance policies from Metropolitan Life Insurance Company (MetLife). They also bought an Inflation Protection Rider, which promised automatic annual benefit increases without corresponding premium hikes, though MetLife reserved the right to adjust premiums on a class basis. In 2015, 2018, and 2019, MetLife informed the plaintiffs of significant premium increases. The plaintiffs filed a class action in 2022, alleging fraud, fraudulent concealment, violations of state consumer protection statutes, and breach of the implied covenant of good faith and fair dealing under Illinois and Missouri law.The United States District Court for the Eastern District of Missouri dismissed the case, ruling that the filed rate doctrine under Missouri and Illinois law barred the plaintiffs' claims. Additionally, the court found that the plaintiffs bringing claims under Missouri law failed to exhaust administrative remedies. The plaintiffs appealed, arguing that the filed rate doctrine did not apply, they were not required to exhaust administrative remedies, and their complaint adequately alleged a breach of the implied covenant.The United States Court of Appeals for the Eighth Circuit reviewed the case de novo and affirmed the district court's dismissal. The appellate court held that the plaintiffs' complaint failed to state a claim upon which relief could be granted. The court found that MetLife's statements about premium expectations were not materially false and that the plaintiffs did not sufficiently allege intentional fraud or fraudulent concealment. The court also concluded that the statutory claims under the Missouri Merchandising Practices Act and the Illinois Consumer Fraud and Deceptive Business Practices Act were barred by regulatory exemptions. Lastly, the court determined that the implied covenant of good faith and fair dealing was not breached, as MetLife's actions were expressly permitted by the policy terms. View "Collins v. Metropolitan Life Insurance Co." on Justia Law

Elizabeth Holt, a former insurance agent for Medicare Medicaid Advisors, Inc. (MMA), alleged that MMA and several insurance carriers (Aetna, Humana, and UnitedHealthcare) violated the False Claims Act (FCA). Holt claimed that MMA engaged in fraudulent practices, including falsifying agent certifications and violating Medicare marketing regulations, which led to the submission of false claims to the Centers for Medicare and Medicaid Services (CMS).The United States District Court for the Western District of Missouri dismissed Holt's complaint. The court found that no claims were submitted to the government, the alleged regulatory violations were not material to CMS’s contract with the carriers, and the complaint did not meet the particularity standard required by Federal Rule of Civil Procedure 9(b). The court also denied Holt's motion for reconsideration, which introduced a fraudulent inducement theory and requested leave to amend the complaint.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court affirmed the district court's dismissal, agreeing that Holt's allegations did not meet the materiality requirement under the FCA. The court applied the materiality standard from Universal Health Services, Inc. v. United States ex rel. Escobar, considering factors such as whether the government designated compliance as a condition of payment, whether the violations were minor or substantial, and whether the government continued to pay claims despite knowing of the violations. The court found that the alleged violations did not go to the essence of CMS’s contract with the carriers and were not material to the government's payment decisions.The Eighth Circuit also upheld the district court's denial of Holt's motion for reconsideration and request to amend the complaint, concluding that adding a fraudulent inducement claim would be futile given the immateriality of the alleged violations. View "United States ex rel. Holt v. Medicare Medicaid Advisors" on Justia Law

A fire damaged a hotel owned by Shri Ganesai, LLC, which had an insurance policy with AmGuard Insurance Company. The policy also covered the mortgagee, Academy Bank, N.A. AmGuard denied Shri's claim, suspecting arson by Shri's principal, Alex Patel. During the investigation, the building suffered additional damage from vandalism and frozen pipes. Shri and Academy sued AmGuard for breach of contract and vexatious refusal to pay. The jury found in favor of the plaintiffs, awarding damages for the fire, vandalism, and freeze damage.The United States District Court for the Western District of Missouri denied AmGuard's motions for judgment as a matter of law and a new trial. AmGuard appealed, challenging the viability of Academy's vexatious-refusal claim, the exclusion of certain evidence, and the sufficiency of the evidence regarding damages from vandalism and frozen pipes. The district court had granted summary judgment to AmGuard on Shri's vexatious-refusal claim but allowed the remaining claims to proceed to trial.The United States Court of Appeals for the Eighth Circuit affirmed the district court's decisions. The court held that Academy's vexatious-refusal claim was viable despite the settlement of the underlying breach-of-contract claim, as AmGuard's delay in payment constituted vexatious conduct. The court also found no abuse of discretion in the district court's exclusion of certain evidence, including the testimony of a witness and parts of Patel's deposition. Additionally, the court ruled that sufficient evidence supported the jury's findings on the timing and extent of the vandalism and freeze damage, and that the expert testimony admitted was reliable. The court concluded that the district court did not err in denying AmGuard's motions for judgment as a matter of law or a new trial. View "Academy Bank, N.A. v. Amguard Insurance Company" on Justia Law

