Justia Insurance Law Opinion Summaries

Donna Vanek, an employee of a construction company, was driving her personal Kia Optima to pick up supplies when a semitruck struck her car, killing her and her young nephew. The company’s Ford F-250, which Vanek would have used for the task, was in the repair shop at the time. The estates of Vanek and her nephew sued Ohio Casualty Insurance Company, arguing that the Kia qualified as a "temporary substitute" for the F-250 under the company’s insurance policy.The United States District Court for the Eastern District of Kentucky granted summary judgment to Ohio Casualty, ruling that the Kia did not qualify as a "temporary substitute" under the policy. The court accepted Ohio Casualty’s interpretation that a non-covered vehicle could not be a "temporary substitute" unless all covered vehicles were out of service.The United States Court of Appeals for the Sixth Circuit reviewed the case and reversed the district court’s decision. The appellate court held that a reasonable jury could find that the Kia qualified as a "temporary substitute" for the F-250. The court noted that witnesses testified Vanek would have used the F-250 if it had been available and that the Kia was used temporarily while the F-250 was in the shop. The court rejected Ohio Casualty’s interpretation that all covered vehicles must be out of service for a vehicle to qualify as a "temporary substitute," finding no basis for this in the policy’s text. The case was remanded for further proceedings consistent with this opinion. View "Olenik v. Ohio Casualty Insurance Co." on Justia Law

Acuity issued a commercial auto policy to Terra-Tek, LLC, which included John Waba and Sheila Foreman as additional named insureds. Waba was injured in an auto accident with an underinsured motorist while driving a vehicle not listed under Terra-Tek’s policy. Acuity denied Waba’s claim for underinsured motorist (UIM) benefits, arguing that the vehicle he was driving was not covered under the policy. Acuity then sought a declaratory judgment to confirm that Waba was not entitled to UIM benefits.The Circuit Court of the First Judicial Circuit in Brule County, South Dakota, reviewed the case. The court found that the UIM endorsement in Terra-Tek’s policy unambiguously provided coverage to Waba for the injuries sustained in the accident, despite the vehicle not being listed as a covered auto. The court granted summary judgment in favor of Waba, determining that the policy’s language did not require Waba to be occupying a covered auto to receive UIM benefits. Acuity appealed this decision.The Supreme Court of the State of South Dakota affirmed the lower court’s decision. The court held that the UIM endorsement’s language did not limit coverage to injuries sustained while occupying a covered auto. The court noted that the policy’s definition of an insured for UIM coverage did not include such a limitation, unlike the liability coverage section, which explicitly required the insured to be occupying a covered auto. The court concluded that the policy provided UIM coverage to Waba for the accident, affirming the circuit court’s judgment in favor of Terra-Tek and Waba. View "Acuity V. Terra-Tek" on Justia Law

This case involves a dispute over insurance coverage following a family business conflict. Brian Flood and his sons, Chris and Shawn, were involved in a waste collection business, Flood Brothers Waste Disposal Company. After being pushed out of the family business, they started a new company, S.B.C. Flood Waste Solutions, Inc. They obtained insurance from Grinnell Mutual Reinsurance Co. without disclosing the ongoing dispute with Flood Brothers over the use of the "Flood" name. When Flood Brothers sued them for improper use of the name, they sought coverage from Grinnell, which refused and sought to rescind the policies due to material misrepresentations.The United States District Court for the Northern District of Illinois granted summary judgment in favor of Grinnell, finding that S.B.C. Flood Waste Solutions, Inc. had made material misrepresentations in their insurance applications. The court identified three categories of false statements: failure to disclose potential claims or occurrences, failure to disclose the existence of another business venture (Flood, Inc.), and misrepresenting the start date of business activities. The court found these misrepresentations material based on the testimony of Grinnell’s underwriter, who stated that the insurance would not have been issued if the true facts were known.The United States Court of Appeals for the Seventh Circuit affirmed the district court’s decision. The appellate court agreed that the misrepresentations were material under Illinois law, which allows for rescission of an insurance policy if a false statement materially affects the acceptance of risk. The court emphasized that the undisclosed dispute and the existence of Flood, Inc. were significant factors that would have influenced Grinnell’s decision to issue the policies. The court did not need to address the alter ego argument, as the material misrepresentations alone were sufficient to justify rescission. View "Grinnell Mutual Reinsurance Company v. S.B.C. Flood Waste Solutions, Inc." on Justia Law

