Justia Insurance Law Opinion Summaries

Articles Posted in Washington Supreme Court
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Krista Peoples and Joel Stedman filed Washington Consumer Protection Act ("CPA") suits against their insurance carriers for violating Washington claims-handling regulations and wrongfully denying them personal injury protection (PIP) benefits. The federal district court for the Western District of Washington certified a question of law relating to whether Peoples and Stedman alleged an injury to "business or property" to invoke their respective policies' PIP benefits. Peoples alleged her insurance carrier refused, without any individualized assessment, to pay medical provider bills whenever a computerized review process determined the bill exceeded a predetermined limit, and that the insurance company's failure to investigate or make individualized determinations violated WAC 284-30-330(4) and WAC 284-30-395(1). Due to this practice of algorithmic review, the insurance carrier failed to pay all reasonable medical expenses arising from a covered event, in violation or RCW 48.22.005(7). Stedman alleged his carrier terminate PIP benefits whenever an insured reached "Maximum Medical Improvement," which he alleged violated WAC 284-30-395(1). The Washington Supreme Court held an insurance carrier's wrongful withholding of PIP benefits injures the insured in their "business or property." An insured in these circumstances may recover actual damages, if proved, including out-of-pocket medical expenses that should have been covered, and could seek injunctive relief, such as compelling payment of the benefits to medical providers. Other business or property injuries, apart from wrongful denial of benefits, that are caused by an insurer's mishandling of PIP claims are also cognizable under the CPA. View "Peoples v. United Servs. Auto. Ass'n" on Justia Law

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The United States District Court for the Ninth Circuit certified a question of law to the Washington Supreme Court. Specifically, the federal appellate court asked whether an insurance company was bound by its agent’s written representation (made in a certificate of insurance) that a particular corporation was an additional insured under a given policy. This question arose in a case where: (1) the Ninth Circuit already ruled that the agent acted with apparent authority; but (2) the agent’s representation turned out to be inconsistent with the policy; and (3) the certificate included additional text broadly disclaiming the certificate’s ability to “amend, extend or alter the coverage afforded by” the policy. The Washington Supreme Court responded yes: an insurance company is bound by the representation of its agent in the circumstances presented by the federal court. “Otherwise, an insurance company’s representations would be meaningless and it could mislead without consequence.” View "T-Mobile USA, Inc. v. Selective Ins. Co. of Am." on Justia Law

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John and Michelle Strauss challenged the Court of Appeals decision affirming summary dismissal of their action against Premera Blue Cross, which arose out of the denial of coverage for proton beam therapy (PBT) to treat John's prostate cancer. At issue was whether the Strausses established the existence of a genuine issue of material fact regarding PBT's superiority to intensity-modulated radiation therapy (IMRT), thereby demonstrating that proton beam therapy was "medically necessary" within the meaning of their insurance contract. The Washington Supreme Court determined they did, and therefore reversed the Court of Appeals' decision, and remanded for a jury trial on the disputed facts. View "Strauss v. Premera Blue Cross" on Justia Law

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While driving his truck, Moun Keodalah and an uninsured motorcyclist collided. After Keodalah stopped at a stop sign and began to cross the street, the motorcyclist struck Keodalah's truck. The collision killed the motorcyclist and injured Keodalah. Keodalah's insurance policy with Allstate Insurance Company included underinsured motorist (UIM) coverage. Keodalah requested Allstate pay him his UIM policy limit of $25,000. Allstate refused, offering $1,600 based on its assessment Keodalah was 70% at fault for the accident. After Keodalah asked Allstate to explain its evaluation, Allstate increased its offer to $5,000. Keodalah sued Allstate asserting a UIM claim. The ultimate issue before the Washington Supreme Court in this case was whether RCW 48.01.030 provided a basis for an insured's bad faith and Consumer Protection Act claims against an insurance company's claims adjuster. The Supreme Court held that such claims were not available, and reversed the Court of Appeals. View "Keodalah v. Allstate Ins. Co." on Justia Law

