Justia Insurance Law Opinion SummariesArticles Posted in US Court of Appeals for the Sixth Circuit
Santo’s Italian Cafe LLC v. Acuity Insurance Co.
In March 2020, the Governor of Ohio declared a state of emergency in connection with the COVID-19 pandemic. A few days later, the Director of the Ohio Department of Health ordered restaurants across the state to close their doors to in-person diners, forcing Santosuossos restaurant in Medina to halt ordinary operations. Although the closure order permitted restaurants to offer takeout services, in-person dining generates the substantial majority of Santosuossos’s revenue.” The restaurant sustained significant losses and laid-off employees. The restaurant filed a claim with Acuity, seeking recovery under its commercial property insurance policy. After Acuity denied coverage, the owner filed suit.The Sixth Circuit affirmed the dismissal of the suit. The policy covers business interruption “caused by direct physical loss of or damage to property.” The cause of the suspension of operations—the prohibition on in-person dining—did not arise from a physical loss of property or physical damage to it. The court also noted policy exclusions for “loss or damage caused directly or indirectly by . . . [a]ny virus . . . capable of inducing physical distress, illness or disease” and for “loss or damage caused directly or indirectly by [ordinance or law] . . . [r]egulating the construction, use or repair of any property.” View "Santo's Italian Cafe LLC v. Acuity Insurance Co." on Justia Law
River City Fraternal Order of Police v. Kentucky Retirement Systems
The plaintiffs retired from the Louisville Metropolitan police department and received free health insurance, administered by Kentucky Retirement Systems. Kentucky initially paid all of their healthcare costs. After the officers turned 65, Medicare became the primary payer, leaving Kentucky to cover secondary expenses. Each officer came out of retirement, joining county agencies different from the ones they served before retiring. They became eligible for healthcare benefits in their new positions. Kentucky notified them that federal law “mandate[d]” that it “cannot offer coverage secondary to Medicare” for retirees “eligible to be on [their] employer’s group health plan” as “active employees.” Some of the officers then paid for insurance through their new employers; others kept their retirement insurance by quitting or going part-time. The officers sued.The district court granted summary judgment to the officers, ordered Kentucky to reinstate their retirement health insurance, and awarded the officers some of the monetary damages requested. The Sixth Circuit affirmed. The officers have a cognizable breach-of-contract claim. Under Kentucky law, the Kentucky Retirement Systems formed an “inviolable contract” with the officers to provide free retirement health insurance and to refrain from reducing their benefits, then breached that contract. The Medicare Secondary Payer Act of 1980 did not bar Kentucky from providing Medicare-eligible police officers with state retirement insurance after they reentered the workforce and became eligible again for employer-based insurance coverage, 42 U.S.C. 1395y. View "River City Fraternal Order of Police v. Kentucky Retirement Systems" on Justia Law
Wilkerson v. American Family Insurance Co.
After a car accident, Wilkerson filed a claim with her insurer, American Family. Her policy will pay for “loss of or damage to your insured car and its equipment, less the deductible[.]” A“Limits of Liability” section adds that American Family will pay no more than the lesser of “the actual cash value of the stolen or damaged property” or “the amount necessary to repair or replace the property.” American Family concluded that the cost to “repair or replace” her Impala exceeded its pre-accident “actual cash value,” and contracted with AudaExplore to calculate that value. AudaExplore estimated the Impala’s market value based on its location, mileage, condition, and the recent advertised prices of 2010 Impalas in the area ($8,218-$10,033). AudaExplore valued Wilkerson’s car at $9,979. American Family subtracted Wilkerson’s deductible and paid her $9,479.Wilkerson brought suit under the Class Action Fairness Act, 28 U.S.C. 1332(d), arguing that “actual cash value” includes sales taxes and fees that a party typically must incur when buying a replacement car (whether or not a party actually incurs those expenses in a given case). She sought $673.58 for the taxes and $19.50 for fees Ohio charges to transfer a car’s title and registration. The Sixth Circuit affirmed the dismissal of her complaint. American Family’s policy indicates that “actual cash value” is best read to refer to market value, not replacement costs less depreciation. View "Wilkerson v. American Family Insurance Co." on Justia Law
Davis v. Hartford Life & Accident Insurance Co.
Davis, insured under a Hartford long-term disability policy, began missing work due to chronic back pain, neuropathy, and fatigue caused by multiple myeloma. Relying on the opinion of Davis’s oncologist, Dr. Reddy, Hartford approved Davis’s claim for short-term disability benefits through April 17, 2012. In June, Hartford approved Davis for long-term disability benefits, retroactive to April, for 24 months. Davis could continue to receive benefits beyond that time if he was unable to perform one or more of the essential duties of “Any Occupation” for which he was qualified by education, training, or experience and that has comparable “earnings potential.” Reddy's subsequent reports were inconsistent. An investigator found “discrepancies" based on surveillance. Davis’s primary care physician and neurologist both concluded that Davis could work full-time under described conditions. Reddy disagreed, but would not answer follow-up questions. An orthopedic surgeon conducted an independent review and performed an examination, and reported that Davis was physically capable of “light duty or sedentary work” within certain restrictions. Other doctors agreed. Hartford notified Davis that he would be ineligible for benefits after April 17, 2014.Davis filed suit under the Employee Retirement Income Security Act, 29 U.S.C. 1132(a). The Sixth Circuit affirmed summary judgment in favor of Hartford. Hartford reasonably concluded that Davis could work full-time, under certain limitations; the decision was not arbitrary. View "Davis v. Hartford Life & Accident Insurance Co." on Justia Law
Pogue v. Principal Life Insurance Co.
