Justia Insurance Law Opinion SummariesArticles Posted in US Court of Appeals for the Sixth Circuit
Laake v. Western & Southern Financial Group Flexible Benefits Plan
The Plan is an employee welfare benefit plan under the Employee Retirement Income Security Act (ERISA). W&S denied Laake’s claim for extended long-term disability (LTD) benefits, indicating that Plan limited LTD benefit to 24 months if the disabling condition is due to any mental, nervous, psychiatric condition or chronic pain.” The Plan refers to “chronic pain syndrome.” No medical doctor had ever diagnosed Laake with “Chronic Pain Syndrome.” Although the Plan fails to define “Chronic Pain Syndrome,” Schedule C—which lists conditions that are excluded from extended LTD benefits—explicitly incorporates the Diagnostic and Statistical Manual of Mental Disorders, which does not specifically include “Chronic Pain Syndrome,” but does detail the symptoms and features of “Pain Disorder.” W&S did not ask Laake’s physicians in its questionnaires about the Mental Illness exclusion or “Chronic Pain Syndrome.” None of her physicians indicated that there was any psychological basis for her pain.The district court determined that Laake was entitled to benefits, imposed penalties against W&S, and awarded Laake attorney’s fees and costs, 29 U.S.C. 1132(g)(1). The Sixth Circuit affirmed. In denying benefits without any explanation or supporting evidence, W&S acted arbitrarily and capriciously. Because W&S provided notice that implied one basis for its denial of benefits, but in its final decision included an entirely new basis, it failed to substantially comply with ERISA’s notice requirements. The court noted a finding that W&S engaged in particularly “egregious conduct throughout the course of this litigation.” View "Laake v. Western & Southern Financial Group Flexible Benefits Plan" on Justia Law
Posted in: ERISA, Insurance Law, US Court of Appeals for the Sixth Circuit
Tranbarger v. Lincoln Life & Annuity Co. of New York
After gallbladder surgery, Tranbarger began suffering from multiple medical conditions, including physical pain and chronic fatigue. At work, Tranbarger continued as an accounts receivable manager, a primarily sedentary position. Her supervisor modified some of her responsibilities to accommodate her reduced capacity. Tranbarger resigned in July 2016, citing pain and fatigue.Through her employer, Tranbarger was enrolled in Lincoln's disability insurance plan. About 14 months after resigning, Tranbarger filed a claim for long-term disability benefits. Tranbarger was entitled to benefits if she could show “total disability” such that she was “unable to perform each of the [m]ain [d]uties” of an accounts receivable manager during a six-month “Elimination Period” following her resignation. Tranbarger presented a Social Security ruling in her favor, doctors’ notes, and statements from individuals otherwise familiar with her condition. Lincoln denied Tranbarger’s claim. She sued under the Employee Retirement Income Security Act (ERISA).The Sixth Circuit affirmed a judgment in favor of Lincoln. Tranbarger did not demonstrate a continuous inability to perform the main duties of an accounts receivable manager during the six months following her resignation. Although she provided diagnoses from the Mayo Clinic and established that she suffered pain and fatigue, there was little evidence about whether Tranbarger could perform her job functions. View "Tranbarger v. Lincoln Life & Annuity Co. of New York" on Justia Law
Posted in: ERISA, Insurance Law, US Court of Appeals for the Sixth Circuit
SHH Holdings, LLC v. Allied World Specialty Ins. Co.
A False Claims Act qui tam action was filed under seal against SHH and its nursing facilities, alleging that SHH provided unreasonable and unnecessary services to claim the highest possible Medicare reimbursement. Three co-relators also alleged that SHH retaliated against them for internally reporting fraudulent billing practices. SHH received a Department of Justice notification that it was the subject of a fraudulent claims investigation, requesting information about recent terminations of SHH employees, including the relators. It did not explicitly refer to the retaliation allegations.Two years later, SHH obtained liability coverage. Allied's claims-made policy applies only to claims first made during the policy period. SHH's application checked "none" when asked to “provide full details of all inquiries, investigations, administrative charges, claims, and lawsuits filed” within the last three years. SHH checked “no” to whether “[SHH], any Subsidiary, any Executive or other entity proposed for coverage kn[ew] of any act, error or omission which could give rise to a claim, suit or action.” An application exclusion, incorporated into the policy, stated that if such information existed, any inquiry, investigation, administrative charge, claim, or lawsuit arising therefrom or arising from such violation, knowledge, information, or involvement is excluded from coverage.The qui tam action was unsealed. SHH notified Allied and sought coverage for defense costs. Allied denied coverage. SHH sued. SHH later settled the relators' retaliation claim ($2.2 million) and finalized a $10 million settlement for the claims-submissions violations. The district court granted SHH partial summary judgment, awarding $2,336,786.35. The Sixth Circuit reversed. The plain language of SHH’s policy excluded coverage. View "SHH Holdings, LLC v. Allied World Specialty Ins. Co." on Justia Law
Westfield National Insurance Co. v. Quest Pharmaceuticals, Inc.