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Group Health Cooperative (GHO) provided health insurance benefits to Nathaniel (Joel) Coon, who suffered a serious fungal infection and amputation following knee surgery at the Everett Clinic (TEC). The Coon family later settled potential negligence claims against TEC, and GHO initiated this lawsuit seeking reimbursement of its payments from the settlement proceeds. At issue before the Washington Supreme Court was whether genuine issues of material fact remained to preclude summary judgment in favor of GHO regarding whether the settlement constituted full compensation to Coon, and whether GHO suffered prejudice from the Coons’ failure to provide notice prior to finalizing the settlement. The Supreme Court concurred with the Court of Appeals’ conclusion that genuine issues of fact still remained, making summary judgment inappropriate. The matter was remanded for further proceedings. View "Grp. Health Coop. v. Coon" on Justia Law

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At issue in this case was whether a first-party insurer, after obtaining a partial recovery in a subrogation action, had to reimburse its fault-free insureds for the full amount of their deductibles before any portion of the subrogation proceeds could be allocated to the insurer. Lazuri Daniels brought claims, and sought class action status, in a lawsuit against State Farm Mutual Automobile Insurance Company arguing that by failing to fully reimburse its insureds for their deductibles, State Farm violated both Washington law and the terms of its own insurance policy. The trial court dismissed the claims, and the Court of Appeals affirmed. In addressing conflicts between subrogated insurers and injured insureds, Washington law generally establishes priority for the interests of the insured through the "made whole doctrine." "Out of the recovery from the third party the insured is to be reimbursed first, for the loss not covered by insurance ,and the insurer is entitled to any remaining balance, up to a sum sufficient to reimburse the insurer fully, the insured being entitled to anything beyond that." If the insured still has uncompensated injuries, both the insurer and insured will generally be looking to recover from the same third party, and that party's own insurance and assets are not always sufficient to cover both claims. In such circumstances, there is a high potential for conflict between insureds who wish to be compensated for the full extent of the damages they have suffered, and first-party insurers who expect to be reimbursed for amounts they have advanced to the insured. Daniels argued that insureds' right to be fully compensated for their losses, including full reimbursement for deductibles, takes priority over an insurer's interest in recouping its payments through a direct subrogation action. The Washington Supreme Court concluded Daniels' complaint asserted valid claims for relief under the common law, under Washington insurance regulations, and under State Farm's own policy language. As such, dismissal was improper. The matter was remanded to the trial court for further proceedings. View "Daniels v. State Farm Mut. Auto. Ins. Co." on Justia Law

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On October 30, 2013, Consuelo Prieto Mariscal was driving her minivan in Pasco, Washington, with her daughter. There were vehicles, including an orange, pickup truck and a van, on the right side of the road. As Prieto passed the orange pickup truck, she heard a noise, felt her van jump a little, and saw a boy, Brayan, lying on the ground. Realizing Brayan was seriously hurt, her daughter called 911. Brayan was taken to a nearby hospital. Prieto and her daughter both told the police they did not see how the accident happened. There were no other eyewitnesses, and though the officer only spoke to Prieto and her daughter, he noted in his report the "bicyclist pulled into the roadway [and] was stuck on the left side and fell to the ground. The passenger side front tire drove over the child['s] right front leg." Brayan gave a number of statements, the most detailed of which related his right shoelace got stuck in the spokes of his bicycle and his right leg was run over when he leaned over to untangle the lace. Monica Diaz Barriga Figueroa, Brayan's mother, retained counsel, and signed a blank personal injury protection (PIP) application form. The English-speaking legal assistant completed the form for the Spanish-speaking Diaz, pulling language of the accident from the police report. The significant difference between the PIP form and Brayan's testimony became a central issue at trial. Prieto's counsel stressed the differences between Diaz's and Brayan's testimony and the PIP form; Diaz's counsel stress the PIP form was based on accounts from people who did not see the accident. At trial, and over Diaz's counsel's objection, Prieto's counsel referenced the PIP form as a statement against interest. Diaz's counsel moved to exclude the PIP form as privileged. The issue before the Washington Supreme Court was whether the form could be considered work product entitled to protection from disclosure. The Court determined that in this instance, where the insured gained the status of insured by statute, rather than contract, the form at issue was privileged. The Court affirmed the Court of Appeals and remanded this matter back to the trial court for a new trial. View "Figueroa v. Mariscal" on Justia Law

