Justia Insurance Law Opinion Summaries

Heimer, one year over the legal drinking age, drank alcohol with friends and then rode motorbikes in a field. Heimer and his friend collided. Heimer suffered extensive injuries, incurring more than $197,333.50 in medical bills. Heimer’s blood alcohol level shortly after the crash was 0.152, nearly twice the limit to legally use an off-road vehicle in Michigan. Heimer was insured. As required by his plan, he submitted a medical claim form shortly after the accident. The plan administrator denied coverage based on an exclusion for “[s]ervices, supplies, care or treatment of any injury or [s]ickness which occurred as a result of a Covered Person’s illegal use of alcohol.” After exhausting administrative appeals, Heimer filed suit. The district court held that the plan exclusion did not encompass Heimer’s injuries, reasoning that there is a difference between the illegal use of alcohol—such as drinking while under 21 or drinking in defiance of a court order—and illegal post-consumption conduct, such as the illegal use of a motor vehicle. The Sixth Circuit affirmed. Reading “illegal use of alcohol” to disclaim coverage only for the illegal consumption of alcohol, and not for illegal post-consumption conduct is consistent with the ordinary meaning of “use” and best gives effect to the contract as a whole. View "Heimer v. Companion Life Insurance Co." on Justia Law

Life Insurance Company of North America’s terminated plaintiff-appellant Carl Van Steen’s long-term disability benefits under Lockheed Martin’s ERISA Plan. Life Insurance Company of North America (LINA) appealed the district court’s finding that its decision to terminate Van Steen’s benefits was arbitrary and capricious. Van Steen, in turn, appealed the district court’s denial of his attorney’s fees request. Van Steen was physically assaulted during an altercation while walking his dog. The assault resulted in a mild traumatic brain injury (mTBI) that impacted Van Steen’s cognitive abilities that prevented him from returning to full time work; Van Steen was eventually allowed to return to part-time work on a daily basis roughly six weeks later. Even on a part-time schedule, Van Steen experienced cognitive fatigue and headaches that required him to frequently rest. Due to his inability to stay organized and keep track of deadlines after the assault, Van Steen received poor feedback on his job performance. Van Steen’s claim for partial long-term disability benefits was approved on March 30, 2012. Roughly a year later, LINA reviewed Van Steen’s file, contacted his doctors, and confirmed that Van Steen’s condition and restrictions were permanent as he was “not likely to improve.” Despite this prognosis, LINA sent Van Steen a letter one week later terminating his long-term disability benefits, explaining that “the medical documentation on file does not continue to support the current restrictions and limitations to preclude you from resuming a full-time work schedule.” Having exhausted his administrative appeals under the Plan, Van Steen next sought relief before the district court. The district court reversed LINA’s decision to terminate Van Steen’s partial long-term disability benefits on the grounds that it was arbitrary and capricious, but denied Van Steen’s request for attorney’s fees. The Tenth Circuit agreed with the district court’s reversal of LINA’s decision to terminate Van Steen’s coverage. The Court also found that Van Steen was not eligible for attorney fees: “Van Steen’s arguments fail to convince us that the district court’s decision was based on a clear error of judgment or exceeded the bounds of permissible choice.” View "Van Steen v. Life Insurance Company N.A." on Justia Law

Plaintiff appealed the district court's grant of summary judgment for Provident on breach-of-contract and tortious-breach-of-contract claims stemming from two disability insurance policies that Provident issued to plaintiff. The Fifth Circuit held that plaintiff presented sufficient evidence to raise a genuine dispute of material fact as to whether his disability resulted from injury and arthritis, in which case he would be entitled to lifelong benefits. Therefore, the court reversed the grant of summary judgment as to the breach-of-contract claim. Even if plaintiff had not waived his claim for punitive damages based on the theory that Provident tortiously breached the contract, he failed to offer evidence showing that Provident lacked an arguable reason for administering his claim under the sickness provisions. Accordingly, the court affirmed as to this issue. View "Cox v. Provident Life & Accident Insurance Co." on Justia Law

The Ninth Circuit certified the following question of law to the Nevada Supreme Court: Under Nevada law, if a plaintiff has filed suit against an insurer seeking damages based on a separate judgment against its insured, does the insurer's liability expire when the statute of limitations on the judgment runs, notwithstanding that the suit was filed within the six-year life of the judgment? View "Nalder v. United Automobile Insurance Co." on Justia Law

Palmer’s vacant Detroit apartment complex was covered by a Scottsdale fire insurance policy until November 2012. The property was vandalized in February 2012. Palmer reported the loss in October 2013. Scottsdale replied that it was investigating. In November, Palmer sent Scottsdale an itemized Proof of Loss. Scottsdale paid Palmer $150,000 in June 2014. Michigan law provides that losses under any fire insurance policy shall be paid within 30 days after receipt of proof of loss. Palmer requested an appraisal. Scottsdale agreed, noting the claim remained under investigation. Appraisers concluded that Palmer’s actual-cash-value loss was $1,642,796.76. The policy limit was $1,000,000. Scottsdale tendered checks over a period of several months that paid the balance. Palmer requested penalty interest for late payment. Michigan law states that if benefits are not paid on a timely basis, they bear simple interest from a date 60 days after satisfactory proof of loss was received by the insurer at the rate of 12% per annum. The Sixth Circuit reversed the district court’s conclusion that the penalty-interest claim arose “under the policy” and was barred by the policy’s two-year limitations provision. Palmer did not allege that Scottsdale breached the policy agreement. Scottsdale paid the insured loss and the policy had no time limit for paying a loss, Palmer has no unvindicated rights and no claim “under the policy” to assert. His claim is under the statute. View "Palmer Park Square, LLC v. Scottsdale Ins. Co." on Justia Law

