Justia Insurance Law Opinion Summaries

Insurer issued an insurance policy to Insured covering his truck. When Insured did not pay the premium amount to renew his policy by the deadline of May 1, Insurer sent Insured a notice of expiration and cancellation summary but offered to reinstate Insured’s coverage without interruption if he would pay the premium by May 18. Insurer wrote a check that was not received by Insured until May 24. On May 14, After Insurer sent the notice of expiration and before Insured’s payment had arrived, Insured was involved in an automobile accident resulting in the total loss of his truck. Insurer denied coverage for the accident, and Insured filed a complaint alleging breach of contract and requesting declaratory relief. The district court determined that there was no automobile insurance policy in effect at the time of Insured’s accident, and therefore, Insurer had no contractual duty to indemnify Insured for his losses. The Supreme Court affirmed, holding that the district court did not err by concluding that Insurer properly cancelled the insurance policy for nonpayment of the renewal premium. View "Finn v. Dakota Fire Ins. Co." on Justia Law

A Challenge employee consulted Dr. Mirza about back pain, agreed to undergo an endoscopic discectomy, and executed an assignment of her benefits under Challenge’s plan. Mizra completed the procedure and submitted a claim for $34,500, which was denied. Mirza submitted additional documents. The claim was denied again. Mirza went through internal review and, on August 12, 2010, received a letter denying his final appeal, indicating that the procedure was not covered because it was medically investigational, and notifying Mirza of his right to bring a civil action under the Employee Retirement Income Security Act, 29 U.S.C. 1001. Neither the letter nor the earlier denials mentioned that, under the plan, Mirza had one year from the final denial to seek judicial review. While the parties debate the substance of an earlier phone call, the first time Mirza received written notice of the one-year deadline was April 11, 2011. On March 8, 2012, Mirza sued. The district court granted defendants summary judgment. The Third Circuit vacated. Plan administrators must inform claimants of plan-imposed deadlines for judicial review in their notifications denying benefits. The appropriate remedy is to set aside the plan’s time limit and apply the limitations period from New Jersey’s six-year deadline for breach of contract claims. View "Mirza v. Ins. Admin. of Am., Inc" on Justia Law

A Union Pacific Railroad train t-boned an SRM dump truck as the truck crossed the tracks in the path of the train. The collision killed the truck driver and derailed the train causing extensive damage to the train’s engines, its cars, and three of its workers. The three injured train workers sued Union Pacific, SRM, and SRM’s primary auto liability insurer, Bituminous Insurance Company, in state court. Union Pacific cross-claimed against SRM and SRM counter cross-claimed. As SRM’s excess liability insurer, Great American Insurance Company, received notice of the claims and monitored the case for potential exposure under its umbrella policy. Under Oklahoma law, a primary insurer owes its insured a duty to initiate settlement negotiations with a third-party claimant if the insured’s liability to the claimant is clear and the insured likely will be held liable for more than its insurance will cover. Here, SRM sought to extend this obligation Great American. Specifically, SRM claimed that Great American breached its insurance policy and duty of good faith and fair dealing by not proactively investigating claims against SRM and by refusing to tender its policy limits to spur settlement negotiations. The district court granted Great American’s motion for summary judgment on SRM’s claims and denied SRM’s request to reconsider. The Tenth Circuit found no reversible error in the district court judgment and affirmed. View "SRM v. Great American Insurance" on Justia Law

The NEI Board administers a self-funded, multi-employer health plan covered by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001. A Trust Agreement, executed by the participating companies and the Board, does not specify Plan details, but provides that “[t]he detailed basis on which payment of benefits is to be made … shall be set forth in the Plan of Welfare Benefits … subject to amendment by the Trustees.” The National Elevator Industry Health Benefit Plan Summary Plan Description, (SPD) provides the details and includes a subrogation provision: The Plan has the right to recover benefits advanced to a covered person for expenses or losses caused by another party. The Plan is only obligated to provide covered benefits resulting from that illness or injury that exceed amounts recovered from another party (regardless of whether designated to cover medical expenses). The Plan sought reimbursement for medical expenses paid on Moore’s behalf, following Moore’s settlement of a negligence action against entities responsible for injuries he suffered in an accident. Moore counterclaimed, alleging that the Board had violated its fiduciary duty by misrepresenting the Plan terms. The Sixth Circuit found that the SPD containing the subrogation provision set out the binding terms of the Plan and that the plain language of the provision required reimbursement. View "Bd. of Trustees v. Moore" on Justia Law

During his employment with a subsidiary of Santander Holdings, Stevens received treatment for ankylosing spondylitis, a chronic inflammatory disease, and participated in a short-term disability plan (STD) and a long-term disability plan (LTD). When Stevens’ condition worsened, Liberty Mutual, the administrator of Santander’s plans, initially awarded STD benefits to Stevens, then determined that Stevens no longer suffered from a qualifying disability and terminated his benefits. Stevens sued under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001. The district court found that Liberty Mutual’s decision to terminate Stevens’s STD benefits was arbitrary and capricious and remanded with instructions to reinstate Stevens’s STD benefit payments retroactively and to determine his eligibility for LTD benefit payments. The Third Circuit dismissed an appeal for lack of jurisdiction, finding that the remand order to the plan administrator was not a “final decision” appealable pursuant to 28 U.S.C. 1291 at that time. The district court retained jurisdiction over the case and the order is not yet appealable. View "Stevens v. Santander Holdings USA Inc." on Justia Law