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Christopher Floeting alleged a Group Health Cooperative employee repeatedly sexually harassed him while he was seeking medical treatment. He sued Group Health for the unwelcome and offensive sexual conduct under the Washington Law Against Discrimination, which made it unlawful for any person or the person's agency or employee to commit an act of discrimination in any place of public accommodation. The trial court dismissed on summary judgment, pursuant to Group Health's argument the employment discrimination standard applied. The Court of Appeals reversed. Group Health argued the Washington Supreme Court should import workplace sexual harassment doctrines into the public accommodations context, thereby limiting its employer liability. Declining to do so, the Supreme Court affirmed the appellate court. View "Floeting v. Grp. Health Coop." on Justia Law

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At issue in this case was whether full faith and credit required Washington courts to enforce an Illinois class action judgment by dismissing subsequent local cases based on the same facts. An Illinois medical provider brought a nationwide consumer protection class action against Liberty Mutual Insurance Company in Illinois. The suit was settled and approved by an Illinois trial court. Chan Healthcare group, a Washington provider, received reasonable notice of the suit, but neither opted out of the class nor objected to the settlement. Chan sought to collaterally challenge the Illinois judgment in Washington courts, arguing the interests of Washington class members were not adequately represented in Illinois. The Washington Supreme Court concluded Chan failed to show its due process rights were violated, thus full faith and credit required Washington courts to enforce the Illinois judgment. View "Chan Healthcare Grp. v. Liberty Mut. Fire Ins. Co." on Justia Law

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The United States District Court for the Western District of Washington certified a question of Washington law to the Washington Supreme Court. This case concerned a class action insurance claim suit pending in federal court. Plaintiff Brett Durant was a State Farm Mutual Automobile Insurance Company insured, and carried a $35,000 personal injury protection (PIP) rider. In 2012, Durant was injured in a motor vehicle accident; he opened a PIP claim with State Farm. The "coverage letter" advised Durant that "Medical services must also be essential in achieving maximum medical improvement for the injury you sustained in the accident." Durant sought treatment with chiropractor Harold Rasmussen, DC, who diagnosed injuries including sprains to the neck, back, pelvis, and right shoulder. After a shoulder MRI showed a ligament sprain and "a possible small type I SLAP [(superior labral anteroposterior)] tear,"Durant was referred to an orthopedic surgeon who diagnosed"mild bursitis/tendinitis,"which was treated with physical therapy and cortisone injections. Durant's injuries were not resolved by a date set by his physicians; his providers billed his PIP claims, but State Farm denied them on grounds that Durant had "previously reached maximum medical improvement." The federal district court asked the Washington Supreme Court (1) whether an insurer violates WAC 284-30-395(1)(a) or (b) if that insurer denied or terminated an insured's medical benefits based on a finding of "maximum medical improvement;" and (2) whether the term "maximum medical improvement" was consistent with the definition of "reasonable" or "necessary" as those terms appeared in WAC 284-30-395(1). The Washington Court answered the first certified question "yes." With regard to the second question, the Court found that under the circumstances of this case, the term "maximum medical improvement" was not consistent with the terms "reasonable" or "necessary" as those terms appeared in WAC 284-30-395(1). View "Durant v. State Farm Mut. Auto. Ins. Co." on Justia Law