Justia Insurance Law Opinion SummariesArticles Posted in US Court of Appeals for the Sixth Circuit
Karst Robbins Coal Co. v. Director, Office of Workers’ Compensation Programs
In 1983, Rice sought benefits under the Black Lung Benefits Act (BLBA), 30 U.S.C. 901–45. The Department of Labor (DOL) looks to employers that employed the miner for at least one year and are capable of paying benefits. The miner’s most recent employer that meets these requirements is the “responsible operator.” Employers must either qualify as a self-insurer or purchase BLBA insurance. KRCC operated a coal mine where Rice worked in 1982-1983 but he was employed by a separate corporate entity, KRMS, which charged KRCC for the cost of Rice’s labor. The entities' ownership and management overlapped; KRMS had no assets and operated out of KRCC's offices. KRCC obtained BLBA coverage from Bituminous Casualty but only listed 10 employees. The other 150 were employed by KRMS. An ALJ identified KRMS as the responsible operator, then denied Rice’s claim on the merits. Rice appealed; KRCC and Bituminous successfully moved to be dismissed from the case, because the ALJ identified KRMS as the responsible operator.In 2002, Rice filed another BLBA claim. DOL again notified KRCC and Bituminous that KRCC might be the responsible operator. Bituminous claims it “denied coverage based on the fraudulent arrangements” between KRCC and KRMS. DOL refused to dismiss Bituminous.The Sixth Circuit affirmed, rejecting arguments that DOL was collaterally estopped from finding that KRCC was the responsible operator; that Bituminous was entitled to rescind its insurance agreement based on fraud by KRCC; and that delays in DOL administrative proceedings violated its right to due process. View "Karst Robbins Coal Co. v. Director, Office of Workers’ Compensation Programs" on Justia Law
Hicks v. State Farm Fire & Casualty Co.
Under its replacement-cost homeowner insurance contracts, State Farm calculated its payment obligations by estimating the amount it would cost to repair or replace damaged property and subtracting depreciation and the deductible. During the class period, State Farm depreciated costs for both materials and labor.Policyholders filed a putative class action. The Sixth Circuit held that in an insurance contract that incorporates Kentucky’s “replacement cost minus depreciation” formula, the insurer cannot depreciate the costs of labor when determining payments. State Farm changed its practice and created a refund program for those who had received payments between the decision and the date State Farm stopped deducting labor depreciation. Most policyholders received refunds of less than $1,000. The court certified the class as: All persons and entities that received “actual cash value” payments ... from State Farm … for loss or damage to a dwelling or other structure in … Kentucky ... where the cost of labor was depreciated," excluding those that received payment in the full amount of insurance.The Sixth Circuit affirmed. The claims share a common legal question central to the validity of each claim: whether State Farm breached the standard form contracts by deducting labor depreciation. No individualized proof is necessary to resolve this question on a classwide basis. That common question predominates over individual questions, although damages will vary. The court did not abuse its discretion in finding class litigation to be the superior method of adjudication and class membership is ascertainable View "Hicks v. State Farm Fire & Casualty Co." on Justia Law
International Union, United Automobile, Aerospace and Agricultural Implement Workers of America v. Honeywell International, Inc.
Beginning in 1965, Honeywell and the labor union negotiated a series of collective bargaining agreements (CBAs). Honeywell agreed to pay “the full [healthcare benefit] premium or subscription charge applicable to the coverages of [its] pensioner[s]” and their surviving spouses. Each CBA contained a general durational clause stating that the agreement would expire on a specified date, after which the parties would negotiate a new CBA. In 2003, the parties negotiated a CBA obligating Honeywell to pay “not . . . less than” a specified amount beginning in 2008. The retirees filed suit, arguing that the pre-2003 CBAs vested lifetime, full-premium benefits for all pre-2003 retirees and that the CBAs of 2003, 2007, and 2011 vested, at a minimum, lifetime, floor-level benefits for the remaining retirees.The Sixth Circuit agreed with the district court that none of the CBAs vested lifetime benefits. Without an unambiguous vesting clause, the general durational clause controls. Reversing in part, the court held that the “not . . . less than” language unambiguously limited Honeywell’s obligation to pay only the floor-level contributions during the life of the 2011 CBA. The court rejected a claim that Honeywell acquired a "windfall" at the retirees' expense. View "International Union, United Automobile, Aerospace and Agricultural Implement Workers of America v. Honeywell International, Inc." on Justia Law
Perry v. Allstate Indemnity Co.
