Justia Insurance Law Opinion Summaries

To combat the spread of COVID-19, the Ohio government ordered child-care programs to shut down for around two months beginning in March 2020. As a result, Dakota Girls and the other plaintiffs could not use their facilities for their intended purpose—as private preschools. They sued their insurer, the Philadelphia Indemnity, citing policy provisions concerning business and personal property, business income, civil-authority orders, and (communicable disease and water-borne pathogens. The suit sought damages for breach of contract and the insurer’s alleged bad faith.The Sixth Circuit affirmed the dismissal of the suit, citing the plain language of the policies. A loss of use is not the same as a physical loss. Reading the communicable-disease coverage to not require an actual illness at the premises, therefore, would engender serious inconsistency within the policy. The court declined to consider the policy’s “virus exception.” Dakota Girls has never shown that it had coverage, much less that Philadelphia’s agents knew it had coverage or that coverage was so obvious it could not have been reasonably denied. View "Dakota Girls, LLC v. Philadelphia Indemnity Insurance Co." on Justia Law

A hospital must provide “necessary stabilizing treatment” for any person in an “emergency medical condition,” 42 U.S.C. 1395dd(b), Health & Saf. Code 1317(a). California’s Knox-Keene Act (section 1340) requires that the patient's health insurance plan reimburse the hospital for providing “emergency services and care.” If the hospital and plan do not have an existing contract, the plan must pay the “reasonable and customary value." If a plan without a contract pays reimbursement that the hospital believes is below the “reasonable and customary value,” the hospital may sue the plan in quantum meruit for the shortfall.The court of appeal held that a hospital may not additionally sue for the tort of intentionally paying an amount that is less than what a jury might later determine is the “reasonable and customary value” of the services, and thereby obtain punitive damages, nor may the hospital sue for injunctive relief under California’s unfair competition law to enjoin the plan from paying too little in possible future claims. In the quantum meruit claim, a trial court properly instructs the jury that the “reasonable value” of emergency medical services is “the price that a hypothetical willing buyer would pay a hypothetical willing seller for the services, [when] neither [is] under compulsion to buy or sell, and both hav[e] full knowledge of all pertinent facts.” Rejecting challenges to several evidentiary rulings, the court affirmed the jury’s verdict finding that the plan paid the suing hospital the reasonable and customary value of its emergency medical services. View "Long Beach Memorial Medical Center v. Kaiser Foundation Health Plan, Inc." on Justia Law

Letgolts and Plattner (plaintiffs) remodeled their home in 2008. The contractor, Pinchevskiy, did some demolition and then walked away, causing extensive damage to the home. The plaintiffs retained attorney Marks, who sued Pinchevskiy, the plaintiffs’ home insurer, and their insurance agent who allegedly inaccurately advised the plaintiffs that their existing homeowners' policy would cover possible property damage by Pinchevskiy. The complaint detailed property damage but did not mention personal injury. Marks withdrew from the case in 2012. The plaintiffs retained Pierce, who secured a default judgment against Pinchevskiy in 2015; his insurer, National, filed for liquidation before Pierce could collect on the judgment. Pinchevskiy was bankrupt.The plaintiffs sued Pierce for negligent delay in seeking recovery from National. Pierce’s lawyers argued the plaintiffs could never have prevailed against National because Pinchevskiy’s policy did not cover construction defects. The court entered judgment for Pierce. The court of appeal affirmed, rejecting the plaintiffs’ attempt to assert a personal injury claim based on Plattner’s alleged 2008 fall from temporary stairs installed by Pinchevskiy. National’s policy did cover personal injuries but the tardy, uncorroborated claim was at odds with the detailed lists of problems given to the insurer years before. Pursuing insurance money from National was a lost cause from the start, so whether Pierce committed malpractice did not matter, View "Letgolts v. David H. Pierce & Associates PC" on Justia Law

The United States and four states sued DISH Network, LLC (“DISH”) for violations of the Telephone Consumer Protection Act (“TCPA”). DISH submitted a claim for defense and indemnity to its insurer, National Union Fire Insurance Company of Pittsburgh, Pennsylvania (“National Union”). National Union denied the claim and filed suit in Colorado federal court seeking a declaration that it had no duty to defend or indemnify DISH in the underlying TCPA lawsuit. The district court granted summary judgment to National Union, relying on the Tenth Circuit's decision in ACE American Insurance Co. v. DISH Network, LLC, 883 F.3d 881 (10th Cir. 2018). Finding no reversible error, the Tenth Circuit affirmed the district court's judgment. Further, the Court affirmed the district court’s denial of DISH’s request for further discovery under Federal Rule of Civil Procedure 56(d). And we deny DISH’s motion to certify a question of state law to the Colorado Supreme Court. View "National Union Fire Insurance v. Dish Network" on Justia Law

The Supreme Judicial Court affirmed the superior court's summary judgment entered in favor of Metropolitan Property and Casualty Insurance Company as to Progressive Northwest Insurance Company's complaint seeking indemnification for a portion of a final settlement paid involving a mutually-insured party, Vincent Micale, holding that there was no error.Micale rented two jet skis from Jet Ski Guys, Inc. (JSG). Two individuals listed on Micale's rental agreement collided while operating the jet skis, resulting in injuries to one individual. At the time of the accident, Progressive provided a boat and personal watercraft liability insurance policy to Micale, and Metropolitan provided homeowner insurance to Micale. JSG filed a complaint alleging that Micale and others were negligent in the operation of the jet skis. The injured individual filed a cross-claim against Micale. In a settlement, Progressive agreed to pay $300,000 to the injured individual on Micale's behalf. Progressive then sued Metropolitan, arguing that Metropolitan had a duty to indemnify Micale for half the amount that Progressive had paid to the injured individual. The court entered judgment in Metropolitan's favor. The Supreme Judicial Court affirmed, holding that the plain meaning of Metropolitan's policy did not provide coverage for injuries arising out of the use of the watercraft involved in the accident. View "Progressive Northwest Insurance Co. v. Metropolitan Property & Casualty Insurance Co." on Justia Law

