Justia Insurance Law Opinion Summaries

The Supreme Court affirmed the judgment of the superior court entered in favor of Plaintiff that granted Plaintiff's motion for additur, holding that there was no error.In 2013, Plaintiff was involved in an automobile accident. Because she believed she was not fully compensated for the injuries she sustained from the accident, Plaintiff brought this complaint against Allstate Insurance Company, her insurer, seeking underinsured motorist benefits. The jury reached a verdict in favor of Plaintiff, awarding damages in the amount of $22,890. Plaintiff filed a motion for an additur, which the trial justice granted in the amount of $6,000. The Supreme Court affirmed, holding that the trial justice did not abuse his discretion in granting an additur of $6,000. View "Mowry v. Allstate Insurance Co." on Justia Law

Plaintiff filed suit against the insurers, seeking to represent a nationwide class of people whose trips were cancelled because of COVID-19 stay-at-home orders and who were not paid by these insurers. The Eighth Circuit affirmed the district court's dismissal of plaintiff's claims under Federal Rule of Civil Procedure 12(b)(6). The court concluded that plaintiff's flight cancellation caused by the government's stay-at-home orders fell under his travel insurance policies' epidemic exclusion. In this case, an ordinary person of average understanding reading the policy terms here would deduce that WHO "recognized" COVID-19 as either a pandemic or an epidemic by including COVID-19 on its list of pandemic or epidemic diseases. Furthermore, plaintiff's flight cancellation resulted from the COVID-19 epidemic and the epidemic affected plaintiff. View "Bauer v. AGA Service Co." on Justia Law

The Supreme Court affirmed the judgment of the trial court granting Insured's application to compel appraisal with regard to a dispute as to the extent of Insurer's replacement obligation under Con. Gen. Stat. 38a-316e(a) (matching statute), holding that there was no error.At issue was whether a dispute as to the extent of an insurer's obligation under the matching statute to replace items or items in a covered loss for real property with "material of like kind and quality so as to conform to a reasonably uniform appearance" was a question properly relegated to the appraisal arbitral process or a question of coverage to be resolved by the court in the first instance. The trial court granted Insured's application to compel arbitration in this case. The Supreme Court affirmed, holding that the parties' dispute fell within the scope of the insurance policy's appraisal clause. View "Klass v. Liberty Mutual Insurance Co." on Justia Law

The Court of Appeals held that only the amount that a workers' compensation insurer actually pays for medical expenses is part of the statutory offset against underinsured motorist benefits.Michael Gilliam was injured in an automobile accident during the course of his employment and received payments from his employer's workers' compensation insurer and the other driver's liability insurer. Gilliam later sought to recover the amounts by which the other driver was underinsured from an insurance policy covering the vehicle he was driving. As required by Maryland law, the healthcare providers who treated Gilliam had generated bills in amounts greater than the amounts set by the Workers' Compensation Commission but accepted payments at those lower amounts in full satisfaction for their services. At issue was whether the difference between the bills' amounts and the workers' compensation insurer's payments constituted a "benefit" that Gilliam had "recovered" under the Workers' Compensation Act that was to be offset against any recovery Gilliam would obtain from the underinsured motorist coverage of the auto policy. The Supreme Court held that a difference between a higher face amount billed by a healthcare provider and the amount actually paid by the workers' compensation insurer was not part of that offset. View "Westfield Insurance Co. v. Gilliam" on Justia Law

Couch falsely represented that he was not HIV positive. Jackson issued Couch a $500,000 life insurance policy. At the time, HIV-positive individuals had a greatly diminished life expectancy, resulting in high demand for HIV-positive insureds willing to engage in viatical settlements. Couch worked with a brokerage, which, months later, found a purchaser, Crum. The premiums were paid through the broker's premium reserve fund until after the two-year contestability period policy expired. Crum paid the premium for eight more years, letting the policy lapse in 2009. In 2016, Crum learned that Couch had died in 2005 and made a claim.Jackson sought a declaration that, under Georgia law, the policy was void as an illegal human life wagering contract. The district court found that Couch took out the policy with the intent to sell it to one without an insurable interest and that the policy was unenforceable as an illegal human life wagering contract under Georgia law. Crum argued that an illegal human life wagering contract involves the knowing, direct involvement of an identified third-party beneficiary at the time of its procurement. The Eleventh Circuit certified, to the Georgia Supreme Court, the question: whether a life insurance policy is void if it is procured by an individual on his own life for the sole purpose of selling the policy to a third party without an insurable interest in the insured, but without the complicity of the ultimate purchaser at the time of procurement. View "Jackson National Life Insurance Co. v. Crum" on Justia Law