On August 10, 2020, a derecho caused significant damage to the plaintiffs' property in Cedar Rapids, Iowa. The plaintiffs filed a claim with their insurer, State Farm, which initially paid $2,297.26 for the damage. After further submissions and inspections, State Farm increased the payment by $3,822.68. The plaintiffs' contractor estimated the repair costs at $21,537.45, but State Farm disagreed, leading to further disputes and inspections. Eventually, the plaintiffs requested an appraisal, which set the actual cash value (ACV) at $16,155.48 and the replacement cost value (RCV) at $21,069.59. State Farm paid the plaintiffs the difference between the initial payments and the new ACV but required documentation of repairs for the RCV.The plaintiffs filed a lawsuit in state court for breach of contract and bad faith, which was removed to federal court. The district court granted summary judgment to State Farm, holding that the insurer had not breached the contract because it had paid the ACV and the plaintiffs had not completed repairs within the two-year policy deadline to claim the RCV. The court also found that State Farm had an objectively reasonable basis for its payment decisions, negating the bad-faith claim.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court affirmed the district court's decision, holding that State Farm did not breach the contract as the plaintiffs failed to complete repairs within the required two-year period. The court also held that State Farm had a reasonable basis for its initial payment decisions and did not act in bad faith. The court concluded that the plaintiffs were not entitled to further payments under the policy and that State Farm's actions were justified. View "Henderson v. State Farm Fire & Casualty Co." on Justia Law

Mychal Byrd was injured in an automobile accident caused by an unknown motorist and subsequently died from his injuries. Byrd's medical expenses, totaling $474,218.24, were covered by the Gilster-Mary Lee Corporation Group Health Benefit Plan, a self-funded plan subject to ERISA. Byrd had an automobile insurance policy with Nationwide Insurance Company, which provided $50,000 in uninsured-motorist coverage. After Byrd's death, his family sued Nationwide in state court to collect the insurance proceeds. The Plan intervened, removed the case to federal court, and claimed an equitable right to the insurance proceeds.The United States District Court for the Eastern District of Missouri granted summary judgment in favor of the Plan, determining that the Plan was entitled to the insurance proceeds under the plan document. The plaintiffs, initially proceeding pro se, did not respond to the motion for summary judgment. After obtaining counsel, they moved for reconsideration, which the district court denied. The plaintiffs then appealed the decision.The United States Court of Appeals for the Eighth Circuit reviewed the case and concluded that the district court lacked subject-matter jurisdiction. The appellate court determined that the plaintiffs' claim did not fall within the scope of ERISA's civil enforcement provisions because the plaintiffs were neither plan participants nor beneficiaries. Consequently, the claim was not completely preempted by ERISA, and the federal court did not have jurisdiction. The Eighth Circuit vacated the district court's judgment and remanded the case with instructions to return it to Missouri state court. View "Kellum v. Gilster-Mary Lee Corporation Group Health Benefit" on Justia Law

Christina Barrera, the office manager at PowerMed, was involved in a scheme to help unqualified individuals, mainly employees of AB InBev, fraudulently obtain disability benefits from the Social Security Administration (SSA) and private insurers. Patients paid PowerMed $21,600 for a "disability package" that included unnecessary medical tests and assistance in fraudulently applying for disability benefits. Barrera explained the scheme to patients, helped them complete paperwork, and coached them on how to appear disabled. An undercover officer's investigation led to Barrera's indictment and subsequent trial, where a jury found her guilty of conspiracy to defraud the SSA but acquitted her of health care fraud and theft of government funds.The United States District Court for the Eastern District of Missouri sentenced Barrera, ordering her to pay restitution to the SSA and private insurers. The presentence investigation report (PSR) recommended $339,407.80 in restitution to the SSA, but the Government argued for additional restitution to private insurers, totaling $203,907.62. The district court adopted the Government's figures, ordering Barrera to pay a total of $543,315.42 in restitution. After Barrera's sentencing, her co-conspirator Clarissa Pogue was sentenced but was not required to pay restitution to private insurers, leading Barrera to appeal.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court held that Barrera's criminal conduct included defrauding private insurers as part of the scheme to defraud the SSA, affirming the district court's decision to order restitution to private insurers. However, the court found errors in the calculation of restitution amounts for Prudential and MetLife, vacating those portions and remanding for further proceedings. The court rejected Barrera's argument regarding sentencing disparities with Pogue, emphasizing that the statutory direction to avoid unwarranted sentence disparities refers to national disparities, not differences among co-conspirators. The judgment was affirmed in part, vacated in part, and remanded. View "United States v. Barrera" on Justia Law

