Justia Insurance Law Opinion Summaries

SC, an outpatient surgical center, permits outside physicians to perform day surgery at its facility. Its insurance limited APA’s liability to $1 million per claim. In 2002, Dr. Hasson, an outside physician, performed outpatient laparoscopic surgery on Tate at SC. Hasson did not see Tate or sign her discharge instructions before SC released her; SC’s anesthesiologist discharged Tate, giving Tate's boyfriend discharge instructions. Days later, Tate checked into the hospital with a perforated bowel that rendered the previously-healthy 34‐year‐old a quadriplegic. Tate sued Hasson and SC. APA hired attorneys to defend SC. APA set the “Reserve” (money the Michigan Department of Insurance required APA to put aside to cover an adverse verdict) at $560,000. APA believed the damages could exceed the policy limit but that SC was not likely to be found liable. In 2007, APA rejected Tate's offer to settle for policy limits. Hasson’s insurer settled for his policy limit ($1 million). After the Illinois Appellate Court remanded the issue of whether SC’s nursing staff breached the standard of care, APA raised the Reserve to $1 million, stating that it still believed the case was defensible. Before the second trial, APA rejected Tate's second settlement demand for the policy limit. The jury returned a $5.17 million verdict. SC then sued APA for bad faith. The Seventh Circuit affirmed judgment as a matter of law in favor of APA. SC did not establish that anyone involved in litigating the case believed there was more than a mere possibility SC would be found liable; the mere possibility of liability is insufficient under the Illinois Supreme Court’s reasonable probability standard. View "Surgery Center at 900 North Michigan Avenue, LLC v. American Physicians Assurance Corp., Inc." on Justia Law

A district court ordered Jackson National Life to pay about $191,000 on a policy of life insurance. The court added that the insurer had litigated unreasonably and ordered it to reimburse Cooke’s legal fees under 215 ILCS 5/155. The insurer paid the death benefit and appealed the attorneys’ fees. Because the district court had not specified the amount, the Seventh Circuit dismissed the appeal as premature. The district court then awarded $42,835 plus interest. The district judge concluded that there had been a good faith coverage dispute, so the insurer could not be penalized for insisting that a judge resolve the parties’ dispute, but added, “Jackson’s behavior in this litigation has been much less reasonable.” The Seventh Circuit reversed, first rejecting Cooke’s appeal on the merits award. Cooke did not appeal within 30 days of the order specifying the amount payable on the policy, and a later award of fees did not reopen that subject. The court erred in applying Illinois state law to the conduct of litigation in federal court and Jackson’s litigation conduct did not violate the Federal Rules of Civil Procedure. View "Cooke v. Jackson National Life Insurance Co." on Justia Law

In 2002, in Texas, Dr. Phillips performed a laparoscopic hysterectomy on Bramlett, a 36-year-old mother. While hospitalized, Bramlett suffered internal bleeding and died. Her family filed a wrongful death lawsuit against the hospital and Dr. Phillips, who held a $200,000 professional liability insurance policy with MedPro. He notified MedPro of the lawsuit. In 2003, the hospital settled with the Bramletts for approximately $2.3 million. The Bramletts wrote to Dr. Phillips’s attorney, Davidson, with a $200,000 Stowers demand; under Texas law, if an insurer rejects a plaintiff's demand that is within the insured’s policy limit and that a reasonably prudent insurer would accept, the insurer will later be liable for any amount awarded over the policy limit. MedPro twice refused to settle. The family won a $14 million verdict. The Supreme Court of Texas capped Dr. Phillips’s liability. The family sued MedPro, which settled. MedPro was insured by AISLIC, which declined to cover MedPro’s settlement. The district court granted AISLIC summary judgment, concluding that coverage was excluded because MedPro should have foreseen the family’s claim. An exclusion precluded coverage for “any claim arising out of any Wrongful Act” which occurred prior to June 30, 2005, if before that date MedPro “knew or could have reasonably foreseen that such Wrongful Act could lead to a claim.” The Seventh Circuit reversed in part, finding genuine issues of material fact regarding whether MedPro’s failure to settle was a Wrongful Act and whether MedPro could have foreseen a "claim" before the malpractice trial. View "Medical Protective Co. of Fort Wayne, Indiana v. American International Specialty Lines Insurance Co." on Justia Law

