Justia Insurance Law Opinion Summaries

Bowling worked as a coal miner for 29 years, most recently for Island Fork. In 2002, Bowling unsuccessfully sought Black Lung Benefits Act (BLBA) benefits. In 2010, Bowling filed the current claim. In the meantime, the Affordable Care Act amended the BLBA to reinstate a rebuttable presumption that claimants with respiratory disabilities and 15 years or more of underground coal-mining work experienced those disabilities as a result of pneumoconiosis, 30 U.S.C. 921(c)(4). The District Director designated Island Fork as the responsible operator and awarded benefits. At a hearing, the ALJ learned that Island Fork and its insurer, Frontier were insolvent. Frontier declared insolvency after the Proposed Order issued. At the initial stages, if the District Director determines that an operator is not financially capable, the Director can select another operator—such as a previous employer—to be the responsible operator; once the claim reaches the ALJ, there is no mechanism to designate a different responsible operator. The Trust Fund, created by the BLBA, provides benefits when there are no responsible operators available, including when an operator is deemed at the ALJ stage not to be financially capable. KIGA, created by the Kentucky Insurance Guaranty Association Act, provides benefits when a member insurance company is insolvent. The ALJ decided that Island Fork was still the responsible operator because benefits could be paid by KIGA. The Sixth Circuit affirmed. The exclusions in the Guaranty Act do not apply; KIGA is liable. View "Island Fork Construction v. Bowling" on Justia Law

A tree fell on Kaitlyn and Joshua. Kaitlyn died. She was pregnant. Doctors delivered the baby, but he died an hour later. Joshua survived with serious injuries. A state jury found the Somerset Housing Authority liable and awarded $3,736,278. The Authority belonged to the Kentucky Housing Authorities Self-Insurance Fund, which provided a policy with Evanston. Evanston sought a declaratory judgment limiting its liability under the Fund’s policy to $1 million. Meanwhile, through mediation of the state court case, Evanston agreed to pay the “policy limits” in return for an agreement to dismiss the state court action and release the Authority from further liability. Evanston claimed that $1 million was the coverage cap; the defendants claimed it was $2 to $4 million. The district court determined that there was complete diversity and ruled for Evanston on the merits. The Sixth Circuit affirmed. The district court properly aligned the parties given their respective interests in the primary dispute at the time of filing, so that diversity jurisdiction was not destroyed. The policy obligates Evanston to provide a maximum of $1 million of coverage per “occurrence,” with an aggregate limit of $2 million for more than one occurrence. The contract defines “occurrence” as “an accident, including continuous or repeated exposure to substantially the same general harmful conditions.” When one tree falls at one time, that is one occurrence and one accident. View "Evanston Insurance Co. v. Housing Authority of Somerset" on Justia Law

Jackson, injured in an accident, taken to University Hospital, where she stated that she had health insurance coverage through United. Jackson received treatment from PRI, which uses MDB for billing services. PRI did not submit charges to United but sent Jackson a letter seeking payment of $1,066 and requesting that Jackson’s attorney sign a letter of protection against any settlement to prevent Jackson’s account from being sent to collections. Jackson did not pay. Her account was submitted to CCC, which sent Jackson a collection letter. Jackson’s attorney negotiated a $852 payment to CCC as final settlement of the charges. PRI or MDB later contacted Jackson, stating that she still owed $3.49. Jackson paid that amount. She brought a class action against CCC, PRI, and MDB for violation of Ohio Rev. Code 1751.60(A), which prohibits directly billing patients who have health insurance when the healthcare provider has a contract with the patient’s insurer to accept that insurance. The complaint also alleged breach of contract, breach of third-party beneficiary contract, violation of the Ohio Consumer Sales Practices Act, violation of the Fair Debt Collection Practices Act, fraud, conversion, unjust enrichment, and punitive damages. The Sixth Circuit reversed dismissal of the claims under section 1751.60 against PRI and MDB, but affirmed as to CCC, which is not subject to the section. View "Jackson v. Professional Radiology, Inc." on Justia Law

Reid founded Capitol, which owned commmunity banks, and served as its chairman and CEO. His daughter and her husband served as president and general counsel. Capitol accepted Federal Reserve oversight in 2009. In 2012, Capitol sought Chapter 11 bankruptcy reorganization and became a “debtor in possession.” In 2013, Capitol decided to liquidate and submitted proposals that released its executives from liability. The creditors’ committee objected and unsuccessfully sought derivative standing to sue the Reids for breach of their fiduciary duties. The Reids and the creditors continued negotiation. In 2014, they agreed to a liquidation plan that required Capitol to assign its legal claims to a Liquidating Trust; the Reids would have no liability for any conduct after the bankruptcy filing and their pre-petition liability was limited to insurance recovery. Capitol had a management liability insurance policy, purchased about a year before it filed the bankruptcy petition. The liquidation plan required the Reids to sue the insurer if it denied coverage. The policy excluded from coverage “any claim made against an Insured . . . by, on behalf of, or in the name or right of, the Company or any Insured,” except for derivative suits by independent shareholders and employment claims (insured-versus-insured exclusion). The Liquidation Trustee sued the Reids for $18.8 million and notified the insurer. The Sixth Circuit affirmed a declaratory judgment that the insurer had no obligation with respect to the lawsuit, which fell within the insured-versus-insured exclusion. View "Indian Harbor Insurance Co. v. Zucker" on Justia Law

Raymond, injured in a slip-and-fall accident, received medical treatment at Mercy Health Anderson Hospital. Strunk, injured in a car accident, received medical treatment at Mercy Health Clermont Hospital. Both have health insurance. Each of their insurers has an agreement with Mercy for the provision of services. Raymond and Strunk provided all information necessary for the hospital to submit claims. Mercy did not submit claims to the insurers. Instead, Avectus, on behalf of Mercy, sent letters to Raymond’s and Strunk’s attorneys stating the balance due for medical services and requesting that, to prevent collection efforts against their respective clients, the attorneys sign a “letter of protection” against any settlement or judgment, agreeing “to withhold and pay directly to Mercy Health the balance of any unpaid charges ... should my firm obtain any settlement or judgment for this patient." Raymond and Strunk claimed that Mercy and Avectus sought compensation from them for their medical expenses, in violation of Ohio Revised Code 1751.60. The district court dismissed. The Sixth Circuit reversed. The defendants sought payment “from a health-insuring corporation’s insured” while in a healthcare services contract with their health-insurance providers. The court rejected a claim that the defendants effectively sought compensation from a third party. View "Raymond v. Avectus Healthcare Solutions, LLC" on Justia Law

Corey worked as a machine operator in Eaton’s Ohio factory. Corey has long suffered from cluster headaches— extremely painful attacks that strike several times per day for weeks on end. In 2014, Corey applied for short-term disability benefits under Eaton’s disability plan after a bout of headaches forced him to miss work. After granting a period of disability, the third party administering Eaton’s disability plan discontinued benefits because Corey failed to provide objective findings of disability. Under the plan, “[o]bjective findings include . . . [m]edications and/or treatment plan.” Corey’s physicians treated his headaches by prescribing prednisone, injecting Imitrex (a headache medication), administering oxygen therapy, and performing an occipital nerve block. The district court upheld the denial. The Sixth Circuit reversed, citing the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B). Corey’s medication and treatment plan satisfy the plan’s objective findings requirement. View "Corey v. Sedgwick Claims Management Services, Inc." on Justia Law