In 2014, Shaundalyn Elliott, a resident of Montgomery County, was injured in an automobile accident in the City of Hayneville in Lowndes County. On February 23, 2017, Elliott filed this lawsuit at the Lowndes Circuit Court against her automobile insurer, Allstate Insurance Company ("Allstate"), seeking uninsured-motorist benefits related to the accident. Elliot alleged that the accident was caused by a "phantom driver," whose location was unknown. Allstate filed a motion to transfer the action from the Lowndes Circuit Court to the Montgomery Circuit Court. Elliott petitioned the Alabama Supreme Court for a writ of mandamus directing the Lowndes Circuit Court to vacate its order transferring this case to the Montgomery Circuit Court. In this case, the Supreme Court found that Lowndes County and Montgomery County had connections to this action. The accident, injuries, and police investigation occurred in Lowndes County. On the other hand, Elliott resided in Montgomery County, where she sought treatment for her injuries resulting from the accident and where the parties' contractual dealings arose. Under the specific facts of this case, Lowndes County's connection to the accident was not "little" or "weak," and Montgomery County did not have a significantly stronger connection to the case to justify a transfer of this case under the interest-of-justice prong of § 6-3-21.1. Therefore, the Court held the trial court erred in transferring this action to the Montgomery Circuit Court. View "Ex parte Shaundalyn N. Elliott." on Justia Law

This was the second time this dispute related to benefits provided under the Public Education Employees' Health Insurance Plan ("PEEHIP") went before the Alabama Supreme Court. In the present case, the remaining defendants below, David Bronner, as secretary-treasurer of PEEHIP, and the current members of the PEEHIP Board, petitioned for permission to appeal the trial court's denial of their motion seeking a summary judgment. "When a trial court fails to correctly identify the controlling question of law, a Rule 5 permissive appeal is due to be dismissed." After thoroughly reviewing the record and the arguments presented by the parties, the Supreme Court concluded the permission to appeal under Rule 5, Ala. R. App. P., was improvidently granted, and the Court dismissed the appeal. View "Bronner v. Burks" on Justia Law

After the Garcias bought their Lake Station Property in 2004, it was used as an automobile repair shop and a day spa. It previously was used as a dry cleaning facility and contained six underground storage tanks: four were used for petroleum-based Stoddard solvent, one was used for gasoline, and the last for heating oil. In 1999, the dry cleaning company reported a leak from the Stoddard tanks to the Indiana Department of Environmental Management (IDEM). In 2000, a site investigation was conducted and five groundwater monitoring wells were installed. IDEM requested additional information and testing in 2001 and 2004. The Garcias claim they had no knowledge of the preexisting environmental contamination before insuring with Atlantic. A 2014 letter from Environmental Inc. brought the contamination to the Garcias’ attention. The Garcias hired Environmental to investigate and learned that Perchloroethylene solvent and heating oil still affected the property. Atlantic obtained a declaration that its Commercial General Liability Coverage (CGL) policies did not apply. The Seventh Circuit affirmed, reading a “Claims in Process” exclusion to preclude coverage for losses or claims for damages arising out of property damage—known or unknown—that occurred or was in the process of occurring before the policy’s inception. View "Atlantic Casualty Insurance Co v. Garcia" on Justia Law

The Court of Appeal affirmed the trial court's order granting Allied's applications for prejudgment attachment stemming from an insurance dispute because Allied had established the probable validity of its claims. The court held that Allied established the probable validity of its unjust enrichment claim where Allied had a right of reimbursement because the intentional noncompliance policy exclusion applied in this case. The court also held that Allied also established the probable validity of its rescission claim because substantial evidence supported the trial court's finding that SCWW and GCES misrepresented and concealed a material fact (that they did not accept, process, transport or discharge hazardous waste). The trial court did not err in granting the applications for prejudgment attachment based on implied contract theories even if an express contract covers the same subject. Finally, the trial court properly calculated prejudgment interest from the date Allied paid $2.5 million. View "Santa Clara Waste Water Co. v. Allied World National Assurance Co." on Justia Law

Plaintiff Mahmoud Alzayat, on behalf of the People of the State of California, filed a qui tam action against his employer, Sunline Transit Agency, and his supervisor, Gerald Hebb, alleging a violation of the Insurance Frauds Prevention Act (IFPA or the Act). (Ins. Code, sec. 1871 et seq.) Alzayat alleged Hebb made false statements in an incident report submitted in response to Alzayat’s claim for workers’ compensation, and Hebb repeated those false statements in a deposition taken during the investigation into Alzayat’s claim for compensation. Hebb’s false statements resulted in Alzayat’s claim being initially denied. Defendants filed motions for judgment on the pleadings contending: (1) this lawsuit was based on allegedly false and fraudulent statements Hebb made in connection with a workers’ compensation proceeding and was, therefore, barred by the litigation privilege under Civil Code section 47(b); and (2) Alzayat’s claim was barred by the workers’ compensation exclusivity rule. The superior court concluded the workers’ compensation exclusivity rule was inapplicable, but ruled the litigation privilege barred Alzayat’s claim. Alzayat appealed, contending the litigation privilege only applied to tort claims and not to statutory claims such as an action under the IFPA, and the IFPA was a specific statute that prevailed over the general litigation privilege. The Court of Appeal agreed with Alzayat that his lawsuit was not barred by the litigation privilege. Furthermore, the Court concluded this lawsuit was not barred by the workers’ compensation exclusivity rule. The trial court erred by granting judgment on the pleadings for defendants, so we reverse the judgment. View "California ex rel. Alzayat v. Hebb" on Justia Law