Plaintiffs hold participating life-insurance policies from State Farm and Country Life that guarantee policyholders annual dividends from their insurers’ surpluses. The insurers decide the dividend amounts. Dissatisfied with their dividends, Plaintiffs filed nearly identical class-action complaints claiming that the dividend provisions in their policies violate the Illinois Insurance Code by failing to include a provision mandated by the Code. Plaintiffs concede that their annual dividends satisfied the terms of their respective policies. In consolidated appeals, the Seventh Circuit affirmed the dismissal of the claims. Illinois requires only that life-insurance policies of this type contain a provision for policyholders to participate in their insurers’ surpluses. The policies at issue here contain the required provision and are in compliance, despite allowing insurers discretion to set dividend amounts. View "Anderson v. Country Life Insurance Co." on Justia Law

MCI held a business owners insurance policy with an “Employment-Related Practices Liability Endorsement” from Society Insurance. When DirecTV sued MCI under 47 U.S.C. 521 for publicly displaying its programming in MCI’s two restaurants without paying the commercial subscription rate, Society denied MCI’s claim. MCI sued Society; the Seventh Circuit affirmed summary judgment for Society. The Endorsement requires Society to cover MCI for “damages resulting from a ‘wrongful act’ to which [the Policy] applies” and defines “wrongful act” to include, “[l]ibel, slander, invasion of privacy, defamation or humiliation.” There is no reasonable interpretation of the DirecTV complaint that could arguably fall within the category of libel, slander or defamation. That complaint alleged that MCI damaged DirecTV’s goodwill by showing its programming without paying the correct subscription fee; there are no allegations that MCI made any false, defamatory statement about DirecTV. DirecTV’s actions did not include allegations that MCI made any kind of statement at all. View "Martinsville Corral, Inc. v. Society Insurance" on Justia Law

Dr. Griffin provided medical care to T.R., a participant in a Central States health plan. Before receiving treatment, T.R. assigned to Griffin the rights to “pursue claims for benefits, statutory penalties, [and] breach of fiduciary duty ….” Griffin confirmed through a Central representative that the plan would pay for the treatment at the usual, reasonable, and customary rate, then treated T.R. and submitted a claim for $7,963. Griffin later challenged the benefits determination, requesting a copy of the summary plan description and documents used to determine her payment. Six months later, Central responded that iSight, a third party, used “pricing methodology” to determine the fee and telling her to negotiate with iSight before engaging in the appeals process that the plan required before a civil suit. Griffin missed a call from iSight, returned the call, and left a message that she “would not take any reductions.” iSight never called back. Central provided a copy of the summary plan description, but no fee schedules or tables. Griffin sued under ERISA, 29 U.S.C. 1132(a)(1)(B), (a)(3), alleging that Central did not pay her the proper rate under the plan; breached its fiduciary duty by not adhering to plan terms; and failed to produce, within 30 days, the summary plan description she requested, nor iSight’s fee schedules. The court dismissed. The Seventh Circuit affirmed in part and vacated in part. Griffin adequately alleged that she is eligible for additional benefits and statutory damages. View "Griffin v. Teamcare" on Justia Law

The Affordable Care Act’s three premium‐stabilization programs were designed to redistribute money among insurance companies and mitigate each company’s exposure to market risks, 42 U.S.C. 18061–18063. The Department of Health and Human Service (HHS) intended to implement these programs in a budget‐neutral way paying out only the funds that each program had taken in from other insurance companies. Land of Lincoln participated in these premium‐stabilization programs and incurred a debt of roughly $32 million but HHS owed Land of Lincoln over $70 million. HHS was not able to pay what it owed because it was taking in far less money than expected, and it refused to dip into its discretionary funds. Like other insurance companies, Land of Lincoln sought the overdue payments in an unsuccessful suit. Land of Lincoln became insolvent and began liquidation. Despite an Illinois court order, HHS began to offset its overdue payments against Land of Lincoln’s debt, as its own regulations permitted. The Director of the Illinois Department of Insurance, Land of Lincoln’s appointed liquidator, asked the state court for a declaration that HHS violated the order, but HHS removed the motion to federal district court arguing that the federal government was not subject to state court jurisdiction. The district court remanded the case back to state court relying on a narrow reading of 28 U.S.C. 1442, and principles of abstention. The Seventh Circuit reversed on both grounds and remanded to the district court. View "Hammer v. United States Department of Health and Human Services" on Justia Law