This case concerned an insured’s assignment of the right to invoke defense and indemnification coverage under a liability policy issued by Hartford Accident & Indemnity Company. The Supreme Court held in Henkel Corp. v. Hartford Accident & Indemnity Co., a case decided on similar facts, that the consent-to-assignment clause was enforceable and precluded the insured’s transfer of the right to invoke coverage without the insurer’s consent even after the coverage-triggering event had already occurred. At issue here was whether Cal. Ins. Code 520 - a statute that was not considered by the Court when it Henkel - changes the Court’s determination in Henkel. Section 520 specifically restricts an insurer’s ability to limit an insured’s right to transfer or assign a claim for insurance coverage. The court of appeal below concluded that section 520 does not apply to liability insurance and that, even assuming the statute applies, it should be construed to reflect the same rule articulated in Henkel. The Supreme Court reversed, holding (1) in light of the relevant language and history of section 520, the statute applies to third party liability insurance and bars an insurer from refusing to honor an insured’s assignment of policy coverage regarding injuries that predate the assignment; and (2) consequently, the decision in Henkel cannot stand. View "Fluor Corp. v. Superior Court of Orange County" on Justia Law

Insurer issued an automobile policy to Philip Laboy as the named insured. The policy provided that Insurer would pay “any negotiated reduced rate accepted by a medical provider.” Three members of Laboy’s family, also insureds under the policy, were involved in an automobile accident. The Laboys submitted some of their medical bills both to Insurer and to their health-insurance provider. The Laboys later reached a settlement with the third-party tortfeasor. When Insurer exercised its contractual right to subrogation against the Laboys, the Laboys objected, arguing that Insurer had overpaid the medical providers. As evidence, the Laboys showed that Insurer had paid discounted rates to medical providers totaling $1,441 in medical expenses but that their own health insurer paid only $648 for those same medical expenses. The Laboys filed a class-action lawsuit against Insurer, alleging claims for breach of contract and breach of good faith and fair dealing. The trial court entered summary judgment for Insurer. The Supreme Court agreed with the trial court’s judgment, holding that the only reasonable interpretation of the policy is that “any negotiated reduced rate accepted by a medical provider” means a negotiated reduced rate that Insurer was contractually entitled to pay and does not include the reduced rates negotiated by the Laboys’ health-insurance provider. View "Laboy v. Grange Indem. Ins. Co." on Justia Law

Castro-Cortes was working for Astro, a subcontractor of JRJ, when he fell through a hole on the jRJ property. He sued JRJ for personal injury in Illinois state court. After being served in that suit, JRJ’s two members, Panfil and Michelon, filed a report with Nautilus under a general commercial liability policy. Nautilus refused to defend, citing three grounds: that the underlying lawsuit was against JRJ, but the named insureds were Panfil and Michelon; the “Contractor-Subcontracted Work Endorsement;” and the “Employee Exclusion.” The JRJ parties filed a federal suit for breach of contract. On summary judgment, the district court determined that Nautilus breached its duty to defend because there was at least the potential for coverage of the underlying lawsuit. The Seventh Circuit affirmed, stating that it is a close case and that the bar to finding a duty to defend is low. The court construed the language of the exclusions in favor of JRJ, noting that the burden of proving that a claim falls within an exclusion rests on the insurer. View "Panfil v. Nautilus Ins. Co." on Justia Law

Federated, a Minnesota corporation, insured Missouri property owned by Hubbard and leased to the McKees. A fire damaged the property. Both Hubbard and the McKees, who said they exercised an option to purchase the property, made claims. Federated claimed it owed $40,980.95 and that Hubbard and the McKees disputed the distribution. Asserting that Federated owed more, Hubbard counterclaimed for vexatious refusal to pay. The district court authorized Federated to deposit $40,980.95 and dismissed Hubbard’s counterclaim. The parties mediated. In an e-mail to Federated’s counsel and the McKees’ counsel, Hubbard’s counsel wrote that the McKee claim was resolved by payment of $10,879.39. The email stated: As the sum owed to the McKee defendants is less than $11,000.00, there is no possible way that the McKee defendants should have to proceed further as Federated has asserted it owes no less than $40,980.95. Seven months later, Hubbard sued Federated and the McKees in state court. Federated removed the case; Hubbard moved to remand. Concluding that Hubbard fraudulently joined the McKees, the court dismissed them, denied remand, and applied res judicata and collateral estoppel to Hubbard’s claim. The Eighth Circuit affirmed, noting that in the original case, the district court has distributed the interpleaded funds and dismissed with prejudice. View "Hubbard v. Federated Mut. Ins. Co." on Justia Law

Abhe, an industrial painting contractor, used stationary leased barges as platforms while painting Pell Bridge over Narragansett Bay. Abhe changed insurance carriers three months into the project. St. Paul Fire did not request that Abhe complete an application, but accepted the application provided to its previous insurer in 2010. The attached schedule of vessels was outdated and did not include vessels leased for the Pell Bridge project. Abhe sent St. Paul an updated schedule in 2011, listing those vessels, but did not provide a 2010 survey that showed that one barge had non-watertight bulkheads. St. Paul did not attempt to survey any of the equipment, as it was entitled to do under the policy. After the barge sunk in a storm, St. Paul denied Abhe’s claims and sought a declaration that the policy was void under the doctrine of uberrimae fidei, which requires that parties to an insurance contract accord each other the highest degree of good faith. Abhe counterclaimed, alleging negligence. The district court granted St. Paul summary judgment, finding the package policy void because Abhe failed to disclose the survey. The Eight Circuit remanded, stating that reliance is an element of the defense, and that there are disputed issues of fact as to whether it is satisfied. View "St. Paul Fire & Marine Ins. v. Abhe & Svoboda, Inc." on Justia Law