Justia Insurance Law Opinion Summaries

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 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

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

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

Some of KVG’s commercial tenants got caught growing marijuana in their rental units and caused substantial damage to the premises before the police caught them. KVG speedily evicted the tenants and sought coverage from its insurers for nearly $500,000 in related losses. Westfield denied the claims. The Sixth Circuit affirmed summary judgment for Westfield, reasoning that the damage was excluded by the policy, which is the Building and Personal Property Coverage Form. Under this Form, Westfield agreed to pay for “direct physical loss of or damage to Covered Property . . . caused by or resulting from any Covered Cause of Loss.” A “Covered Cause of Loss” is any “Risk[] Of Direct Physical Loss,” with several exclusions, including that Westfield “will not pay for loss or damage caused by or resulting from” any “[d]ishonest or criminal act by you, any of your partners, members, officers, managers, employees (including leased employees), directors, trustees, authorized representatives or anyone to whom you entrust the property for any purpose.” While cultivating marijuana is a crime under federal law, it is protected by Michigan law under certain conditions but no reasonable jury could find that KVG’s tenants complied with Michigan law. View "K.V.G. Properties, Inc. v. Westfield Insurance Co." on Justia Law

In 2010, the defendants formed PremierTox, a urinalysis testing company: Doctors Peavler and Wood owned a substance abuse treatment company, SelfRefind; Doctor Bertram previously worked for SelfRefind. Bottom and Walters owned a drug testing service and laboratory. Physicians at clinics ordered urinalysis tests to check if their patients used illicit drugs and to monitor their medications. PremierTox was to receive those urine samples, perform the testing, and report back. In October 2010, SelfRefind began to send frozen urine samples to PremierTox for testing, but PremierTox did not have the correct equipment. In 2011, after PremierTox bought the necessary, expensive machines, they broke down. Urine samples from SelfRefind piled up. PremierTox started testing them between February and April 2011 and finished testing them in October. Over the same period, it tested and billed for fresh samples as they came in, aiming for a 48-hour turnaround. PremierTox billed insurers, saying nothing about the delays. The defendants were charged with 99 counts of health care fraud and with conspiracy. A jury acquitted them of conspiracy and 82 of the health care fraud charges and convicted them of 17 health care fraud charges. The trial judge imposed sentences of 13-21 months in prison. The Sixth Circuit affirmed the convictions. A reasonable jury could find that the defendants violated 18 U.S.C. 1347 by requesting reimbursement for tests that were not medically necessary. View "United States v. Walters" on Justia Law

Springer, a Utah physician, began a fellowship at the Cleveland Clinic and enrolled his family in its employee benefit plan, administered by Antares. During the enrollment period, Springer had his 14-month-old son, J.S., transported from a Utah hospital to the Cleveland Clinic by Angel Jet’s air ambulance service. J.S. had been hospitalized since birth for multiple congenital abnormalities. He required a mechanical ventilator. J.S.’s physician prepared a letter of medical necessity for the service. Before the flight, Angel Jet contacted Antares, which was unable to confirm that Springer and his son were members of the plan and did not precertify the service. Angel Jet proceeded with the transportation and submitted a bill to Antares for $340,100. Antares denied it for failure to obtain precertification. The Plan affirmed the denial but paid $34,451.75, reflecting the amount their preferred provider would have charged. Angel Jet brought suit under the Employee Retirement Security Act. The district court dismissed the suit, finding that Springer had not properly assigned his rights under the plan to Angel Jet. Springer then brought his own claim under ERISA Section 502(a)(1)(B). The Sixth Circuit affirmed, first finding that Springer had standing despite having received the service and not being billed. The denial was not arbitrary and capricious because J.S.’s transportation was not an emergency or precertified as required for a nonemergency. View "Springer v. Cleveland Clinic Employee Health Plan Total Care" on Justia Law