Landmark issued a “deductible buyback” insurance policy, covering SCD properties. SCD’s high-deductible primary insurance policy was issued by Lexington. The Landmark policy covers damage also covered by Lexington and states: “Perils Covered: Windstorm or Hail associated with a Named Storm,” following the Lexington policy's Named Storm definition: “a storm that has been declared by the National Weather Service to be a Hurricane, Typhoon, Tropical Cyclone, Tropical Storm, or Tropical Depression.” In August 2017, Hurricane Harvey, a “Named Storm,” under the Lexington and Landmark policies, caused tremendous flooding damage to one of SCD’s insured properties. There was no reported wind damage to the property nor evidence that the property suffered damage from hail. The Lexington policy paid out millions of dollars for loss in excess of the “Windstorm deductible” in that policy,Landmark sought a declaration that SCD’s policy did not apply to the loss sustained. The Fifth Circuit reversed a judgment in favor of SCD and rendered judgment for Landmark. If SCD’s interpretation of the policy were correct, then the Landmark policy simply could have stated that all damage from a Named Storm is covered (regardless of the peril that caused the damage). The policy does not state that but frames its coverage as applying to specific “[c]overed perils.” View "Landmark American Insurance Co. v. SCD Memorial Place II, L.L.C." on Justia Law

Alissa's Flowers filed suit against State Farm, alleging that it had overpaid its premiums to State Farm in light of its significantly lower exposure rate due to COVID-19. State Farm moved to dismiss the amended complaint, arguing that Missouri law required that Alissa's Flowers bring its claims before the director of the Missouri Department of Insurance.The Eighth Circuit affirmed the district court's dismissal of the complaint, concluding that the administrative review process set forth in Mo. Rev. Stat. 379.348 applies in the commercial insurance context and to plaintiff's claims in this case. The court explained that the district court properly determined that Alissa's Flowers was required to exhaust administrative remedies because the claims, in essence, constitute a challenge to State Farm's rates, rating plan, rating system and underwriting rules. Finally, the complaint should not have been dismissed for lack of subject matter jurisdiction, but rather for lack of authority to grant relief. View "Alissa's Flowers, Inc. v. State Farm Fire & Casualty Co." on Justia Law

Appellant Dameron Hospital Association (Dameron) required patients or their family members to sign Conditions of Admissions (COAs) when Dameron provided the patients’ medical care. The COAs at issue in this case contained language that assigned 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 California State Automobile Association Inter-Insurance Bureau'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 judgment in CSAA’s favor following CSAA’s successful motion for summary judgment. 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. Further, the Court held: (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 was 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 this 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. etc." on Justia Law

The issue this case presented for the New Jersey Supreme Court's review in this appeal was who bore the primary responsibility for the payment of Dale Mecouch’s medical bills arising from an automobile accident that took place before December 5, 1980: the issuer of an automobile insurance policy or Medicare. In 2016, Mecouch was hospitalized for approximately two months at Cooper Hospital University Medical Center (Cooper) due to complications arising from a 1977 automobile accident that left him paralyzed from the waist down. At the time of his accident, Mecouch had a no-fault automobile insurance policy with Selective Insurance Company of America (Selective), which provided Mecouch with unlimited personal-injury-protection (PIP) benefits. Sometime after 1979 but before 2016, Mecouch was enrolled in Medicare. Selective continued to pay Mecouch’s medical expenses related to the 1977 accident until December 11, 2015, when it notified Mecouch by letter that, going forward, “Medicare is the appropriate primary payer for any treatment related to” the 1977 accident. After Mecouch’s 2016 hospital stay, Cooper forwarded to Selective a bill for over $850,000 for medical services rendered to Mecouch. Instead of paying that bill, Selective directed Cooper to seek reimbursement from Medicare. Cooper was a participating Medicare provider, and, at that time, Mecouch was a Medicare enrollee. Cooper then billed Medicare, which issued a payment of under $85,000. Selective eventually agreed to reimburse Cooper for Mecouch’s co-payments and deductibles. Cooper filed a complaint against Selective, seeking the total cost of Mecouch’s care. The trial court granted summary judgment in favor of Cooper, awarding Cooper the cost of Mecouch’s care minus the amount covered by Medicare. The Appellate Division reversed, concluding Medicare was the “primary payer” for Mecouch's medical bills at Cooper. The Supreme Court concluded that because Mecouch was a Medicare enrollee in 2016, Cooper was required to bill and accept payment from Medicare, which promptly covered Mecouch’s medical expenses in accordance with its fee schedule. Cooper could not seek payment from Selective other than for reimbursement of the Medicare co-payments and deductibles. View "Cooper Hospital University Medical Center v. Selective Insurance Company of America" on Justia Law

The Supreme Court affirmed the judgment of the superior court granting Plaintiffs' claims against Joseph and Lynne Miller and also in favor of the third-party defendant, Assurance Company of America, denying Joseph's third-party claim for indemnification, holding that there was no error.Judgment entered in favor of Plaintiffs and against Joseph and Lynne in the amount of $178,891 and in favor of Assurance on Joseph's third-party claim. Joseph and Lynne appealed, raising three allegations of error. The Supreme Court affirmed, holding (1) the first three allegations of error raised on appeal were waived; and (2) the fourth issue was not properly before the Court. View "Boisse v. Miller" on Justia Law