Lawsuits brought by governmental bodies and health clinics alleged that Quest, a wholesale pharmaceutical distributor, engaged in misconduct that contributed to a nationwide epidemic of opioid abuse. The plaintiffs plead violations of the RICO Act and state statutes, common law public nuisance, and negligence, seeking damages for “significant expenses for police, emergency, health, prosecution, corrections, rehabilitation, and other services.” Some complaints clarify that the claims “are not based upon or derivative of the rights of others” and that the plaintiffs “do not seek damages for death, physical injury to person, emotional distress, or physical damages to property[.]”Quest's insurance policies covered "damages because of 'bodily injury' or 'property damage'" and explain that “[d]amages because of ‘bodily injury’ include damages claimed by any person or organization for care, loss of services or death resulting at any time from the ‘bodily injury.’” “Bodily injury” is defined as “bodily injury, sickness or disease sustained by a person, including death resulting from any of these at any time.”The insurers sought declaratory judgments that they had no duty to defend or indemnify Quest. The district court granted the insurers summary judgment. The Sixth Circuit affirmed. Based on the plain language of the policies and their overall context and purpose, the court concluded that the Kentucky Supreme Court would find that the insurers have no duty to defend because the lawsuits do not seek damages “because of bodily injury” and claim only economic damages. View "Westfield National Insurance Co. v. Quest Pharmaceuticals, Inc." on Justia Law
Bachman Sunny Hill Fruit Farms v. Producers Agriculture Insurance Co.
Bachman Farms grows apples in Ohio and protected its 2017 crop with federally reinsured crop insurance from Producers Agriculture. When farmers and private insurers enter a federally reinsured crop insurance contract, they agree to common terms set by the Federal Crop Insurance Corporation (FCIC), including a requirement that the parties arbitrate coverage disputes. In those proceedings, the arbitrator must defer to agency interpretations of the common policy. Failure to do so results in the nullification of the arbitration award. Bachman lost at its arbitration with Producers Agriculture and alleged that the arbitrator engaged in impermissible policy interpretation. Bachman petitioned to nullify the arbitration award.The Sixth Circuit affirmed the dismissal of the suit. The petition to nullify did not comply with the substance or the three-month time limit of the Federal Arbitration Act (FAA), 9 U.S.C. 12. When a dispute concerning federally reinsured crop insurance involves a policy or procedure interpretation, the parties “must obtain an interpretation from FCIC.” Bachman did not seek an interpretation from FCIC but went directly to federal court to seek nullification under the common policy and its accompanying regulations—an administrative remedy—rather than vacatur under the FAA. View "Bachman Sunny Hill Fruit Farms v. Producers Agriculture Insurance Co." on Justia Law
Safety Specialty Insurance Co. v. Genesee County Board of Commissioners
The Fox and Puchlak filed purported class actions, alleging that Michigan counties seized property to satisfy property-tax delinquencies, sold the properties, and kept the difference between the sales proceeds and the tax debts.. The suits assert that the counties committed takings without just compensation or imposed excessive fines in violation of the Michigan and federal constitutions. Genesee County’s insurance, through Safety, precludes coverage for claims “[a]rising out of . . . [t]ax collection, or the improper administration of taxes or loss that reflects any tax obligation” and claims “[a]rising out of eminent domain, condemnation, inverse condemnation, temporary or permanent taking, adverse possession, or dedication by adverse use.”Safety sought a ruling that it owed no duty to defend or to indemnify. The district court entered summary judgment, finding no Article III case or controversy between Safety and Fox and Puchlak. The court also held that Safety owes Genesee County no duty to defend. The Sixth Circuit affirmed. Safety lacks standing to sue Fox and Puchlak over its duty to defend and its claim for the duty to indemnify lacks ripeness. Safety owes no duty to defend; the alleged tax-collection process directly caused the injuries underlying each of Fox’s and Puchlak’s claims. View "Safety Specialty Insurance Co. v. Genesee County Board of Commissioners" on Justia Law
Messing v. Provident Life & Accident Insurance Co.
