Justia Insurance Law Opinion Summaries

Douglas Ghee, as the personal representative of the estate of Billy Fleming, appealed a circuit court order dismissing a wrongful-death claim brought against USAble Mutual Insurance Company d/b/a Blue Advantage Administrators of Arkansas ("Blue Advantage"). Fleming presented to the emergency department complaining of constipation and abdominal pain. He would ultimately need a colectomy, but the hospital informed him Blue Advantage had decided that a lower quality of care (continued non-surgical management) was more appropriate than the higher quality of care (surgery) that Fleming's surgeon felt was appropriate. Fleming and his family had multiple conversations with agents of Blue Advantage in an unsuccessful attempt to convince the company that the higher surgery was the more appropriate course of care. Ultimately, an agent of Blue Advantage suggested to Fleming that he return to the hospital in an attempt to convince hospital personnel and physicians to perform the surgery on an emergency basis. For five days, Fleming would present to the emergency room, each time he was treated by non-surgical means, then returned home. On the evening of July 15, 2013, Fleming's condition had deteriorated such that he had to be intubated. He died after midnight of septic shock due to a perforated sigmoid colon with abundant fecal material in the peritoneal cavity. A lawsuit was filed against Blue Advantage, asserting that the combined negligence of the hospitals and clinics involved and Blue Advantage, proximately caused Fleming's death. Because the trial court determined that Ghee's allegations against Blue Advantage as stated in the original complaint were defensively preempted by ERISA, the Alabama Supreme Court found Ghee should have had the right to amend his complaint to clarify his state-law claims. Because the Court concluded that Ghee should have been afforded the right to amend his complaint, it reversed the judgment of the trial court and remanded for further proceedings. View "Ghee v. USAble Mutual Insurance Company d/b/a Blue Advantage Administrators of Arkansas" on Justia Law

Defendant Nationwide Mutual Fire Insurance Company ("Nationwide") appealed a judgment entered in favor of plaintiff The David Group, Inc. ("TDG"), which held TDG was entitled to coverage and indemnification under a commercial general- liability ("CGL") insurance policy issued by Nationwide. Under the terms of that CGL policy, Nationwide agreed to "pay those sums that the insured becomes legally obligated to pay as damages because of 'bodily injury' or 'property damage' to which this insurance applies." According to the policy, its coverage applied to "bodily injury" and "property damage" only if "[t]he 'bodily injury' or 'property damage' is caused by an 'occurrence.'" In October 2006, while TDG's CGL policy with Nationwide was in effect, Saurin and Valerie Shah purchased a newly built house from TDG. After they moved in, the Shahs began experiencing problems with their new house. Despite TDG's efforts at correcting the problems, however, in February 2008, the Shahs sued TDG. Although Nationwide initially defended TDG against the Shahs' action, Nationwide withdrew its defense after conducting its own investigation into the Shahs' allegations. It concluded that it had no duty either to defend or to indemnify TDG because, according to Nationwide, the damage the Shahs complained of did not constitute an "occurrence" so as to trigger coverage under the CGL policy. The Alabama Supreme Court concluded the trial court erred in finding that TDG was entitled to coverage and indemnification under its CGL policy with Nationwide. Thus, the Court reversed the trial court's judgment and remanded the case for further proceedings. View "Nationwide Mutual Fire Insurance Company v. The David Group, Inc." on Justia Law

The First Circuit affirmed the district court's grant of summary judgment to AXIS Reinsurance Company (AXIS) on Plaintiffs' complaint seeking to enforce a directors and officers insurance policy with AXIS, holding that the district court did not err in granting summary judgment in favor of AXIS and in denying Plaintiffs' motion for partial summary judgment.Plaintiffs were BioChemics, Inc., a pharmaceutical company based in Massachusetts, and John Masiz, its president and chief executive officer. Plaintiffs sought damages for what they claimed was AXIS's breach, under the relevant policy, of its duty to defend them in connection with an investigation conducted by the Securities and Exchange Commission against BioChemics and its officers. In its motion for summary judgment, AXIS argued that it did not breach its duty to defend under the policy because Plaintiffs were seeking to enforce that duty in relation to a claim that was first made before the policy took effect and thus was not covered by the policy. The district court granted the motion. The First Circuit affirmed, holding that the district court did not err in granting summary judgment to AXIS. View "Biochemics, Inc. v. Axis Reinsurance Co." on Justia Law

Plaintiff filed suit against Allstate and its agent for breach of contract after Allstate refused to pay a claim for flood damage. The Fifth Circuit affirmed the district court's judgment in favor of Allstate, holding that the district court did not err in granting summary judgment on the breach of contract claim because the claim was time-barred. The court also held that the district court did not abuse its discretion in denying petitioner's Federal Rule of Civil Procedure 59(e) motion. View "Cohen v. Allstate Insurance Co." on Justia Law

GEICO appealed a judgment awarding punitive damages to plaintiff for GEICO's bad faith breach of an insurance contract. The Court of Appeal affirmed the punitive damages award and held that there was sufficient evidence in the record to show that GEICO's managing agent ratified conduct warranting punitive damages. In this case, GEICO concluded that plaintiff's claim was worth far less than the policy limits by disregarding information provided by plaintiff showing that he had a permanent, painful injury, and instead selectively relied on portions of medical records that supported GEICO's position that plaintiff had fully recovered. Furthermore, the $1 million in punitive damages was within the constitutionally permitted range in view of the degree of reprehensibility of GEICO's conduct. View "Mazik v. GEICO General Insurance Co." on Justia Law

