Justia Insurance Law Opinion Summaries
Standard Security Life Insurance Co. of New York v. FCE Benefit Administrators, Inc.
FCE administered health insurance policies underwritten by the Insurers. After a few years, the Insurers became dissatisfied with FCE’s performance and invoked the Agreement’s arbitration clause. In Phase I of the arbitration, the arbitrators awarded the Insurers damages of more than five million dollars. The Insurers attempted to confirm this award under the Federal Arbitration Act, 9 U.S.C. 9, but the district court concluded that the case was not yet ripe for adjudication. The arbitrators had not yet resolved all matters that had been submitted to them. In Phase II, the arbitrators denied the Insurers’ remaining claim for reimbursement of excessive administrative fees and FCE’s counterclaim for lost profits.The district court confirmed the arbitration results in their entirety. The Seventh Circuit affirmed. The court rejected FCE’s arguments that the Phase II Award superseded the Phase I Award such that the district court could confirm only the Phase II Award; that part of the Phase I Award must be vacated because the arbitrators exceeded their authority by hearing and deciding the Insurers’ indemnification claims; and that it was reversible error for the court to confirm the portion of the Phase I Award labeled as damages for “embezzlement.” View "Standard Security Life Insurance Co. of New York v. FCE Benefit Administrators, Inc." on Justia Law
Berry v. Queen
In two cases involving similar underlying facts and an identical legal issue the Court of Appeals held that the phrase "damage to property," incorporated by reference in the uninsured motorist statute, requires an insurer to reimburse loss of use damages, such as rental car costs, to an insured.At issue was whether the Maryland Uninsured Motorist statutory provision of Md. Code Ann., Ins. 19-509(e)(1) and the provisions of Title 17 of the Transportation Article and Title 20 Subtitle 6 of the Insurance Article require an insurer to pay benefits for loss of use of a vehicle damaged by an uninsured driver. The Court of Appeals held that the phrase "damage to property," as incorporated by reference in the uninsured motorist statute, embraces loss of use damages caused by an uninsured driver, regardless of any limitations or omissions that may exist in the applicable policy of insurance. View "Berry v. Queen" on Justia Law
Sigler v. Geico Casualty Co.
Sigler totaled his 2001 Dodge Ram and filed a claim with GEICO, his auto insurer, for the loss. GEICO paid him for the value of the car, adjusted for depreciation, minus his deductible. Sigler claims he is entitled to sales tax and title and tag transfer fees for a replacement vehicle, though he did not incur these costs. He filed a proposed class action against GEICO seeking damages for breach of contract. The district court dismissed the suit, holding that neither the GEICO policy nor Illinois insurance law requires payment of these costs when the insured does not incur them.The Seventh Circuit affirmed. The premise of Sigler’s suit, that sales tax and title and tag transfer fees are always part of “replacement cost” in a total-loss claim regardless of whether the insured incurs these costs, misreads the policy and Illinois insurance regulations. GEICO’s policy does not promise to pay sales tax or title and tag transfer fees; the Illinois Administrative Code requires a settling auto insurer to pay these costs only if the insured actually incurs and substantiates them with appropriate documentation. View "Sigler v. Geico Casualty Co." on Justia Law
Storm v. The Standard Fire Insurance Co.