Malcolm H. Wiener, the plaintiff, purchased three life insurance policies from AXA Equitable Life Insurance Company in 1986. Over the years, Wiener's policies lapsed multiple times due to insufficient funds, but he managed to reinstate them each time. In 2013, the policies lapsed again, and AXA terminated them after Wiener failed to make the necessary payments within the grace period. Wiener claimed that AXA and his insurance agent, David Hungerford, caused the lapse by not sending premium notices and by changing the mailing address without his authorization. He also alleged that AXA wrongfully denied his application to reinstate the policies.The United States District Court for the Southern District of New York granted summary judgment in favor of AXA and Hungerford on all claims. The court found that AXA was not obligated to send premium notices after the policies lapsed and that Wiener had waived any objection to the address change by acquiescing for nearly five years. The court also concluded that Hungerford had no duty to notify Wiener of the lapse. Regarding the reinstatement claim, the court ruled that AXA's denial was not arbitrary and capricious, as it was based on Wiener’s low serum albumin levels, which were consistent with AXA’s underwriting guidelines.The United States Court of Appeals for the Second Circuit affirmed the district court’s summary judgment on the termination claims, agreeing that Wiener could not show that AXA’s failure to send premium notices caused the policies to lapse and that he had waived any objection to the address change. However, the appellate court vacated the summary judgment on the reinstatement claim, finding that there were genuine disputes of material fact regarding the actual reasons for AXA’s denial and whether those reasons were arbitrary. The case was remanded for further proceedings on the reinstatement claim. View "Wiener v. AXA Equitable Ins. Co." on Justia Law

Paul Carnes, an employee of Consolidated Grain and Barge Co., was diagnosed with degenerative disc disease in 2019 and received medical treatment for it. HMO Louisiana, Inc., the administrator of Consolidated Grain’s employer-sponsored health plan governed by ERISA, paid for some of Carnes’s treatments but not all. Carnes filed a workers’ compensation claim against his employer, which was settled without the employer accepting responsibility for his medical claims. With an outstanding medical balance of around $190,000, Carnes sued HMO Louisiana, alleging it violated Illinois state insurance law by not paying his medical bills and sought penalties for its alleged "vexatious and unreasonable" conduct.The United States District Court for the Central District of Illinois dismissed Carnes’s complaint on the grounds that his state law insurance claim was preempted by ERISA. The court allowed Carnes to amend his complaint to plead an ERISA claim, but instead, Carnes moved to reconsider the dismissal. The district court denied his motion and ordered the case closed. Carnes then appealed the final order.The United States Court of Appeals for the Seventh Circuit reviewed the case de novo. The court affirmed the district court’s decision, agreeing that Carnes’s state law claim was preempted by ERISA. The court noted that ERISA’s broad preemption clause supersedes any state laws relating to employee benefit plans, and Carnes’s claim fell within this scope. The court also found that ERISA’s saving clause did not apply because the health plan in question was self-funded, making it exempt from state regulation. The court concluded that Carnes’s attempt to frame his suit as a "coordination of benefits dispute" was an impermissible effort to avoid ERISA preemption. Consequently, the court affirmed the dismissal of Carnes’s case. View "Carnes v. HMO Louisiana, Inc." on Justia Law