Pogue, believing that he had a severe anxiety disorder that prevented him from practicing as a family doctor, submitted a disability claim to his long-term disability insurers: Northwestern Mutual and Principal Life. Pogue failed to disclose that the Tennessee Board of Medical Examiners had suspended his license for mis-prescribing painkillers. His insurers found out and denied both of his claims. Pogue sued, alleging breach of contract and breach of the duty of good faith and fair dealing.In Pogue’s lawsuit against Northwestern, the district court granted Northwestern summary judgment on two alternative grounds: the suspension occurred before Pogue became disabled, and the suspension caused stress and anxiety and thus contributed to his disability. The Sixth Circuit court affirmed on the first ground and declined to consider the second ground. When Pogue’s lawsuit against Principal reached summary judgment, the district court applied issue preclusion and relied on the Northwestern district court’s holding that the suspension of Pogue’s license contributed to his disability. The court did not address whether the suspension occurred before Pogue became disabled and also granted summary judgment on Pogue’s bad-faith claims. The Sixth Circuit reversed. The district court erred by giving preclusive effect to an alternative holding on which the Sixth Circuit declined to rule. View "Pogue v. Principal Life Insurance Co." on Justia Law
DaVita, Inc. v. Marietta Memorial Hospital Employee Health Benefit Plan
Beginning in 2017, DaVita provided dialysis treatment to Patient A, who was diagnosed with end-stage renal disease (ESRD). Patient A assigned his insurance rights to DaVita. Through August 2018, the costs of Patient A’s dialysis were reimbursed by the Employee Health Benefit Plan, governed by the Employee Retirement Income Security Act (ERISA), at its bottom tier, which applied to providers who are “out-of-network.” All dialysis providers were out-of-network. While most out-of-network providers are reimbursed in the bottom tier based on a “reasonable and customary” fee as understood in the healthcare industry, dialysis providers are subject to an “alternative basis for payment”; the Plan reimburses at 87.5% of the Medicare rate. Patient A was exposed to higher copayments, coinsurance amounts, and deductibles and was allegedly at risk of liability for the balance of what was not reimbursed . The Plan identified dialysis as subject to heightened scrutiny, which allegedly incentivizes dialysis patients to switch to Medicare. Patient A switched to Medicare. DaVita and Patient A sued, alleging that the Plan treats dialysis providers differently from other medical providers in violation of the Medicare Secondary Payer Act (MSPA) and ERISA. The Sixth Circuit reversed, in part, the dismissal of the claims. A conditional payment by Medicare is required as a precondition to suing under the MSPA’s private cause of action; the complaint sufficiently alleges such a payment. DaVita plausibly alleged that the Plan violates the nondifferentiation provision of the MSPA, resulting in denials of benefits and unlawful discrimination under ERISA. View "DaVita, Inc. v. Marietta Memorial Hospital Employee Health Benefit Plan" on Justia Law
Hanover American Insurance Co. v. Tattooed Millionaire Entertainment, LLC
The House of Blues music studio in Memphis suffered a burglary and arson in 2015. Brown owned House of Blues through TME. He and two tenants, Falls and Mott, submitted insurance claims to Hanover for the loss. Brown submitted fraudulent documents in connection with this claim, resulting in an insurance-fraud lawsuit. Brown was found liable after admitting on the stand that he had forged documents submitted in his insurance claim. Falls prevailed before the jury, only to have the judge set aside the verdict and direct judgment for Hanover under Federal Rule of Civil Procedure 50(b). Rule 50(a) provides for a motion for judgment as a matter of law at trial; Rule 50(b) provides for “Renewing the [50(a)] Motion after Trial.” Hanover failed to make a Rule 50(a) motion at trial. The Sixth Circuit affirmed as to Mott, who failed to raise any issues on appeal, and as to Brown. The court rejected Brown’s arguments that the district court abused its discretion by refusing to allow him to introduce an exhibit that he tried to introduce several times; by intervening excessively to question witnesses; and by imposing a time limit on Brown and not on Hanover. The court reversed as to Falls. Hanover forfeited its ability to “renew” a motion for a directed verdict after trial under Rule 50(b). View "Hanover American Insurance Co. v. Tattooed Millionaire Entertainment, LLC" on Justia Law
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