In an action arising from an underinsured motorist arbitration, the Court of Appeal reversed the trial court's order striking plaintiff's memorandum of costs and remanded the matter with directions for the trial court to consider whether the costs as claimed by plaintiff are recoverable within the meaning of Code of Civil Procedure section 998 and 1293.2.The court held that the relevant policy language, which stated that "[e]ach party will . . . [p]ay the expenses it incurs [in arbitration]" and "[b]ear the expenses of the arbitrator equally," does not preclude the recovery under section 998 of arbitration costs, or the recovery under section 1293.2 of post-arbitration costs. The court explained that specifying how the costs are to be paid in the first instance says nothing about whether such costs may be recouped later under the cost-shifting provisions of sections 998 or 1293.2.The court also held that the insurance policy strictly limited the decisional authority of the arbitrator to two issues—plaintiff's entitlement to damages, and the amount thereof. However, the court explained that it did not give the arbitrator the power to award costs. Therefore, the court found Heimlich v. Shivji (2019) 7 Cal.5th 350 (Heimlich) distinguishable. View "Storm v. The Standard Fire Insurance Co." on Justia Law
M. v. Premera Blue Cross
The parents of a teenage girl (L.M.) sued Premera Blue Cross under the Employee Retirement Income Security Act (ERISA), claiming improper denial of medical benefits. L.M. experienced mental illness since she was a young girl. L.M. was eventually placed in Eva Carlston Academy, where she obtained long-term psychiatric residential treatment. For this treatment, the parents submitted a claim to Premera under the ERISA plan’s coverage for psychiatric residential treatment. Premera denied the claim ten days into L.M.’s stay. But Premera agreed to cover the first eleven days of L.M.’s treatment, explaining the temporary coverage as a "courtesy." The parents appealed the denial of subsequent coverage, and Premera affirmed the denial based on a physician's medical opinion. The parents filed a claim for reimbursement of over $80,000 in out-of-pocket expenses for L.M.’s residential treatment at the Academy. Both parties moved for summary judgment, and the district court granted summary judgment to Premera based on two conclusions: (1) Premera’s decision was subject to the arbitrary-and- capricious standard of review; and (2) Premera had not acted arbitrarily or capriciously in determining that L.M.’s residential treatment was medically unnecessary. The district court granted summary judgment to Premera, and the parents appealed. After review, the Tenth Circuit concluded the district court erred by applying the arbitrary-and-capricious standard and in concluding Premera had properly applied its criteria for medical necessity. Given these conclusions, the Court reversed and remanded the matter back to the district court for de novo reevaluation of the parents’ claim. View "M. v. Premera Blue Cross" on Justia Law
Carter v. Pulte Home Corp.
Pulte, a residential developer, was sued for construction defects by the owners of 38 homes. Many subcontractors worked on the projects, under contracts requiring each subcontractor to indemnify Pulte and to name it as an additional insured on the subcontractor’s commercial general liability insurance. Pulte cross-complained against subcontractors who worked on the homes. Travelers, the insurer for four subcontractors, provided a defense. The “Blanket Additional Insured Endorsements” to Travelers’s named insureds’ policies stated that the “person or organization is only an additional insured with respect to liability caused by ‘your work’ for that additional insured.Travelers filed a complaint in intervention against the insurers for seven subcontractors (respondents), who declined to provide a defense, seeking equitable subrogation. Pulte settled the homeowners’ claims and its claims against all the subcontractors. The court concluded that it “would not be just” to find respondents jointly and severally liable for the costs Travelers sought to recover. There was considerable variation in the number of homes each respondent worked on. The homeowners’ complaints did not indicate which subcontractor worked on which home, and no evidence was presented as to whether the work of any subcontractor was defective.The court of appeal affirmed. Pulte was entitled to indemnity and defense from each respondent only with respect to its own scope of work. Travelers was "not seeking to stand in Pulte’s shoes. It is seeking to stand in a different, more advantageous" shoes. View "Carter v. Pulte Home Corp." on Justia Law
State Farm Lloyds v. Richards
