Justia Insurance Law Opinion Summaries

Defendant Russell Blodgett appealed a superior court order granting summary judgment in favor of plaintiff Cincinnati Specialty Underwriters Insurance Company (CSU). Blodgett argued the trial court erred by concluding that the terms of a commercial general liability policy issued by CSU clearly and unambiguously excluded coverage for Blodgett’s damages in a separate personal injury action against CSU’s insured resulting from Blodgett’s fall from an alleged negligently constructed staircase. The New Hampshire Supreme Court concluded that, pursuant to the policy’s clear and unambiguous language, CSU had no duty or obligation to defend or indemnify its insured in the underlying litigation. View "Cincinnati Specialty Underwriters Insurance Company v. Best Way Homes, Inc. & a." on Justia Law

Hospitals provided emergency medical services to members of the county’s health plan, which is licensed and regulated by the state Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act, Health & Saf. Code 1340. The county reimbursed the Hospitals for $28,500 of a claimed $144,000. The Hospitals sued, alleging breach of an implied-in-fact or implied-in-law contract. The trial court rejected the county’s argument that it is immune from the Hospitals’ suit under the Government Claims Act (Gov. Code 810).The court of appeal reversed. The county is immune from common law claims under the Government Claims Act and the Hospitals did not state a claim for breach of an implied-in-fact contract. The county does not contest its obligation to reimburse the Hospitals for the reasonable and customary value of the services; the issue is what remedies may be pursued against the county when the reasonableness of the reimbursement is disputed. The Knox-Keene Act provides alternative mechanisms to challenge the amount of emergency medical services reimbursements. A health care service plan has greater remedies against a private health care service plan than it does against a public entity health care service plan, a result driven by the Legislature broadly immunizing public entities from common law claims and electing not to abrogate that immunity in this context. View "County of Santa Clara v. Superior Court" on Justia Law

Appellant Dameron Hospital Association (Dameron) required patients or their family members sign Conditions of Admissions (COAs) when Dameron provides the patients’ medical care. The COAs at issue here contained language assigning to Dameron direct payment of uninsured and underinsured motorist (UM) benefits and medical payment (MP) benefits that would otherwise be payable to those patients under their automobile insurance policies. Dameron treated five of AAA Northern California, Nevada & Utah Insurance Exchange’s (CSAA) insureds for injuries following automobile accidents. Those patients had UM and/or MP coverage as part of their CSAA coverage, and Dameron sought to collect payment for those services from the patients’ UM and/or MP benefits at Dameron’s full rates. Instead of paying to Dameron the lesser of either all benefits due to the patients under their UM and MP coverage, or Dameron’s full charges, CSAA paid portions of those benefits directly to the patients which left balances owing on some of Dameron’s bills. Dameron sued CSAA to collect UM and MP benefits it contended CSAA owed Dameron under the assignments contained in the COAs. The trial court concluded that Dameron could not enforce any of the assignments contained in the COAs and entered summary judgment in CSAA’s favor. After its review, the Court of Appeal held Dameron could not collect payment for emergency services from the UM or MP benefits due to patients that were covered under health insurance policies. Additionally, the Court found: (1) the COA forms were contracts of adhesion; (2) it was not within the reasonable possible expectations of patients that a hospital would collect payments for emergency care directly out of their UM benefits; and (3) a trier of fact might find it is within the reasonable expectations of patients that a hospital would collect payments for emergency care directly out of their MP benefits. Accordingly, the Court concluded Dameron could not maintain causes of action to collect MP or UM benefits due to four of the five patients directly from CSAA. However, consistent with its opinion, the trial court could consider whether an enforceable assignment of MP benefits was made by one adult patient. View "Dameron Hospital Assn. v. AAA Northern Cal., Nevada etc." on Justia Law

The Supreme Court vacated the order of the circuit court entering summary judgment in favor of Alexis Still in this dispute over whether there was a settlement agreement between the parties, holding that there was no settlement agreement between the parties.Clifton Jameson and Still were involved in an automobile accident. Jameson sent MetLife, Still's insurer, an offer to settle. MetLife made a counteroffer. Jameson took the counteroffer as a rejection of his offer to settle and sued Still for damages arising from the accident. MetLife then attempted to accept Jameson's original settlement offer. The circuit court granted summary judgment for Still, concluding that MetLife's counteroffer did not terminate the settlement offer and that its subsequent letter of acceptance created a settlement agreement between the two parties. The Supreme Court vacated the judgment, holding that that the circuit court erred in granting summary judgment on the basis of settlement because no settlement agreement was reached. View "Jameson v. Still" on Justia Law

In this insurance dispute, the Supreme Court affirmed the orders of the circuit court granting partial summary judgment to Insured, denying summary judgment to Insurer, and awarding Insured her attorney's fees, holding that there was no error.At issue in this case was the "medical payments coverage" provision in Insured's automobile insurance contract that required that Insurer reimburse Insured for any medical expenses she "incurred" in an accident. The circuit court concluded that the contract obligated Insurer to reimburse Insured the full amount of Insured's medical bill she received after an automobile accident and further concluded that Insurer was required to reimburse Insured for her attorney's fees. The Supreme Court affirmed, holding (1) there was no error in the circuit court's interpretation of the medical payments provision in the insurance contract; and (2) there was no error in the circuit court's rulings on costs and attorney's fees. View "Auto Club Property Casualty Insurance Co. v. Moser" on Justia Law

