Justia Insurance Law Opinion Summaries

Methodist and Saint Francis are the two largest hospitals in Peoria, Illinois. Saint Francis is considerably larger and more profitable. Methodist filed suit, charging Saint Francis with violating the Sherman Act by entering into exclusive contracts with insurance companies, covering more than half of all commercially-insured patients in the area. Methodist argued that it could not obtain a sufficiently high volume of patients to enable it to invest in improvements. The Seventh Circuit affirmed summary judgment in favor of Saint Francis, noting that health insurers regard Saint Francis as a “must have” hospital, because it provides certain services that the other hospitals in the area do not provide, such as solid-organ transplants, neonatal intensive care, and a Level 1 trauma center. The contracts are a form of requirements contract; an insurance company may get better rates from a hospital by agreeing to an exclusive contract, which will drive more business to the hospital. The contracts are of fixed duration; when they terminate, the insurance companies are free to contract with other hospitals. Competition-for-the-contract is protected by the antitrust laws and is common. The court noted that none of the other four area hospitals had joined the case and the Department of Justice declined to file a case. View "Methodist Health Services Corp v. OSF Healthcare System" on Justia Law

A party’s attorney-billing information is normally not discoverable when the party challenges an opposing party’s attorney-fee request as unreasonable or unnecessary but neither uses its own attorney fees as a comparator nor seeks to recover any portion of its own attorney fees.Several lawsuits brought by insured homeowners against various insurers and claims adjustors alleging underpayment of insured property-damage claims were consolidated into a single multidistrict litigation (MDL) for pretrial proceedings, including discovery. In this discovery dispute, individual homeowners sought attorney fees incurred in prosecuting their claims. The homeowners sought discovery regarding the insurer’s attorney-billing information. The insurer argued that the requested discovery was overly broad and sought information that was both irrelevant and protected by the attorney-client and work-product privileges. The MDL pretrial court ordered the insurer to respond to the discovery requests. The court of appeals denied the insurer’s petition for mandamus relief. The Supreme Court conditionally granted mandamus relief and directed the trial court to vacate its discovery order, holding that, absent unusual circumstances, information about an opposing party’s attorney fees and expenses is privileged or irrelevant and, thus, not discoverable. View "In re National Lloyds Insurance Co." on Justia Law

Corey worked as a machine operator in Eaton’s Ohio factory. Corey has long suffered from cluster headaches— extremely painful attacks that strike several times per day for weeks on end. In 2014, Corey applied for short-term disability benefits under Eaton’s disability plan after a bout of headaches forced him to miss work. After granting a period of disability, the third party administering Eaton’s disability plan discontinued benefits because Corey failed to provide objective findings of disability. Under the plan, “[o]bjective findings include . . . [m]edications and/or treatment plan.” Corey’s physicians treated his headaches by prescribing prednisone, injecting Imitrex (a headache medication), administering oxygen therapy, and performing an occipital nerve block. The district court upheld the denial. The Sixth Circuit reversed, citing the Employee Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B). Corey’s medication and treatment plan satisfy the plan’s objective findings requirement. View "Corey v. Sedgwick Claims Management Services, Inc." on Justia Law

Where an insurance policy is restricted to liability for any bodily injury “caused, in whole or in part” by the “acts of omissions” of the named insured, the coverage applies to injury proximately caused by the named insured.The Appellate Division denied summary judgment in favor of the insurance company on the issue of coverage after interpreting this policy language as extending coverage broadly to any injury causally linked to the named insured. The court also concluded that an additional insured may collect for an injury caused solely by its own negligence even where the named insured bears no legal fault for the underlying harm. The Court of Appeals reversed, holding that the language “caused, in whole or in part” requires the insured to be the proximate cause of the injury giving rise to liability, not merely the “but for” cause. View "Burlington Insurance Co. v. New York City Transit Authority" on Justia Law

The panel certified the following questions of state law to the Oregon Supreme Court: 1. If the Director of the Department of Consumer and Business Services approves a contractual limitations provision in an insurance policy under Oregon Revised Statutes 742.021, does the language of the policy always control or do the standard provisions of the Oregon Insurance Code apply if the standard provisions are more favorable than the approved insurance policy provision? 2. If the Oregon standard provisions do apply, when does "the period for which the insurer was liable" under Oregon Revised Statutes section 743.429 end? View "Raynor v. United of Omaha Life Insurance" on Justia Law