State Farm filed suit seeking a declaratory judgment that it had no duty to defend or indemnify the insureds in the underlying action. In the underlying action, Jayden Meals' mom filed a personal injury suit against his paternal grandparents, the insureds, after Jayden, who was 10 years old, died in an ATV accident. The district court found that the extrinsic evidence satisfied both the motor-vehicle exclusion and the insured exclusion.The Fifth Circuit certified a question of Texas law to the Texas Supreme Court, which answered that the policy-language exception to the eight-corners rule is not a permissible exception under Texas law. Therefore, the district court erred by applying the policy-language exception in this case. The court held that the eight-corners rule applies here; the underlying third-amended complaint contains allegations within its four corners that potentially constitute a claim within the four corners of the policy; and thus the court reversed the district court's holding that State Farm does not have a duty to defend the insureds. The court stated that State Farm has a duty to defend, so the exception to non-justiciability does not apply. Because the underlying suit remains pending, the court reversed the district court's holding that State Farm has no duty to indemnify. View "State Farm Lloyds v. Richards" on Justia Law
Central States, Southeast & Southwest Areas Health & Welfare Fund v. Haynes
Doctors removed Haynes’s gallbladder. She was injured in the process and required additional surgery that led to more than $300,000 in medical expenses. Her father’s medical-benefits plan (the Fund) paid these because Haynes was a “covered dependent.” The plan includes subrogation and repayment clauses: on recovering anything from third parties, a covered person must reimburse the Fund. Haynes settled a tort suit against the hospital and others for $1.5 million. She and her lawyers refused to repay the Fund, which sued to enforce the plan’s terms under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132(a)(3). Haynes argued that she did not agree to follow the plan’s rules and was not a participant, only a beneficiary. The district judge granted the Fund summary judgment and enjoined Haynes and her lawyer from dissipating the settlement proceeds. The Fund had named each of them as a defendant.The Seventh Circuit affirmed. ERISA allows fiduciaries to bring actions to obtain “equitable relief … to enforce ... the terms of the plan.” The nature of the remedy sought—enforcement of a right to identifiable assets—is equitable. Having accepted the plan’s benefits, Haynes must accept the obligations The absence of a beneficiary’s signed writing, regardless of the beneficiary's age, does not invalidate any of the plan’s terms. View "Central States, Southeast & Southwest Areas Health & Welfare Fund v. Haynes" on Justia Law
LM Insurance Corp. v. Dubuque Barge and Fleeting Service Co.
LM filed suit against Newt Marine for breach of contract, alleging that Newt Marine wrongfully refused to pay premiums owed under three separate workers' compensation insurance policies.The Eighth Circuit affirmed the district court's grant of Newt Marine's motion for summary judgment, because the premiums LM sought from Newt Marine were not merited by the terms of the policies. Therefore, the court held that Newt Marine did not breach its obligations under the workers' compensation insurance policies by refusing to pay. View "LM Insurance Corp. v. Dubuque Barge and Fleeting Service Co." on Justia Law
Plastic Surgery Center, P.A. v. Aetna Life Insurance Co
J.L. and D.W. were covered by employer-sponsored Aetna insurance plans that provided out-of-network benefits only in cases of “Urgent Care or a Medical Emergency” (J.L.) or not at all (D.W.). J.L. needed bilateral breast reconstruction surgery and there were no in-network physicians available to perform the procedure. D.W. required facial reanimation surgery—a niche procedure performed by only a few U.S. surgeons. Both were referred for treatment to the Plastic Surgery Center, an out-of-network New Jersey medical practice. The Center negotiated with Aetna, which agreed to pay a “reasonable amount.” The Center billed $292,742 for J.L.’s services, Aetna paid only $95,534.04. Of the $420,750 the Center billed for D.W.’s services, Aetna paid only $40,230.32.The district court dismissed common law breach of contract, promissory estoppel, and unjust enrichment claims, holding that section 514(a) of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1000, expressly preempted all claims. The Third Circuit reversed as the breach of contract and promissory estoppel claims, which do not require impermissible “reference to” ERISA plans. The claims, as pleaded, plausibly seek to enforce obligations independent of the plan and do not require interpretation or construction of ERISA plans. The claims plausibly arise out of a relationship that ERISA did not intend to govern. View "Plastic Surgery Center, P.A. v. Aetna Life Insurance Co" on Justia Law