Justia Insurance Law Opinion Summaries

The emergency-care physician plaintiffs did not participate in the insurance company’s (UHC) provider network. Doctors must serve all patients requiring emergent care regardless of whether their patient is in-network. Texas law requires that emergency-care providers must be paid their “usual and customary rate[s]” for care provided to out-of-network plan enrollees, Tex. Ins. Code 1271.155(a), 1301.0053(a), and 1301.155(b). The Plaintiff-Doctors alleged that UHC violated those statutes. The district court declined to dismiss all of the claims. UHC sought an interlocutory review of whether the statutes include an implied private right of action and, if so, whether the Employee Retirement Income Security Act preempts the claims.The Fifth Circuit certified the first issue to the Texas Supreme Court after considering the closeness of the question and the existence of sufficient sources of state law; the relevance of considerations of comity; and practical limitations such as delay and framing the issue to produce a helpful response. The court stated that a court could plausibly read the emergency-care statutes to provide an implied right of action but that a Texas appellate court has found to the contrary. Whether there is an implied private right of action either enables or eliminates thousands of claims; the state of Texas has a strong interest. View "ACS Primary Care Physicians Southwest, P.A. v. UnitedHealthcare Insurance Co." on Justia Law

Lereta maintained an ERISA-governed benefits plan, subject to the Employee Retirement Income Security Act (ERISA) that provided short-term disability (STD) and long-term disability (LTD) to its employees, including Newsom. Reliance issued the policies that funded these benefits and served as the benefits claims administrator. Newsom filed suit following Reliance’s determination that he was ineligible for LTD benefits.The district judge entered an order in favor of Newsom, awarding him LTD benefits. The Fifth Circuit affirmed as to Newsom’s eligibility for LTD benefits and alleged date of disability but vacated as to Newsom’s entitlement to LTD benefits. The court remanded with instructions for the district court to remand Newsom’s claim to the administrator for further proceedings. The district court did not err by interpreting the term “full time” and its reference to a “regular work week” to mean the “scheduled workweek” set by Lereta for Newsom. Although that factual record contains medical records Newsom submitted during Reliance’s evaluation of his claim, the merits evidence is at best incomplete and undermines the district court’s benefits determination; the court’s benefits determination does not fully square with the record. View "Newsom v. Reliance Stnrd Life Ins" on Justia Law

After incurring a million-plus-dollar loss for sending gold coins to a thief who forged check payments and intercepted the shipment of those coins, Gage filed an insurance claim. The underwriters denied the claim citing a coverage exclusion for losses incurred “consequent upon” delivering insured property to any third party against payment by a fraudulent check.The Fifth Circuit certified questions to the Texas Supreme Court: Whether Gage's losses were sustained consequent upon delivering insured property to UPS against a fraudulent check, causing the policy exclusion to apply; if yes. whether UPS's alleged errors are considered an independent cause of the losses under Texas law. The Texas Supreme Court concluded the ordinary meaning of “consequent upon” is but-for causation and answered “yes” to the first question. On the second question, the Texas Supreme Court answered “no” by concluding UPS’s alleged negligence was a concurrent cause of loss, dependent upon Gage’s handing over of the gold coins against fraudulent checks. In light of those answers, the Fifth Circuit affirmed the district court. Gage’s losses were excluded from coverage. Gage’s extra-contractual claims were properly dismissed as they were predicated on coverage under the policy. View "Dillon Gage, Inc. v. Certain Underwriters at Lloyds" on Justia Law

CP and Cimarex entered into the Master Service Agreement (MSA). Cimarex hired CP to work at Cimarex’s Oklahoma oil well. CP assigned Trent, an employee of one of its subcontractors, to work at the well. A flash fire occurred at the well. Trent was severely burned Trent sued Cimarex and CP. Cimarex and its insurers settled with Trent for $4.5 million. The Texas Oilfield Anti-Indemnity Act (TOAIA) voids indemnity agreements that pertain to wells for oil, gas, or water or to mineral mines unless the indemnity agreement is supported by liability insurance. The MSA's mutual indemnity provision required Cimarex and CP to indemnify each other; CP was obligated to obtain a minimum of $1 million in commercial general liability insurance and $2 million in excess liability insurance, Cimarex was required to obtain $1 million in general liability insurance and $25 million in excess liability insurance. CP obtained more coverage than the minimum required by the MSA, but its policy limited indemnity coverage. Cimarex sought indemnity from CP, which paid Cimarex $3 million, but refused to indemnify Cimarex for the remaining $1.5 million.The Fifth Circuit affirmed summary judgment for CP. TOAIA contemplates that mutual indemnity obligations will be enforceable only up to the limits of insurance each party has agreed to provide in equal amounts to the other party as indemnitee. CP did not breach the MSA because CP was only required to indemnify Cimarex up to $3 million. View "Cimarex Energy Co. v. CP Well Testing L.L.C." on Justia Law

Landmark issued a “deductible buyback” insurance policy, covering SCD properties. SCD’s high-deductible primary insurance policy was issued by Lexington. The Landmark policy covers damage also covered by Lexington and states: “Perils Covered: Windstorm or Hail associated with a Named Storm,” following the Lexington policy's Named Storm definition: “a storm that has been declared by the National Weather Service to be a Hurricane, Typhoon, Tropical Cyclone, Tropical Storm, or Tropical Depression.” In August 2017, Hurricane Harvey, a “Named Storm,” under the Lexington and Landmark policies, caused tremendous flooding damage to one of SCD’s insured properties. There was no reported wind damage to the property nor evidence that the property suffered damage from hail. The Lexington policy paid out millions of dollars for loss in excess of the “Windstorm deductible” in that policy,Landmark sought a declaration that SCD’s policy did not apply to the loss sustained. The Fifth Circuit reversed a judgment in favor of SCD and rendered judgment for Landmark. If SCD’s interpretation of the policy were correct, then the Landmark policy simply could have stated that all damage from a Named Storm is covered (regardless of the peril that caused the damage). The policy does not state that but frames its coverage as applying to specific “[c]overed perils.” View "Landmark American Insurance Co. v. SCD Memorial Place II, L.L.C." on Justia Law