This appeal arose from an application by State Farm General Insurance Company (SFG) to increase its homeowners’ insurance rates, under the prior approval system implemented by Proposition 103. Nonprofit Consumer Watchdog (CW) intervened in the proceeding, and challenged SFG’s proposed rates. The Commissioner relied on regulation section 2644.20, addressing projected yield, to use the combined annual statement of SFG’s parent company, State Farm Mutual Automobile Insurance Company (State Farm Mutual) and its property-casualty affiliates. The Commissioner ordered SFG to decrease its rate retroactively and issue refunds (Rate Order). SFG filed a petition for writ of mandate. The superior court determined Insurance Code section 1861.05(a) required the rate to mathematically reflect the applicant insurer’s income, and the Commissioner’s interpretation and application of regulation Insurance Code section 2644.20 to use the income of SFG’s affiliates conflicted with the statute. The court entered judgment for SFG, issued a peremptory writ of mandate requiring the Rate Order be set aside, and remanded remaining issues to the Commissioner, including the propriety of the retroactive rate and refund. The Commissioner and CW (Appellants) appealed the judgment and writ of mandate, contending the Commissioner properly interpreted the statute and regulation and had authority to set an earlier effective date and require refunds. SFG cross-appealed the order directing remand to the Commissioner, which it argued was unnecessary in light of the impropriety of the retroactive rate and refund as well as a subsequent rate change for SFG. The Court of Appeal concluded the superior court correctly determined section 1861.05(a) required use of the applicant insurer’s income, and the Commissioner erred in interpreting and applying Regulation 2644.20 here. Furthermore, the Court concluded the retroactive rate and refund were impermissible, and remand was not warranted under the circumstances. The superior court was directed to modify the writ of mandate to require the Rate Order be vacated in its entirety, and affirmed the judgment and writ of mandate in all other respects. View "State Farm General Insurance Company v. Lara" on Justia Law

State Farm General Insurance Company (SFG) appealed an order awarding attorney fees to intervenor Consumer Watchdog (CW), in a dispute over documents SFG designated as confidential in a rate hearing under Proposition 103. After the administrative law judge (ALJ) denied SFG’s motion to seal, SFG sought writ relief from the superior court, which CW and the Insurance Commissioner successfully opposed. CW then moved for fees under section 1861.10, which provided for reasonable advocacy fees to a consumer representative that makes a substantial contribution to the adoption of an order. The court awarded CW’s requested fees, and SFG appealed, contending the fee motion was untimely, and the fee award was inconsistent with the statutory requirements and an abuse of discretion. Rejecting these arguments, the Court of Appeal affirmed. View "State Farm General Insurance Company v. Lara" on Justia Law

The Fifth Circuit affirmed the district court's issuance of a declaratory judgment that an automobile driver's death was not covered by the terms of the defendant insurance company's policy. In this case, as the driver was driving his personal vehicle to a logging site owned by V & B, he collided with a sawmill's metal gate that had swung out across the road. The driver sustained multiple traumatic injuries and died at the scene. The court agreed with the district court's well-reasoned and thorough order on summary judgment concluding that the policy unambiguously excludes coverage for any injury arising from an automobile accident, regardless of the car's ownership. View "Colony Insurance Co. v. Wright" on Justia Law

The Supreme Court reversed the decision of the circuit court granting judgment as a matter of law in favor of Mutual Benefit Group and against Eric Parks in this action brought by Mutual Benefit as a result of an automobile accident, holding that the circuit court erred.Mutual Benefit brought this action to recover monies it paid in another action stemming from an automobile accident involving Parks. The magistrate court found in favor of Mutual Benefit. After a trial de novo, the circuit court granted judgment as a matter of law to Mutual Benefit on the grounds that Parks had failed to respond to requests for admissions that Mutual Benefit had served upon him in the magistrate court. The Supreme Court reversed and remanded the case for further proceedings, holding that the West Virginia Rules of Civil Procedure for Magistrate Courts provide the exclusive means of discovery in magistrate courts and do not provide for parties to serve requests for admission. View "Parks v. Mutual Benefit Group" on Justia Law

In 1993, the County and the Orange County Employee Retirement System (OCERS) entered into a Memorandum of Understanding (MOU), allowing the County to access surplus investment earnings controlled by OCERS and depositing a portion of the surplus into an account to pay for county retirees' health insurance. The county adopted the Retiree Medical Plan, funded by those investment earnings and mandatory employee deductions. The Plan explicitly provided that it did not create any vested rights. The labor unions then entered into MOUs, requiring the county to administer the Plan and that retirees receive a Medical Insurance Grant. In 1993-2007, retired employees received a monthly grant benefit to defray the cost of health insurance. In 2004, the county negotiated with its unions to restructure the underfunded program, reducing benefits for retirees.Plaintiffs filed suit. The Ninth Circuit affirmed summary judgment in favor of the county. The 1993 Plan explicitly provided that it did not create any vested right to benefits. The Plan was adopted by resolution and became law with respect to Grant Benefits, part of the MOUs. The MOUs expired on their own terms by a specific date. Absent express language providing that the Grant Benefits vested, the right to the benefits expired when the MOUs expired. The Plan was not unilaterally imposed on the unions and their employees without collective bargaining; the unions executed MOUs adopting the Plan. The court rejected an assertion that the Grant Benefit was deferred compensation and vested upon retirement, similar to pension benefits. View "Harris v. County of Orange" on Justia Law