Justia Insurance Law Opinion Summaries

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

Erick Pena filed a declaratory action against Viking Insurance Company of Wisconsin (“Viking”), alleging the automobile insurance policy he purchased was illegal because it provided illusory minimum limits of UIM coverage. Pena then filed a motion for summary judgment asking the court to declare that the UIM coverage was illusory. Viking filed a cross-motion for summary judgment, arguing that the policy was not illusory because it provided tangible benefits to a group of insured persons and that the offset provision in the policy complied with Idaho public policy. The district court granted Viking’s motion for summary judgment. Pena timely appealed. After review, the Idaho Supreme Court reversed, finding the policy at issue indeed provided illusory coverage. View "Pena v. Viking Insurance Company" on Justia Law

The Fifth Circuit affirmed the district court's grant of summary judgment to Atlantic, concluding that the action is precluded on res judicata grounds. The court clarified some doctrinal confusion in its law about Louisiana principles of res judicata that one of its sister circuits has observed. The court concluded that this action arises out of the same nucleus of facts as plaintiff's initial suit, the issue of Atlantic's alleged bad faith misrepresentation of underinsured motorist coverage could have been raised in that initial suit, and plaintiff did not specifically reserve the right to bring this second suit as part of his settlement agreement with Atlantic. While plaintiff is correct that Louisiana's bad faith statutes impose duties on Atlantic that are separate and distinct from its duties under the insurance contract, this action remains barred by res judicata. Finally, this case does not present an exceptional circumstance exception to res judicata. View "Dotson v. Atlantic Specialty Insurance Co." on Justia Law

ATC purchased a commercial general liability insurance policy from Westchester, which provided coverage against liability incurred because of “advertising,” a defined term that included trade dress infringement. BizBox sued ATC for breach of contract and interference with its business expectancies, alleging that ATC manufactured and sold a knock-off trailer using BizBox’s design. ATC sought a declaratory judgment that Westchester owed it a duty to defend and a duty to indemnify. Westchester argued that BizBox’s underlying suit was not covered under the insurance policy because BizBox did not allege, in that litigation, an infringement of its trade dress in ATC’s advertising.The Seventh Circuit affirmed the dismissal of the suit. BizBox’s complaint never alleged a trade dress infringement claim against ATC nor an advertising injury and could not be construed to plausibly allege a trade dress infringement claim against ATC. BizBox alleged no facts that can plausibly be construed to show that it asserted that an advertising injury occurred. Westchester, therefore, has no duty to defend or indemnify ATC under the “personal and advertising injury” provision of the Policy. View "Aluminum Trailer Co. v. Westchester Fire Insurance Co" on Justia Law

The First Circuit affirmed the decision of the district court granting Defendant's motion to dismiss as to count one of Plaintiffs' complaint and reversed the dismissal and remanded for further proceedings on counts two through four, holding that dismissal was improper as to the remaining three counts.Plaintiffs, S.R. and T.R. and their child N.R., brought this action against Raytheon Company, T.R.'s employer, after United Healthcare, which administered the company's health insurance plan, refused to pay for N.R.'s speech therapy, alleging various violations of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001, et seq. The district court granted Defendant's motion to dismiss in full. The First Circuit held (1) the district court properly dismissed count one of the complaint; but (2) the dismissal of Plaintiffs' remaining claims was improper. View "N.R. v. Raytheon Co." on Justia Law

Plaintiffs Calvin and Mary Landry filed a petition for damages, alleging they suffered injuries arising out of an automobile collision. Plaintiffs brought the action against defendant-driver Riyad Shaibi, his insurer Financial Indemnity Company (“Financial”), and Progressive Security Insurance Company (“Progressive”), as the insurer of the 2008 Toyota Sienna that Shaibi was driving at the time of the collision. Shaibi was bringing the 2008 Toyota Sienna to a tire shop to repair a flat tire as a favor to its owner, Aziz Ali. The Louisiana Supreme Court granted review of this matter to address whether the court of appeal erred in finding public policy mandated liability coverage by a defendant driver’s automobile insurance policy for an accident occurring while operating a non-owned automobile. Under the narrow facts presented, the Court found neither statutory law nor public policy considerations required automobile insurance liability coverage related to a defendant driver’s negligent operation of a non-owned vehicle. Accordingly, the Court reversed the court of appeal and reinstated the ruling of the district court granting summary judgment in favor of the defendant insurer. View "Landry v. Progressive Security Ins. Co., et al." on Justia Law