Justia Insurance Law Opinion Summaries

Plaintiff appealed a judgment in favor of Farmers Insurance Exchange and Truck Insurance Exchange after the trial court determined that she was entitled to coverage under the Farmers policy as an heir of an insured under Insurance Code section 11580.2, subdivision (a)(1), but was not entitled to coverage under the Truck umbrella policy.The Court of Appeal affirmed the trial court's judgment and held that it properly ruled that plaintiff was not entitled to the uninsured motorist coverage under the Truck umbrella policy, because section 11580.2, subdivision (a)(1) did not modify the language of the Truck uninsured motorist endorsement and the endorsement governed who would be paid by Truck. The court also held that the trial court properly denied leave to file a second amended complaint; plaintiff was not entitled to coverage by estoppel; and the complaint failed to allege facts sufficient to justify reformation. View "Komorsky v. Farmers Insurance Exchange" on Justia Law

Lou Hodges submitted a claim for long-term-disability (LTD) benefits to Life Insurance Company of North America (LINA) through his employer’s group-insurance plan. Although LINA approved his claim, Hodges contended LINA should have classified him as a “sales” employee under the policy, which would have entitled him to more benefits. This led Hodges to sue LINA. The district court remanded for further factfinding, but LINA once again reached the same result. The district court then reversed LINA’s decision, concluding that Hodges qualified as a salesperson under the policy. LINA appealed, but finding no reversible error, the Tenth Circuit affirmed that ruling. View "Hodges v. Life Insurance Co." on Justia Law

The Second Circuit affirmed the district court's dismissal of plaintiffs' amended complaint under Federal Rule of Civil Procedure 12(b)(6). This appeal arose from a multitude of lawsuits filed by Connecticut homeowners whose basements walls were likely constructed with defective concrete manufactured by the now‐defunct J.J. Mottes Company.The court held that the "collapse" provision in the Allstate homeowner's insurance policy in this case did not afford coverage for basement walls that exhibit signs of deterioration but that have not collapsed suddenly, accidentally, and entirely, as required by the policy. Therefore, the horizontal and vertical cracking in plaintiffs' basement walls did not constitute a covered "collapse" under the policy and Allstate did not breach its contract by denying coverage for plaintiffs' claim. View "Valls v. Allstate Insurance Co." on Justia Law

After its workers’ compensation insurance premiums rapidly increased, Jackpot believed that Applied Underwriters had mishandled its claims and had wrongfully failed to disclose how it calculated premiums. Jackpot filed suit. Applied sought to compel arbitration based on the arbitration agreement contained in a Request to Bind. Jackpot argued that the arbitration agreement was invalid. Applied contended that, under the Federal Arbitration Act, only the arbitrator could decide the threshold question of whether the arbitration agreement was enforceable. The trial court held that the arbitration agreement was invalid. The court of appeal affirmed. In light of Jackson’s specific arguments that the arbitration provision was unenforceable due to fraud, ambiguity, and unconscionability, the trial court was obligated to consider its validity. Allied violated California law in issuing the Request to Bind without first submitting it for regulatory approval. The policy does not provide for arbitration but allows for administrative review by the Insurance Commissioner for certain disputes and otherwise leaves Jackpot’s rights to judicial review intact. The Request to Bind’s arbitration agreement, which compels arbitration in Nebraska for a wide array of disputes, materially changes the policy's dispute-resolution terms and constituted “a collateral agreement that should have been filed and endorsed to the Policy” under Insurance Code section 11658. View "Jackpot Harvesting, Inc. v. Applied Underwriters, Inc." on Justia Law

John Teets, a participant in an employer retirement plan, invested money in Great-West Life Annuity and Insurance Company’s investment fund which guaranteed investors would never lose their principal or the interest they accrued. The investment fund was offered to employers as an investment option for their employees’ retirement savings plans, which were governed by the Employee Retirement Income Security Act (“ERISA”). Teets later sued Great-West under ERISA, alleging Great-West breached a fiduciary duty to participants in the fund or that Great-West was a nonfiduciary party in interest that benefitted from prohibited transactions with his plan’s assets. After certifying a class of 270,000 plan participants like Mr. Teets, the district court granted summary judgment for Great-West, holding that: (1) Great-West was not a fiduciary; and (2) Mr. Teets had not adduced sufficient evidence to impose liability on Great-West as a non-fiduciary party in interest. Finding no reversible error in that judgment, the Tenth Circuit affirmed the district court’s judgment. View "Teets v. Great-West Life" on Justia Law