Charlotte Erdmann, a massage therapist insured by Allied Professionals Insurance Company (APIC), was sued by a patient, Kristin Schantzen, and her husband, Jay, for injuries sustained during a massage session. Erdmann's employer, Valley Chiropractic Clinic, was insured by NCMIC Insurance Company (NCMIC). APIC and Erdmann requested NCMIC to cover the claims, but NCMIC refused and instead filed a declaratory judgment action seeking a declaration that it was not obligated to defend or indemnify Erdmann. The Schantzens settled with Erdmann and Valley, with NCMIC agreeing to pay $250,000 of the settlement, leaving the dispute over who would pay Erdmann’s $1.6 million settlement.The United States District Court for the District of Minnesota denied APIC's motion to compel arbitration based on a clause in APIC’s policy with Erdmann. APIC argued that NCMIC should be compelled to arbitrate under the theory of direct-benefits estoppel. The district court concluded that Minnesota law did not support APIC's position, as NCMIC did not seek direct benefits from the APIC-Erdmann policy and was not a third-party beneficiary.The United States Court of Appeals for the Eighth Circuit reviewed the case de novo. The court predicted that the Minnesota Supreme Court would adopt a limited version of direct-benefits estoppel, only allowing a nonsignatory to be compelled to arbitrate if they directly benefited from the contract containing the arbitration clause. The court found that NCMIC did not directly benefit from the APIC-Erdmann policy and thus could not be compelled to arbitrate. Consequently, the Eighth Circuit affirmed the district court's decision, holding that APIC could not compel NCMIC to arbitrate its claims under Minnesota law. View "NCMIC Insurance Company v. Allied Professionals Ins. Co." on Justia Law

In this case, Allied Professionals Insurance Company (APIC) sought to compel arbitration in a dispute with NCMIC Insurance Company (NCMIC). The dispute arose after a patient sued Charlotte Erdmann, a massage therapist insured by APIC, for injuries sustained during a massage. Erdmann's employer, Valley Chiropractic Clinic, was insured by NCMIC. NCMIC declined to defend or indemnify Erdmann and instead filed a declaratory judgment action seeking a declaration that it was not obligated to cover Erdmann or, alternatively, that its coverage was secondary to APIC's. The patient settled with Erdmann and Valley, leaving the question of whether NCMIC or APIC was responsible for Erdmann's $1.6 million settlement.The United States District Court for the District of Minnesota denied APIC's motion to compel arbitration. The court concluded that Minnesota law did not support APIC's argument for direct-benefits estoppel, which would have allowed APIC to compel NCMIC to arbitrate based on a clause in APIC's policy with Erdmann. The district court found that NCMIC did not seek or obtain direct benefits from the APIC-Erdmann policy and thus could not be compelled to arbitrate under the doctrine of direct-benefits estoppel.The United States Court of Appeals for the Eighth Circuit affirmed the district court's decision. The appellate court held that Minnesota law would likely adopt a limited version of direct-benefits estoppel, which only applies when a nonsignatory directly benefits from the contract containing the arbitration clause. The court found that NCMIC did not directly benefit from the APIC-Erdmann policy and therefore could not be compelled to arbitrate. The court also noted that neither the Eighth Circuit nor the Minnesota Supreme Court had applied direct-benefits estoppel in a similar fact pattern, where a signatory sought to compel a nonsignatory to arbitrate. Thus, the judgment of the district court was affirmed. View "United States v. Osorio" on Justia Law

Martin Brauner transmitted HPV to M.O. through sexual activity in Brauner’s GEICO-insured automobile. M.O. threatened to sue Brauner for negligence and demanded $1,000,000 from GEICO, which denied the claim and sought a federal court declaration that the policy did not cover M.O.’s injuries. Brauner and M.O. settled the threatened lawsuit, agreeing that M.O. would collect only from GEICO if an arbitrator found Brauner negligent. The arbitrator awarded M.O. $5,200,000, which M.O. sought to confirm in Missouri state court. The Supreme Court of Missouri vacated the confirmation and remanded the case to allow GEICO to intervene.The United States District Court for the District of Kansas initially handled the case but transferred it to the United States District Court for the Western District of Missouri due to lack of personal jurisdiction over M.O. The district court granted GEICO’s motion for summary judgment, ruling that the policy required bodily injury to arise out of the use of the automobile, and that sexual activity in an automobile did not constitute “use” under Kansas insurance law. Brauner and M.O. appealed.The United States Court of Appeals for the Eighth Circuit reviewed the grant of summary judgment de novo. The court affirmed the district court’s decision, holding that the insurance policy unambiguously required bodily injury to arise out of the ownership, maintenance, or use of the automobile. The court found that sexual activity in an automobile did not meet this requirement, as the automobile was merely the situs of the injury and not causally connected to the negligent act. Therefore, M.O.’s injuries were not covered under the policy. View "GEICO General Insurance Co. v. M.O." on Justia Law