Joel M. Guy, Jr. murdered his parents in 2016 with the intent to collect the proceeds from his mother’s insurance plans. His mother had life insurance and accidental death and dismemberment insurance through her employer, naming Guy and his father as beneficiaries. Guy was convicted of first-degree premeditated murder, felony murder, and abuse of a corpse by a Tennessee jury.The United States District Court for the Eastern District of Tennessee determined that Guy would be entitled to the insurance proceeds if not disqualified. However, the court ruled that Guy was disqualified under Tennessee’s slayer statute or federal common law, which prevents a murderer from benefiting from their crime. The court granted summary judgment in favor of Guy’s family members, who argued that Guy was not entitled to the benefits. Guy appealed, arguing that ERISA preempts Tennessee’s slayer statute and that no federal common-law slayer rule applies.The United States Court of Appeals for the Sixth Circuit reviewed the case de novo. The court held that ERISA does not explicitly address the issue of a beneficiary who murders the insured, and thus, either Tennessee law or federal common law must apply. The court found that both Tennessee’s slayer statute and federal common law would disqualify Guy from receiving the insurance proceeds. The court affirmed the district court’s decision, concluding that Guy’s actions disqualified him from benefiting from his mother’s insurance plans under both state and federal law. View "Standard Insurance Co. v. Guy" on Justia Law

In 2013, Johnny Ray Penegar, Jr. was diagnosed with mesothelioma, and Medicare partially covered his treatment costs. He filed a workers' compensation claim against his employer, UPS, and its insurer, Liberty Mutual. After his death, his wife, Carra Jane Penegar, continued the claim and added a death benefits claim. The North Carolina Industrial Commission (NCIC) ruled in her favor, ordering Liberty Mutual to cover all medical expenses related to the mesothelioma and reimburse any third parties, including Medicare. The NCIC's decision was affirmed by the North Carolina Court of Appeals and the Supreme Court of North Carolina denied further review. In 2020, Penegar and Liberty Mutual settled, with Liberty Mutual agreeing to pay $18,500 and to handle any Medicare liens.Penegar filed a class action lawsuit in the Western District of North Carolina under the Medicare Secondary Payer Act (MSP Act), alleging that Liberty Mutual failed to reimburse Medicare, leading to a collection letter from the Centers for Medicare and Medicaid Services (CMS) demanding $18,500. Liberty Mutual moved to dismiss, arguing Penegar lacked standing and that the settlement precluded her claims. The district court agreed, finding Penegar lacked standing and dismissed the case.The United States Court of Appeals for the Fourth Circuit reviewed the case and affirmed the district court's decision. The court held that Penegar did not suffer a cognizable injury in fact at the time she filed the lawsuit. The NCIC had ordered Liberty Mutual to reimburse Medicare directly, not Penegar, distinguishing her case from Netro v. Greater Baltimore Medical Center, Inc. Additionally, the CMS letter only posed a risk of future harm, which is insufficient for standing in a damages suit. Finally, any out-of-pocket expenses Penegar incurred were already compensated by Liberty Mutual before she filed the lawsuit, negating her claim of monetary injury. View "Penegar v. Liberty Mutual Insurance Co." on Justia Law

Plaintiffs, representing a class of drivers whose cars were totaled in accidents, alleged that their insurers, State Farm Mutual Automobile Insurance Company and State Farm Fire and Casualty Company, failed to pay the actual cash value of their vehicles. They contended that State Farm applied two unlawful discounts: a negotiation discount, which reduced the value based on typical buyer negotiations, and a condition discount, which adjusted for the car's condition compared to similar vehicles.The United States District Court for the Western District of Washington initially certified two classes: a negotiation class and a condition class. However, following the Ninth Circuit's decision in Lara v. First National Insurance Company of America, the district court decertified both classes and granted summary judgment in favor of State Farm, concluding that the plaintiffs failed to demonstrate injury.The United States Court of Appeals for the Ninth Circuit reviewed the case. The court reversed the district court's decertification of the negotiation class, holding that plaintiffs could prove injury on a class-wide basis by adding back the unlawful negotiation adjustment to determine the value each class member should have received. However, the court affirmed the decertification of the condition class, as determining injury required an individualized comparison of the unlawful condition adjustment and a hypothetical lawful adjustment.The Ninth Circuit also vacated the district court's summary judgment against the named plaintiffs, remanding the case for the district court to reassess whether the plaintiffs provided sufficient evidence of injury. The court clarified that plaintiffs could rely on the Autosource reports, minus the unlawful adjustments, as relevant evidence of injury. The court rejected State Farm's argument that Article III standing was a barrier to the plaintiffs' suit, affirming that the plaintiffs' claim of receiving less than owed under their insurance policies constituted a concrete injury. View "JAMA V. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY" on Justia Law