The Indian Health Service (IHS), operates direct healthcare facilities and funds Contract Health Services (CHS) programs for persons of American Indian descent, 25 U.S.C. 1603(5), (12). Under 25 U.S.C. 5301, tribes may manage and staff their own IHS facilities, contract with private insurers for tribal coverage, and operate their own CHS programs. IHS health programs are “the payer of last resort.” Medicare, Medicaid, or private insurance must pay before IHS reimbursement is available. The 2003 Medicare Prescription Drug Improvement Act authorized HHS to demand Medicare pricing from hospitals providing services to tribes through CHS programs, 42 U.S.C. 1395cc. The Tribe, which administers a CHS program, contracted with BCBSM for healthcare coverage. The Sixth Circuit previously reversed the dismissal of the Tribe’s lawsuit based on BCBSM’s alleged failure to insist on “Medicare-like rates” for care authorized by the Tribe’s CHS program and provided by Medicare-participating hospitals. On remand, the district court granted BCBSM summary judgment, concluding that the Tribe’s payments for CHS care through BCBSM's plans were not eligible for Medicare-like rates. The district court interpreted federal regulations as limiting the requirement of Medicare-like rates to payments for care that was authorized by CHS, provided by Medicare-participating hospitals, and directly paid for with CHS funds. The Sixth Circuit reversed. On remand, the district court must first address whether the Tribe’s CHS program authorized the care for which they assert they were entitled to Medicare-like rates. If the CHS program authorized this care, the court should then consider BCBSM’s alternative arguments. View "Saginaw Chippewa Indian Tribe of Michigan v. Blue Cross Blue Shield of Michigan" on Justia Law

United Talent Agency (UTA) purchased business insurance policies through two insurance companies. UTA filed suit against both companies after they denied property insurance coverage for economic losses related to the COVID-19 pandemic. The trial court sustained the insurers' demurrer claiming UTA failed to state facts sufficient to constitute a viable cause of action.The Second Appellate District affirmed, rejecting both of UTA's arguments on appeal. First, UTA claimed that the danger posed by the COVID-19 gave rise to the closure orders and other restrictions, which, in turn, caused UTA to suffer physical loss because these restrictions limited the company's use of and operations at its insured locations. The court explained that temporary loss of use of a property due to pandemic-related closure orders, does not alone constitute direct physical loss or damage.Second, UTA claims that the physical presence of COVID-19 virus constitutes physical damage. The court held that the mere presence of a virus or other contaminant, without evidence of required remediation, does not rise to the level of physical loss or damage. Thus, the court affirmed the trial court's order sustaining the insurance companies' demurrer. View "United Talent Agency v. Vigilant Insurance Co." on Justia Law

Plaintiffs’ sought coverage for losses and expenses during the COVID-19 pandemic. The district court granted the insurers’ motion to dismiss.   The Eighth Circuit affirmed the district court’s ruling granting Defendant summary judgment. The court held that the primary rule for contract interpretation is to ascertain and effectuate the parties' intent. In cases where the insurance policy language is unambiguous, the court will enforce the contract as written and will give each term its ordinary meaning. Here, the contract at issue provides coverage for “direct physical loss of or damage to property.” Neither business alleges COVID-19 was physically present on its premises or that anything physical happened to its properties. The parties’ dispute regarding whether the policies’ Virus Exclusion applies is irrelevant because the Plaintiffs’ failed to show any direct physical loss of or damage to their property. View "Monday Restaurants v. Intrepid Insurance Company" on Justia Law

In this insurance coverage dispute, Plaintiff, an insured company, sought to sidestep its insurer by collecting a $22 million claim from ten insurance brokers and reinsurers. The district court dismissed Plaintiff’s claims for breach of contract and declaratory judgment.   The D.C. Circuit affirmed the district court’s dismissal. The court held that Plaintiff failed to plead facts to establish a contractual relationship with reinsurers. Plaintiff’s evidence of the reinsurance binders did not create a contractual relationship between Plaintiff and reinsurers. Further, the court held that summary judgment for reinsurers was proper; finding that Plaintiff’s claims of implied contract, promissory estoppel, and unjust enrichment are wholly unsupported by record evidence. The court further held that the “economic loss doctrine” bars Plaintiff’s claims against the other defendants. The economic loss doctrine prohibits claims of negligence where, as here, a claimant seeks to recover purely economic losses. View "Vantage Commodities Financial Services v. Assured Risk Transfer PCC" on Justia Law

In this wrongful death and survival action brought against an automobile insurer, the Supreme Court reversed the judgment of the court of appeals reversing the trial court's judgment in favor of the insurer as to Plaintiff's negligence and gross negligence claims, holding that the court of appeals erred.An insured motorist was involved in a single car accident. The motorist's husband later arrived and began taking photos, but while he was engaged in that activity on the side of the road, he was struck by another vehicle and killed. Plaintiff, the motorist, brought this action alleging that the insurer had instructed her to take the photos and that her husband was complying with that instruction when the other driver hit him. Thus, Plaintiff argued, the insurer proximately caused her husband's death. The trial court granted summary judgment for the insurer on the negligence and gross negligence claims. The court of appeals reversed. The Supreme Court reversed, holding that Defendant did not have a duty to exercise reasonable care in providing post-accident guidance so as not to increase the risk of harm to its insured. View "Elephant Insurance Co., LLC v. Kenyon" on Justia Law