The Supreme Court accepted a question certified to it by the United States District Court for the District of Montana to address an Estate's third-party claim to stacked liability limits in an aircraft insurance policy that covered multiple aircraft, concluding that the answer to the question, which the Court reformulated, was no.The Supreme Court reformulated the question as follows: "Is the Estate of Darrell L. Ward entitled to stack the limits of liability coverage for three separate aircraft under the terms of an insurance policy issued to the pilot of an aircraft in which Ward was a passenger at the time it crashed?" The Supreme Court answered no to the reformulated certified question because (1) the plain, unambiguous language of the contract limits the coverage to the aircraft that is involved in the accident; (2) there is no public policy or statute that mandates payment of the cumulative coverage for separate aircraft in an aviation liability insurance policy that does not provide for such payment; and (3) the insurance policy at issue was not subject to stacking of its passenger liability coverages. View "U.S. Specialty v. Estate of Ward" on Justia Law

A district court ordered Jackson National Life to pay about $191,000 on a policy of life insurance. The court added that the insurer had litigated unreasonably and ordered it to reimburse Cooke’s legal fees under 215 ILCS 5/155. The insurer paid the death benefit and appealed the attorneys’ fees. Because the district court had not specified the amount, the Seventh Circuit dismissed the appeal as premature. The district court then awarded $42,835 plus interest. The district judge concluded that there had been a good faith coverage dispute, so the insurer could not be penalized for insisting that a judge resolve the parties’ dispute, but added, “Jackson’s behavior in this litigation has been much less reasonable.” The Seventh Circuit reversed, first rejecting Cooke’s appeal on the merits award. Cooke did not appeal within 30 days of the order specifying the amount payable on the policy, and a later award of fees did not reopen that subject. The court erred in applying Illinois state law to the conduct of litigation in federal court and Jackson’s litigation conduct did not violate the Federal Rules of Civil Procedure. View "Cooke v. Jackson National Life Insurance Co." on Justia Law

The First Circuit affirmed the judgment of the district court concluding that the actions of Defendant, a claims-management firm, did not constitute unfair claims settlement practices under Mass. Gen. Laws ch. 176D, holding that Plaintiff failed to show that the district court either misapplied applicable law or clearly erred in finding the facts.Plaintiff won a multi-million dollar jury verdict for wrongful death and conscious pain and suffering against a nursing home. Thereafter, Plaintiff brought this suit alleging that Defendant’s actions, both pre- and post-verdict, violated Chapter 176D. The district court entered a take-nothing judgment, concluding that Defendant’s actions did not constitute unfair claims settlement practices. The First Circuit affirmed, holding that the district court did not err in concluding that Defendant did not violate Chapter 176D. View "Calandro v. Sedgwick Claims Management Services, Inc." on Justia Law

The Ninth Circuit affirmed the district court's dismissal of plaintiffs' claim that their insurer, Blue Shield, violated the Medical Loss Ratio (MLR) provision of the Patient Protection and Affordable Care Act (ACA). The MLR is the ratio between what an insurer pays out in claims for medical services and the revenue it takes in.The panel held that there was no basis in the language, history, intent or spirit of the ACA to narrow the MLR by excluding payments for services rendered by out-of-network physicians. In this case, the MLR was properly calculated under federal law by including the settlement reimbursements for medical services by nonnetwork providers. Therefore, the district court correctly recognized the services were covered by the plan and the payments were made. View "Morris v. California Physicians' Service" on Justia Law

At the summary judgment stage, the district court found that an employee of Greenwald Neurosurgical, P.C. caused over $100,000 in losses to the P.C., while he was acting in the ordinary course of the P.C.’s business. The district court then issued a judgment to the P.C. for the policy amount of $100,000 pursuant to a Dishonesty Bond issued by Western Surety Company. Western appealed the district court’s determinations that the employee caused the loss while acting in the ordinary course of business and that the P.C. actually suffered the loss. The P.C. cross-appealed the district court’s findings that it was the only entity insured under the bond and argued it was awarded too little by way of attorney’s fees. The Idaho Supreme Court determined: (1) the district court correctly concluded that only the P.C. was an insured and the only entity that could recover under the bond; (2) whether the employee was acting the “ordinary course of [the P.C.’s] business” was a jury question; (3) a genuine issue of fact existed regarding the amount of losses the P.C. sustained; and (4) the district court erred in awarding attorney’s fees to the P.C. The Supreme Court therefore vacated summary judgment, and remanded for further proceedings. View "Greenwald v. Western Surety" on Justia Law