ATC, a Michigan manufacturer, outsources orders, including to YiFeng, a Chinese company. ATC pays vendors in four separate payments, based on manufacturing progress. YiFeng emails ATC invoices. On March 18, 2015, ATC’s vice-president, Gizinski, emailed YiFeng employee Chen requesting all outstanding invoices. An unidentified third party intercepted this email, and impersonating Chen, began corresponding with Gizinski. On March 27, the impersonator emailed Gizinski that, due to an audit, ATC should wire its payments to a different account from usual. YiFeng had previously, legitimately informed ATC it had changed its banking details; ATC had no process for verifying the information. Gizinski wired the money to the new account. On April 3, the impersonator emailed Gizinski, stating that “due to some new bank rules,” the previous transfer was not credited to its account so it would return the payment. The impersonator requested that Gizinski wire the money to a different bank account. Gizinski wired the money to this new account. The impersonator ran this scam twice more. Gizinski wired additional payments of $1575 and $482,640.41. When the real YiFeng demanded payment, ATC paid YiFeng approximately 50% of the outstanding debt; the remaining 50% was contingent on ATC’s insurance claim. ATC sought recovery from Travelers, under the Policy’s “Computer Fraud” provision. Travelers denied the claim. ATC sued for breach of contract. The court granted Travelers summary judgment. The Sixth Circuit reversed. Computer fraud “directly caused” ATC’s “direct loss” and no exclusion applied. View "American Tooling Center, Inc. v. Travelers Casualty & Surety Co." on Justia Law

Heimer, one year over the legal drinking age, drank alcohol with friends and then rode motorbikes in a field. Heimer and his friend collided. Heimer suffered extensive injuries, incurring more than $197,333.50 in medical bills. Heimer’s blood alcohol level shortly after the crash was 0.152, nearly twice the limit to legally use an off-road vehicle in Michigan. Heimer was insured. As required by his plan, he submitted a medical claim form shortly after the accident. The plan administrator denied coverage based on an exclusion for “[s]ervices, supplies, care or treatment of any injury or [s]ickness which occurred as a result of a Covered Person’s illegal use of alcohol.” After exhausting administrative appeals, Heimer filed suit. The district court held that the plan exclusion did not encompass Heimer’s injuries, reasoning that there is a difference between the illegal use of alcohol—such as drinking while under 21 or drinking in defiance of a court order—and illegal post-consumption conduct, such as the illegal use of a motor vehicle. The Sixth Circuit affirmed. Reading “illegal use of alcohol” to disclaim coverage only for the illegal consumption of alcohol, and not for illegal post-consumption conduct is consistent with the ordinary meaning of “use” and best gives effect to the contract as a whole. View "Heimer v. Companion Life Insurance Co." on Justia Law

Palmer’s vacant Detroit apartment complex was covered by a Scottsdale fire insurance policy until November 2012. The property was vandalized in February 2012. Palmer reported the loss in October 2013. Scottsdale replied that it was investigating. In November, Palmer sent Scottsdale an itemized Proof of Loss. Scottsdale paid Palmer $150,000 in June 2014. Michigan law provides that losses under any fire insurance policy shall be paid within 30 days after receipt of proof of loss. Palmer requested an appraisal. Scottsdale agreed, noting the claim remained under investigation. Appraisers concluded that Palmer’s actual-cash-value loss was $1,642,796.76. The policy limit was $1,000,000. Scottsdale tendered checks over a period of several months that paid the balance. Palmer requested penalty interest for late payment. Michigan law states that if benefits are not paid on a timely basis, they bear simple interest from a date 60 days after satisfactory proof of loss was received by the insurer at the rate of 12% per annum. The Sixth Circuit reversed the district court’s conclusion that the penalty-interest claim arose “under the policy” and was barred by the policy’s two-year limitations provision. Palmer did not allege that Scottsdale breached the policy agreement. Scottsdale paid the insured loss and the policy had no time limit for paying a loss, Palmer has no unvindicated rights and no claim “under the policy” to assert. His claim is under the statute. View "Palmer Park Square, LLC v. Scottsdale Ins. Co." on Justia Law