Christina Barrera, the office manager at PowerMed, was involved in a scheme to help unqualified individuals, mainly employees of AB InBev, fraudulently obtain disability benefits from the Social Security Administration (SSA) and private insurers. Patients paid PowerMed $21,600 for a "disability package" that included unnecessary medical tests and assistance in fraudulently applying for disability benefits. Barrera explained the scheme to patients, helped them complete paperwork, and coached them on how to appear disabled. An undercover officer's investigation led to Barrera's indictment and subsequent trial, where a jury found her guilty of conspiracy to defraud the SSA but acquitted her of health care fraud and theft of government funds.The United States District Court for the Eastern District of Missouri sentenced Barrera, ordering her to pay restitution to the SSA and private insurers. The presentence investigation report (PSR) recommended $339,407.80 in restitution to the SSA, but the Government argued for additional restitution to private insurers, totaling $203,907.62. The district court adopted the Government's figures, ordering Barrera to pay a total of $543,315.42 in restitution. After Barrera's sentencing, her co-conspirator Clarissa Pogue was sentenced but was not required to pay restitution to private insurers, leading Barrera to appeal.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court held that Barrera's criminal conduct included defrauding private insurers as part of the scheme to defraud the SSA, affirming the district court's decision to order restitution to private insurers. However, the court found errors in the calculation of restitution amounts for Prudential and MetLife, vacating those portions and remanding for further proceedings. The court rejected Barrera's argument regarding sentencing disparities with Pogue, emphasizing that the statutory direction to avoid unwarranted sentence disparities refers to national disparities, not differences among co-conspirators. The judgment was affirmed in part, vacated in part, and remanded. View "United States v. Barrera" on Justia Law

Cynthia Roberge, a State of Rhode Island employee, was involved in a car accident with an underinsured motorist while driving her personal vehicle during the course of her employment. She sought uninsured/underinsured motorist (UM/UIM) coverage under the State's insurance policy issued by Travelers Property Casualty Company of America. Travelers denied her claim, stating that she was not entitled to UM/UIM coverage because she was not driving a "covered auto" as defined by the policy.Roberge filed a lawsuit in Providence County Superior Court, asserting claims for breach of contract, declaratory judgment, and bad faith. Travelers removed the case to the United States District Court for the District of Rhode Island. The district court granted summary judgment in favor of Travelers, concluding that Roberge was not entitled to UM/UIM coverage under the policy's terms and that neither the Rhode Island Supreme Court's decision in Martinelli v. Travelers Insurance Companies nor the Rhode Island Uninsured Motorist Statute required such coverage.On appeal, the United States Court of Appeals for the First Circuit reviewed the case. The court noted that the policy's language clearly excluded Roberge from UM/UIM coverage because she was not driving a "covered auto." However, the court found that the case raised unresolved questions of Rhode Island insurance law, particularly regarding the applicability of the Martinelli exception and the requirements of the Rhode Island Uninsured Motorist Statute. The First Circuit decided to certify two questions to the Rhode Island Supreme Court: whether an employee must be considered a named insured under an employer's auto insurance policy when operating a personal vehicle in the scope of employment, and whether it violates Rhode Island law and public policy for an employer's policy to provide liability but not UM/UIM coverage to employees in such circumstances. The case was stayed pending the Rhode Island Supreme Court's response. View "Roberge v. Travelers Property Casualty Co. of America" on Justia Law