Perry’s home suffered water damage and required extensive repairs. She filed a claim with her insurer, Allstate, which did not dispute that Perry’s home was seriously damaged, or that it was required to pay for repairs or replacement. The parties agreed that the total estimated cost to repair or replace Perry’s home is $32,965.09. After making deductions for “depreciation,” Allstate provided Perry with a net payment of $28,394.74. Perry’s Allstate policy provides, “If you do not repair or replace the damaged, destroyed or stolen property, payment will be on an actual cash value basis. This means there may be a deduction for depreciation.” The policy does not define “depreciation.” Allstate contends that “depreciation” must account for the cost of both materials and labor. Perry claims that “depreciation” is ambiguous with respect to labor costs. The district court reversed the dismissal of Perry’s lawsuit. Under Ohio law, when an insurance policy is ambiguous, courts must interpret the policy strictly against the insurer, so long as the insured’s interpretation is reasonable. Perry’s reading of the term “depreciation” is a reasonable interpretation of an ambiguous policy, so Allstate may not include the cost of labor in calculating depreciation. View "Perry v. Allstate Indemnity Co." on Justia Law
Miller v. Bruenger
The Office of Personnel Management (OPM), manages the Federal Employees’ Group Life Insurance Act (FEGLIA), 5 U.S.C. 8705(a). Absent a valid beneficiary selection, FEGLIA provides an order of precedence for the proceeds, starting with the policyholder's surviving spouse, followed by the policyholder's descendants. FEGLIA will not follow that order if a “court decree of divorce, annulment, or legal separation, or . . . any court order or court-approved property settlement agreement” “expressly provides” for payment to someone else. The decree, order, or agreement must be “received” by the policyholder’s “employing agency” or OPM before the policyholder’s death. At the time of his death, Miller worked at Tinker Air Force Base and maintained a MetLife policy. Coleman's 27-year marriage to Donna ended in divorce in 2011. Their property settlement agreement states that “[Donna] shall remain the beneficiary of the life insurance policy.” The court ordered Coleman to assign his FEGLI benefits to Donna.Upon Coleman’s death, his only child, Courtenay, was appointed administratrix of his estate. The Air Force informed Courtenay that the court order had not been filed with Coleman’s employing office. Courtenay was paid $172,000 in proceeds and sought a declaration that she is the rightful owner. Citing lack of subject-matter jurisdiction, the district court dismissed the suit. The Sixth Circuit affirmed, noting the lack of a substantial federal question. FEGLIA does not contain an express cause of action for Donna. There is no federal agency involved. View "Miller v. Bruenger" on Justia Law
United Specialty Ins. Co. v. Cole’s Place, Inc.
One summer night in 2015, at a Louisville nightclub, someone discharged a firearm, shooting eight people. Six of those people sued the nightclub’s owner, Cole’s Place, in state court, arguing that Cole’s Place failed to protect them from foreseeable harm. United Specialty Insurance (USIC) obtained a federal declaratory judgment that it is not obligated to defend or indemnify Cole’s Place in the state court litigation. The Sixth Circuit affirmed. The district court did not abuse its discretion in exercising Declaratory Judgment Act jurisdiction over USIC’s lawsuit and did not err in finding that an assault-and-battery exclusion in Cole’s Place’s insurance policy with USIC applies to the state court litigation. There are no factual issues remaining in the state-court litigation or complex state-law issues that are “important to an informed resolution” of this case. View "United Specialty Ins. Co. v. Cole's Place, Inc." on Justia Law
Osborne v. Metropolitan Government of Nashville and Davidson County
Due to an unsafe condition on the premises, Osborne suffered a broken arm at the Center, which is owned and operated by Metro Nashville. Osborne obtained a state court judgment against Metro under the Tennessee Governmental Tort Liability Act; the damages included specific medical expenses related to the incident and found Osborne’s comparative fault to be 20 percent. Before the state court suit, Osborne incurred medical expenses for which Metro did not pay at the time. Medicare made conditional payments to Osborne totaling at least $9,453.09. Osborne claims he incurred—in addition to the costs of his state court litigation—the cost of his co-pays, deductibles, and co-insurance for treatments not covered through Medicare. Osborne alleged Metro is a primary payer who failed to pay under the Medicare Secondary Payer Act (MSPA), 42 U.S.C. 1395y(b), and was therefore liable for reimbursement of Medicare’s conditional payments and a double damages penalty under section 1395y(b)(3)(A). Metro claimed it paid the judgment in full, including discretionary costs. The Sixth Circuit affirmed that Osborne lacked statutory standing to sue for his individual losses and the conditional payments made by Medicare because the MSPA does not permit a private cause of action against tortfeasors. Because the MSPA is not a qui tam statute and financial injury suffered by Medicare is not attributed to Osborne, he also lacked Article III standing to sue for Medicare’s conditional payments. View "Osborne v. Metropolitan Government of Nashville and Davidson County" on Justia Law
Doe v. BlueCross BlueShield of Tennessee, Inc.