Hennen worked as a sales specialist for NCR, 2010-2012, and was covered by long-term disability insurance under a group policy provided by MetLife. She sought treatment for a back injury. When physical therapy and surgery failed to resolve her injury, Hennen applied for long-term disability benefits. Acting as plan administrator, MetLife agreed that Hennen was disabled and paid benefits for two years. The plan has a two-year limit for neuromusculoskeletal disorders, subject to exceptions, including on for radiculopathy, a “Disease of the peripheral nerve roots supported by objective clinical findings of nerve pathology.” After MetLife terminated Hennen’s benefits, she sued under the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001 (ERISA), arguing that MetLife’s determination that she did not have radiculopathy was arbitrary and capricious. The district court granted MetLife summary judgment. The Seventh Circuit reversed. MetLife acted arbitrarily when it discounted the opinions of four doctors who diagnosed Hennen with radiculopathy in favor of the opinion of one physician who ultimately disagreed, but only while recommending additional testing that MetLife declined to pursue. View "Hennen v. Metropolitan Life Insurance Co." on Justia Law

Packgen's customer, CRI, required a new type of intermediate bulk container (IBC) for a chemical catalyst used in refining crude oil into other petroleum products. The new IBC's outer surface consisted primarily of polypropylene fabric rather than metal; it could be collapsed for storage. CRI's catalyst is self-heating and can ignite when exposed to oxygen. Packgen engaged Berry to manufacture a laminate of woven polypropylene chemically bonded to aluminum foil, to strengthen the IBC’s exterior and serve as a barrier to oxygen, ultraviolet light, and infrared radiation. By April 2008, Packgen was selling an average of 1,261 IBCs per month to CRI and was making overtures to other petroleum refiners. While CRI personnel were lifting an IBC full of catalyst, the foil layer separated from the polypropylene, exposing the interior lining. Other failures followed, some resulting in fires. Packgen determined that foil laminate obtained from Berry was defective. CRI canceled pending orders and destroyed and refused to pay for IBCs that Packgen had provided. Word reached other potential Packgen customers. Packgen sued Berry. The First Circuit affirmed an award of $7.2 million in damages. Berry unsuccessfully demanded that Illinois National indemnify it for all but the first $1 million, which Berry’s primary liability insurer agreed to cover. The Seventh Circuit affirmed summary judgment in favor of Illinois National. The policy covers damages that Berry is required to pay “because of … Property Damage.” While some portion of the lost profits award might be attributable to property damage, Berry did not attempt to make that showing. View "Berry Plastics Corp. v. Illinois National Insurance Co." on Justia Law

Cehovic’s employer offered its employees an insurance benefit plan through ReliaStar. Cehovic had two ReliaStar policies: a basic policy with a death benefit of $263,000, and a supplemental policy with a death benefit of $788,000. Both listed his sister, Cehovic‐Dixneuf, as the sole and primary beneficiary. After Cehovic died, his ex‐wife claimed that she and the child she had with Cehovic were entitled to the death benefits from the supplemental policy. The district court granted summary judgment for Cehovic‐Dixneuf. The Seventh Circuit affirmed. The Employee Retirement Income Security Act (ERISA) requires administrators of employee benefit plans to comply with the documents that control the plans, 29 U.S.C. 1104(a)(1)(D). For life insurance policies, that means death benefits are paid to the beneficiary designated in the policy, notwithstanding equitable arguments or claims that others might assert. The supplemental policy is governed by ERISA even though Cehovic paid all of its premiums without any direct subsidy from the employer. Cehovic’s employer performed all administrative functions associated with the maintenance of the policy. The plan description made clear that the supplemental life insurance policy would remain part of the employer’s group policy, but could be converted to an individual policy in certain situations. Nothing in the record shows that Cehovic executed a conversion. View "Cehovic-Dixneuf v. Wong" on Justia Law