In 1985, Messing, an attorney, obtained a long-term disability (LTD) insurance policy through Provident. Beginning in 1994, Messing struggled with depression. In 1997, Messing was hospitalized for his depression for more than three weeks. Provident began paying LTD benefits but later initiated a dispute. Messing's subsequent lawsuit settled in 2000 with Provident resuming payments. In 2018, Provident sought proof, beyond Messing’s own certifications, that he was unable to work as an attorney. Messing’s treating psychiatrist, Dr. Franseen, submitted a report diagnosing Messing with “Major Depressive Disorder, recurrent, minimal to mild,” and noting that Messing had stopped using medications to treat his depression in 2012 “and ha[d] been stable for the most part since then.” Franseen refused to render an opinion as to whether Messing could return to work. Provident had Dr. Lemmen interview Messing. Lemmen concluded, “[t]here is no objective evidence that [Messing] would not be able to practice as an attorney, should he desire to do so.” Messing appealed the termination of his benefits, providing affidavits from attorneys and a report from a third psychiatrist, Callaghan.The Sixth Circuit affirmed the denial of Provident’s claim for reimbursement of benefits it had paid but reversed with respect to the termination of benefits. Messing has proven that he remains unable to return to work as an attorney. Improvements in Messing’s health do not necessarily mean he can return to working as a full-time personal injury attorney. Dr. Callaghan noted Messing’s progress is likely attributable to his abstention from practicing law. View "Messing v. Provident Life & Accident Insurance Co." on Justia Law
Wild Eggs Holdings, Inc. v. State Auto. Property & Casualty Insurance Co.
Wild Eggs owns and operates restaurants in Indiana, Ohio, and Kentucky. When the COVID-19 pandemic began, those states imposed Stay-at-Home orders for all “non-essential” businesses. Wild Eggs was forced to suspend in-person dining and to restrict restaurant use to curbside pickup and delivery. State Auto has insured Wild Eggs since 2016. Wild Eggs notified State Auto of its claim for business losses under the Restaurant Extension Endorsement, which provides for 30 days of lost business income for the suspension of restaurant operations due to the order of a civil authority that resulted from an actual or alleged exposure of a restaurant to a disease. It also claimed coverage for all lost business income resulting from “direct physical loss of or damage to property” under the “Business Income Coverage” provision. State Auto denied coverage. Wild Eggs filed a breach-of-contract suit.The Sixth Circuit affirmed the dismissal of the suit. The Endorsement did not apply because the closures of Wild Eggs’s restaurants did not result from exposure to COVID-19 at the restaurants themselves. The Business Income Coverage provision did not apply because Wild Eggs did not suffer tangible damage to its property. View "Wild Eggs Holdings, Inc. v. State Auto. Property & Casualty Insurance Co." on Justia Law
P.I. & I. Motor Express, Inc. v. RLI Insurance Co.
While working at Dura-Bond’s Duquesne, Pennsylvania plant, Marshall stepped out of his truck, while others were loading metal pipes onto it. A worker accidentally ran a forklift into the pipes, causing one to roll off the truck and crash into Marshall. Doctors had to amputate both of Marshall’s legs, leaving him totally disabled.Russell Trucking had contracted with Express to use its license. Express would ensure that drivers met federal requirements, but Russell could otherwise retain the drivers they wanted. Marshall had completed an Express application, passed a background check, and completed training with Russell. Marshall leased a truck from Russell and drove it under Express’s license. Although he signed a contract stating that he was an independent contractor, Marshall believed that he was an employee of both Express and Russell.Marshall filed a workers’ compensation claim. Russell, Express, and Dura-Bond all disclaimed an employment relationship with Marshall. Marshall conceded that he had agreed to obtain his own workers’ compensation insurance and had failed to do so. An ALJ found that Russell was Marshall’s “immediate employer” and that Express and Dura-Bond were Marshall’s “statutory employers” under Pennsylvania’s workers’ compensation statute. Neither Express nor Russell had insurance for Marshall. The judge ordered Dura-Bond (which had insurance) to pay Marshall’s benefits and allowed it to seek indemnity. Express reimbursed Dura-Bond for the benefits.Marshall subsequently brought tort claims against Express and Russell. RLI, which had issued Express a commercial general liability policy, refused to reimburse for a $2.4 million settlement, citing policy exclusions for “[a]ny obligation” “under a workers’ compensation” “law” and for injuries to an “employee.” The Sixth Circuit affirmed a jury finding that Marshall was a “temporary worker,” leaving the tort-suit settlement covered by the policy. View "P.I. & I. Motor Express, Inc. v. RLI Insurance Co." on Justia Law
Wesco Insurance Co. v. Roderick Linton Belfance, LLP
Lawyers brought claims against schools under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400. After the claims failed, the schools sought their attorney’s fees from the lawyers under the IDEA’s fee-shifting provision. The School Districts alleged that, during the administrative process, the attorneys presented sloppy pleadings, asserted factually inaccurate or legally irrelevant allegations, and needlessly prolonged the proceedings. The lawyers asked their insurer, Wesco, to pay the fees. Wesco refused on the ground that the requested attorney’s fees fell within the insurance policy’s exclusion for “sanctions.”The Sixth Circuit affirmed summary judgment in favor of Wesco. The IDEA makes attorney misconduct a prerequisite to a fee award against a party’s lawyer, so the policy exclusion applied. The court noted that the legal community routinely describes an attorney’s fees award as a “sanction” when a court grants it because of abusive litigation tactics. View "Wesco Insurance Co. v. Roderick Linton Belfance, LLP" on Justia Law