In this insurance coverage dispute, the Supreme Court reversed the judgment of the circuit court ruling in favor of Doswell Truck Stop, LLC (DTS) on DTS's declaratory judgment action against James River Insurance Company and entered final judgment declaring that an auto exclusion precluded coverage of James Smith's injuries under the policy at issue, holding that the trial court erred in ruling in favor of DTS.Smith filed a personal injury lawsuit against DTS for injuries he allegedly suffered as a result of a tire explosion that occurred when DTS was repairing a tire on Smith's tractor-trailer. DTS filed an insurance claim with James River, which had issued a commercial general liability policy to DTS. James River denied coverage on the basis that DTS's claim was precluded by the auto exclusion. DTS then filed this action seeking a determination of whether the policy covered Smith's injury. The circuit court ruled in favor of DTS. The Supreme Court reversed, holding (1) the circuit court erred determining that the auto exclusion was ambiguous with respect to the meaning of "maintenance" of an auto; and (2) the circuit court erred in ruling that an independent basis existed for coverage under the policy. View "James River Insurance Co. v. Doswell Truck Stop, LLC" on Justia Law

After a fire seriously damaged the insureds' home, the insurer paid for their total property damage and then brought a diversity action against Entergy, alleging that the utility's equipment caused the fire. The insurer alleged subrogation claims for damages in excess of the amount paid for the damage.Although the district court erred in determining that the insurer did not have standing, the Eighth Circuit affirmed the district court's grant of Entergy's motion for judgment as a matter of law because the insurer failed to prove that the insureds were made whole either before or during this lawsuit. Therefore, a reasonable jury could not have found that the insurer proved an essential element of its subrogation claim. View "EMC Insurance v. Entergy Arkansas" on Justia Law

After insurers denied McDonnel's claim, McDonnel initiated a declaratory and breach of contract action. The Fifth Circuit affirmed the district court's dismissal of the action in favor of arbitration and held that the insurance policy's conformity provision did not negate the agreement to arbitrate. The court held that the state statute, La. Rev. Stat. Ann. 22:868, was preempted by the Convention on the Recognition and Enforcement of Foreign Arbitral Awards, and thus the statute did not and could not apply to McDonnel's policy. Consequently, there was no conflict between the policy and the state statute. Therefore, the court held that the conformity provision was not triggered, and its inapplicability leads only to the conclusion that the arbitration provision survives, undiminished by state law. View "McDonnel Group, LLC v. Great Lakes Insurance SE" on Justia Law

Defendant-appellant Ricardo Lara, the California Insurance Commissioner, filed a notice of noncompliance against plaintiffs-respondents Mercury Insurance Company, Mercury Casualty Company, and California Automobile Insurance Company (collectively Mercury) alleging Mercury charged rates not approved by the California Department of Insurance (CDI) and that the rates were unfairly discriminatory in violation of Insurance Code sections 1861.01 (c) and 1861.05 (b). The allegedly unapproved rates were in the form of broker fees charged by Mercury agents, which should have been disclosed as premium. After prevailing at an administrative hearing, the Commissioner imposed civil penalties against Mercury totaling $27,593,550 for almost 184,000 unlawful acts. Mercury filed a petition for writ of mandate, which the court granted, reversing the Commissioner’s decision. The court found the “broker fees” were not premium because they were charged for separate services. The court also rejected the Commissioner’s interpretation of the term premium under the Insurance Code and regulations. In addition, the court ruled Mercury did not have proper notice it was subject to penalties, in violation of due process, and the action was barred by laches because CDI had unduly delayed in bringing the action. Commissioner and intervener-appellant, Consumer Watchdog (CWD), appealed on several grounds, among them: (1) the trial court did not use the proper standard of review; (2) failed to give the Commissioner’s findings a strong presumption of correctness and failed to put the burden of proof on Mercury to show the findings were against the weight of the evidence; (3) the trial court’s finding the fees were charged for separate services was precluded by collateral estoppel; (4) Mercury received proper notice of the potential imposition of a penalty; and (5) laches did not bar the action. The Court of Appeal agreed with Commissioner and CWD the writ was issued in error and reversed the judgment. View "Mercury Insurance Co. v. Lara" on Justia Law

Petitioner Theodore Morrison had surgery on his right knee in 2004 after injuring it at work. He returned to work after the surgery and did not consult a doctor about that knee for almost ten years, until he again injured it in 2014 while working for a different employer. Following the 2014 injury he sought to have arthroscopic surgery as his doctor recommended. His 2014 employer disputed its liability for continued medical care, and the worker filed a written claim against the 2014 employer. The Alaska Workers’ Compensation Board joined the earlier employer to the claim and decided, after a hearing, that the 2014 work injury was the substantial cause of the worker’s current need for medical care, requiring the 2014 employer to pay the cost of treatment for the right knee. The 2014 employer appealed to the Alaska Workers’ Compensation Appeals Commission, which decided the Board misapplied the new compensability standard and remanded the case to the Board for further proceedings. Morrison petitioned the Alaska Supreme Court for review of the Commission’s decision, and the Supreme Court reversed the Commission’s decision and reinstated the Board’s award. Based on the medical testimony, the Court found the Board identified two possible causes of Morrison’s need for medical treatment at the time of the hearing. It then considered the extent to which the two causes contributed to that need and decided the 2014 injury was the more important cause of the need for treatment then. "The legislature gave the Board discretion to assign a cause based on the evidence before it. The Board did here what the statute directs." View "Morrison v. Alaska Interstate Construction Inc." on Justia Law