The Colorado Supreme Court concluded here that nothing in the language of the Colorado uninsured/underinsured motorist statute, 10-4-609 C.R.S. (2016) precluded an agent from exercising either apparent or implied authority to reject UM/UIM coverage on behalf of a principal. In line with this reasoning, the agent’s rejection of UM/UIM coverage was indeed binding on the principal. Respondent Brian Johnson tasked a friend with purchasing automobile insurance for the new car that he and the friend had purchased together. The friend did so, and in the course of that transaction, she chose to reject uninsured/underinsured motorist (UM/UIM) coverage on the new car. After an accident in that car with an underinsured motorist, Johnson contended that his friend’s rejection of UM/UIM coverage was not binding on him. View "State Farm v. Johnson" on Justia Law

After soil and rock slid down a hill located to the rear of Responents’ property and damaged a building, Respondents submitted a claim for property damage to Erie Insurance Property, their insurance carrier. Erie denied coverage based upon its conclusion that Respondents’ loss was not covered due to the policy’s earth movement exclusion. Respondents sued Erie and Stephen Myers, an adjuster for Erie (collectively, Petitioners), seeking a declaratory judgment as to whether coverage existed. The circuit court granted declaratory judgment in favor of Respondents. The Supreme Court reversed and remanded the matter with instructions to enter declaratory judgment for Petitioners, holding (1) the plain and unambiguous terms of the ensuing loss provision of the policy provided a narrow exception to the earth movement exclusion and permitted coverage for the portion of the loss caused by glass breakage; and (2) the other damage caused by the earth movement was not covered. View "Erie Insurance Property & Casualty Co. v. Chaber" on Justia Law

After a fatal vehicular accident, Christina Varvel asserted a declaratory judgment action against Universal Underwriters Insurance Co. and Zurich American Insurance Co. (collectively, Zurich) to determine the amount of insurance coverage available. Varvel also sued Salvatore Cava, Daniel Cava, and Dan’s Car World, LLC (collectively, the Cava defendants). The Cava defendants filed individual cross-claims against Zurich, their insurer. Zurich filed a motion to dismiss the Cava defendants’ cross-claims under W. Va. R. Civ. P. 12(b)(6). The circuit court denied Zurich’s motion to dismiss, determining that the Cava defendants asserted recognized causes of action against Zurich. Zurich sought a writ of prohibition to prevent enforcement of the circuit court’s order. The Supreme Court granted a writ of prohibition, as moulded, holding that the Cava defendants’ cross-claims against Zurich were not ripe for adjudication. Therefore, the circuit court lacked subject matter jurisdiction, and the order denying Zurich’s motion to dismiss the Cava defendants’ cross-claims was void and unenforceable. View "State ex rel. Universal Underwriters Insurance v. Honorable Patrick N. Wilson" on Justia Law

The Supreme Court reversed an order of the circuit court that granted summary judgment to Steve Sayre in connection with determining the amount of underinsured motorist insurance (UIM) owed by GEICO to Sayre. Concluding that the GEICO policy language was ambiguous, the trial court ruled that, where there were two underinsured motorists in this case, the UIM coverage was triggered separately by each of those motorists. The court then ordered GEICO to pay an additional $20,000 in UIM coverage. The Supreme Court held that the circuit court erred in applying the policy language to require GEICO to pay double the amount of UIM coverage purchased by Sayre. View "Government Employees Insurance Co. v. Sayre" on Justia Law

Pacific Bay treated an individual who was a subscriber to a Blue Shield health plan. It submitted invoices to Blue Shield for payment for the services rendered to the subscriber. Pacific Bay contends it was underpaid and brought suit against Blue Shield to recover the additional amount it claimed to be owed. The court sustained Blue Shield's demurrer to the first amended complaint (FAC) without leave to amend, finding that Pacific Bay had not shown that it was entitled to any payment from Blue Shield. As an out-of-network, nonemergency service provider, Pacific Bay was entitled to payment for treating Blue Shield's subscriber under the terms of the applicable evidence of coverage (EOC). Pacific Bay did not allege Blue Shield paid it improperly under the EOC, nor did it argue that it could allege additional facts to support such a claim. Pacific Bay claimed it was underpaid. Against this backdrop, Pacific Bay's other allegations did not give rise to any valid cause of action. View "Pacific Bay Recovery v. Cal. Physicians' Services" on Justia Law