Doe is HIV-positive and takes Genvoya to control his condition. Doe's BlueCross health insurance covers Genvoya. After February 2017, BlueCross required Doe to fill the HIV prescription through mail order or by picking it up at certain brick-and-mortar pharmacies. If Doe used BlueCross's specialty pharmacy network, his co-pay for each monthly batch of Genvoya would be $120. If Doe continued to get the medicine at his local pharmacy, he would have to pay the full cost, thousands of dollars per batch. Doe preferred interacting with his regular pharmacists, who knew his medical history and could spot the effects of harmful drug interactions. He also worried that deliveries to his house might compromise his privacy or risk heat damage to the medicine. Doe filed a putative class action, alleging that BlueCross discriminated against HIV-positive beneficiaries in violation of the Affordable Care Act and the Americans with Disabilities Act (ADA), which breached their insurance contract. The district court dismissed. The Sixth Circuit affirmed. The Affordable Care Act prohibits discrimination against the disabled in the provision of federally supported health programs under section 504 of the Rehabilitation Act. BlueCross did not violate the Rehabilitation Act; it did not exclude Doe from participating in the plan or deny him benefits covered by it. Section 504 does not prohibit disparate-impact discrimination. The ADA claim failed because Doe targets BlueCross’s operation of his health care plan, not its control over his pharmacy (a public accommodation). View "Doe v. BlueCross BlueShield of Tennessee, Inc." on Justia Law
Lindenberg v. Jackson National Life Insurance Co.
Defendant issued a life insurance policy to the Decedent. Plaintiff, Decedent’s former wife, is the primary beneficiary; the contingent beneficiaries are Decedent’s “surviving children equally.” Plaintiff and Decedent divorced. Their Dissolution Agreement required that Plaintiff pay the premium of the Defendant’s policy and required “Husband at his expense [to] maintain" insurance on his life with the parties’ children as irrevocable primary beneficiaries. The couple had minor children at the time of Decedent’s death. When Plaintiff requested payment, Defendant requested that Plaintiff obtain waivers from "other potential parties” and court-appointed guardians for the children or that Plaintiff waive her rights so that Defendant could disburse the proceeds to the minor children. The court dismissed Defendant’s subsequent interpleader complaint and ordered Defendant to disburse to Plaintiff. A jury found that Defendant breached its contract, resulting in actual damages of $350,000; Defendant’s refusal to pay was in bad faith, resulting in additional damages of $87,500; and Defendant’s refusal to pay was either intentional, reckless, malicious, or fraudulent. The jury awarded punitive damages of $3,000,000. A Tennessee statute capped punitive damages at two times the compensatory damages awarded or $500,000, whichever is greater. Plaintiff challenged the cap under the Tennessee Constitution. The Tennessee Supreme Court declined to provide an opinion on certified questions. The district court then rejected Plaintiff’s challenge, reducing Defendant’s punitive damages liability to $700,000. The Sixth Circuit vacated in part, finding that the statutory cap on punitive damages, T.C.A. 29-39-104, violates the individual right to a trial by jury. View "Lindenberg v. Jackson National Life Insurance Co." on Justia Law
Vest v. Resolute FP US Inc.
Plaintiff Mead Vest contended defendant Resolute FP US Inc. breached its fiduciary-duty obligations set forth in the Employee Retiree Income Security Act when it failed to notify her late husband of his right to convert a group life insurance policy to an individual life insurance policy after he ceased employment and began drawing long-term disability benefits. The district court ruled plaintiff did not adequately plead a breach-of-fiduciary-duty cause of action. After review, the Sixth Circuit agreed and affirmed. View "Vest v. Resolute FP US Inc." on Justia Law