The Fifth Circuit affirmed the district court's grant of summary judgment to Atlantic, concluding that the action is precluded on res judicata grounds. The court clarified some doctrinal confusion in its law about Louisiana principles of res judicata that one of its sister circuits has observed. The court concluded that this action arises out of the same nucleus of facts as plaintiff's initial suit, the issue of Atlantic's alleged bad faith misrepresentation of underinsured motorist coverage could have been raised in that initial suit, and plaintiff did not specifically reserve the right to bring this second suit as part of his settlement agreement with Atlantic. While plaintiff is correct that Louisiana's bad faith statutes impose duties on Atlantic that are separate and distinct from its duties under the insurance contract, this action remains barred by res judicata. Finally, this case does not present an exceptional circumstance exception to res judicata. View "Dotson v. Atlantic Specialty Insurance Co." on Justia Law

BP retained the Responders (O’Brien’s and NRC) for nearly $2 billion to assist with the cleanup of the Deepwater Horizon oil spill. Thousands of the Responders' workers filed personal injury lawsuits against BP, which were consolidated and organized into “pleading bundles.” The B3 bundle included “all claims for personal injury and/or medical monitoring for exposure or other injury occurring after the explosion and fire of April 20, 2010.” In 2012, BP entered the “Medical Settlement” on the B3 claims with a defined settlement class. The opt-out deadline closed in October 2012. The Medical Settlement created a new type of claim for latent injuries, BackEnd Litigation Option (BELO) claims. After the settlement, plaintiffs could bring opt-out B3 claims if they did not participate in the settlement, and BELO claims if they were class members who alleged latent injuries and followed the approved process. Responders were aware of the settlement before the district court approved it but neither Responder had control over the negotiations, nor did either approve the settlement.In 2017, BP sought indemnification for 2,000 BELO claims by employees of the Responders. The Fifth Circuit held that BP was an additional insured up to the minimum amount required by its contract with O’Brien’s; the insurance policies maintained by O’Brien’s cannot be combined to satisfy the minimum amount. O’Brien’s is not required to indemnify BP because BP materially breached its indemnification provision with respect to the BELO claims. View "O'Brien's Response Management, L.L.C. v. BP Exploration & Production, Inc." on Justia Law

Braylon Jordan swallowed small magnets when he was two years old. The magnets shredded his internal organs and necessitated surgery to remove most of his intestines, leaving him severely disabled. At issue in this appeal is whether there is insurance coverage for M&O's defense and for a partial settlement of the Jordans' claims.The Fifth Circuit concluded that, because no claim arising from Braylon Jordan's injuries was timely made against M&O during Evanston's policy period, Evanston is not obligated to provide M&O costs of its defense or coverage for the partial settlement between the Jordans and its then-CEO Craig Zucker. Accordingly, the court affirmed the district court's judgment that Evanston was not obligated to indemnify Zucker. However, the court reversed the district court's denial of Evanston's motion for summary judgment and rendered judgment in Evanston's favor. View "Jordan v. Evanston Insurance Co." on Justia Law

In 2012, the Archdiocese purchased a roof membrane system from Siplast, for installation at a Bronx high school. Siplast guaranteed that the system would “remain in a watertight condition for a period of 20 years.” In 2016, school officials observed water damage in the ceiling tiles after a rainstorm and notified the installing contractor and Siplast. A designated Siplast contractor unsuccessfully attempted to repair the damage and prevent leaks. The Archdiocese ultimately obtained an estimate for remediation and replacement of approximately $5,000,000.The ensuing lawsuit alleged “Breach of the Guarantee” Siplast submitted a claim to its insurer, EMCC, asserting coverage under commercial general liability policies that covered “property damage” caused by an “occurrence,” defined as “an accident, including continuous or repeated exposure to substantially the same general harmful conditions.” The policies were subject to exclusions for “Your Product/Your Work” and “Contractual Liability.” The district court granted EMCC summary judgment, finding that while the complaint did allege property damage that was caused by an “occurrence,” the alleged damage fit within the Your Product/Your Work Exclusion. The Fifth Circuit reversed, finding that EMCC had a duty to defend. The underlying complaint contains allegations of damage to property other than Siplast’s roof membrane as part of the claim against Siplast; the exclusion does not apply. View "Siplast, Inc. v. Employers Mutual Casualty Insurance Co." on Justia Law

TBB filed suit seeking to recoup losses stemming from the limitations on the operations of nonessential businesses during the COVID-19 pandemic through its commercial property insurance policy which covers business interruption losses caused by "direct physical loss of or damage to property."The Fifth Circuit concluded that the suspension of dine-in services during the COVID-19 pandemic is not a direct physical loss of or damage to property. Applying Texas law, the court concluded that the district court correctly determined that TBB's losses are not covered by either the business income and extra expense coverage (BI/EE) or the restaurant extension endorsement (REE) provision. Without coverage, the court need not address whether any policy exclusions also apply. In regard to TBB's extra-contractual claims, the court concluded that they were properly dismissed as abandoned. Finally, the court found no err in the district court's decision to deny TBB leave to amend. Accordingly, the court affirmed the district court's grant of judgment on the pleadings in favor of the insurer. View "Terry Black's Barbecue, LLC v. State Automobile Mutual Insurance Co." on Justia Law