Justia Insurance Law Opinion Summaries

Kielar, a pharmacist, got many patients from Dr. Barros, whose office was in the same building, and began defrauding two insurance companies. Kielar forged prescriptions for Procrit under Barros’s name and submitted them for payment, knowing that Procrit had neither been prescribed, nor provided, to the individuals under whose policies he sought reimbursement. The insurers lost $1,678,549. Kielar was indicted for health care fraud, 18 U.S.C. 1347, with a forfeiture allegation, 18 U.S.C. 982(a)(7) that identified properties subject to forfeiture, including a Florida property. Kielar asserted that he needed the proceeds of its sale to pay legal fees. The court granted a motion to release lis pendens and ordered that the proceeds of the sale be placed in escrow with the U.S. Marshals Service. Kielar unsuccessfully requested that the court allow him to use the sale proceeds “for taxes, legal fees and other expenses.” He was convicted of six counts of health care fraud; three counts of aggravated identify theft, 18 U.S.C. 1028A(a)(1); and of using false records to impede a federal investigation, 18 U.S.C. 1519. The Seventh Circuit affirmed, rejecting arguments that the court erred in failing to hold a hearing on his request to release his escrowed funds, by limiting cross-examination of Barros, and by preventing Kielar from calling a former patient as a defense witness. View "United States v. Kielar" on Justia Law

In 2009, CE filed a class action suit under the Telephone Consumer Protection Act, 47 U.S.C. 227, against King. King had commercial general liability and umbrella policies from three insurance companies, but all three disclaimed any obligation to defend or indemnify, based on provisions in the policies that appeared to exempt liability under the Telephone Consumer Protection Act from coverage. The district court certified the class. On remand, CE and King agreed to settle the case for $20 million, the limit of the insurance policies. Their agreement, approved by the district court, provided that only one percent of the judgment ($200,000) could be executed against King. Upon learning of the proposed settlement, the insurers sought a state court declaratory judgment. A state court ruled that the insurance policies do not cover liability under the Act, but CE is appealing that decision. After the settlement agreement in the federal case, but before its approval, the insurers moved to intervene under Fed.R.Civ.P. 24(a), (b), hoping to delay approval of the settlement until there was a state-court determination. The Seventh Circuit affirmed denial of the motion to intervene as untimely. View "Valley Forge Ins. Co. v. King Supply Co., LLC" on Justia Law

Manuel’s home burned down while he and his family were vacationing in Las Vegas. Manuel had insured his home through MDOW with a policy providing $150,000 for the house, $75,000 for personal property, and $45,000 for added costs. Manuel filed a claim for the fire, but MDOW denied it. MDOW told Manuel that it believed he or someone acting on his behalf had intentionally set the fire and that Manuel’s claim form contained fraudulent information. Manuel sued. A jury found that MDOW proved by a preponderance of the evidence that Manuel “either burned his home or caused it to be burned.” The jury did not decide whether Manuel had intentionally misrepresented information during the fire investigation. The Eighth Circuit affirmed, agreeing even under an “implied bias” test of juror impartiality, there was insufficient potential bias alleged to warrant a new trial. The court rejected an argument that the court erred by allowing the testimony of MDOW’s expert witness, who disagreed with parts of the National Fire Protection Association 921 Guide for Fire and Explosion Investigations. View "Manuel v. MDOW Ins. Co." on Justia Law

McGinnes Industrial Waste Corporation dumped pulp and paper mill waste sludge into disposal pits near the San Jacinto River in Pasadena, Texas (the site). After environmental contamination was discovered at the site, the Environmental Protection Agency (EPA) instituted superfund cleanup proceedings under the federal Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA). During the period that McGinnes was dumping waste at the Site, it was covered by standard-form commercial general liability (CGL) insurance policies issued by Phoenix Insurance Company and Travelers Indemnity Company (together, the Insurers). McGinnes requested a defense in the EPA proceedings from the Insurers. The Insurers refused, determining that the proceedings were not a “suit” under the policy. McGinnes sued the insurers in federal court seeking a declaration that the policies obligated them to defend the EPA’s CERCLA proceedings. The district court granted the Insurers’ motion for partial summary judgment on the duty-to-defend issue. The U.S. Court of Appeals for the Fifth Circuit certified a question regarding the issue to the Texas Supreme Court. The Supreme Court answered that “suit” in the CGL policies at issue must also include CERCLA enforcement proceedings by the EPA. View "McGinnes Indus. Maint. Corp. v. Phoenix Ins. Co." on Justia Law

Gladys Tellis, Sherry Bronson, Gwendolyn Moody, Nadine Ivy, and Uneeda Trammell (collectively, "the policyholders") initiated separate actions against American Bankers Insurance Company of Florida, asserting generally that American Bankers had sold them homeowner's insurance policies providing a level of coverage they could never receive, even in the event of a total loss involving the covered property. American Bankers moved the trial court hearing each action to compel arbitration pursuant to arbitration provisions it alleged were part of the subject policies; however, the trial courts denied those motions, and American Bankers appealed. The Supreme Court consolidated the five appeals for the purpose of writing one opinion, and reversed those orders denying the motions to compel arbitration. The Court based its decision on its holdings that the policyholders manifested their assent to the arbitration provision in their policies by continuing to renew the policies, that the sale of the policies affected interstate commerce, and that the arbitration provision in the policies was not unconscionable. View "American Bankers Ins. Co. of Florida v. Tellis" on Justia Law

Alfa Mutual General Insurance Company ("Alfa") petitioned for a writ of mandamus to direct the Mobile Circuit Court to grant its motion seeking to realign the parties to the underlying litigation so that Alfa may "opt out" of participation in the trial. In October 2012, respondent Mark Trotter was injured when a "road sweeper" he was operating was struck by a vehicle being operated by Daniel Elijah Davis, an uninsured motorist. In October 2014, Trotter sued Alfa seeking to recover uninsured/underinsured motorist ("UIM") benefits pursuant to a policy of insurance issued by Alfa to Trotter, which was in place at the time of the 2012 accident. Trotter did not include Davis as a codefendant in his action against Alfa. Alfa subsequently filed a third-party complaint adding Davis as a third-party defendant. Specifically, Alfa's third-party complaint alleged that, to the extent it was determined to be liable to Trotter for UIM benefits, then Alfa was subrogated to and entitled to recover the amount of that liability from Davis. Thereafter, Alfa filed a "Motion to Realign Parties" in which it asked to "opt out" of the litigation. Without explaining the findings on which its decision was based, the trial court denied Alfa's motion. The Alabama Supreme Court concluded after a review of the record, that Alfa has demonstrated a clear legal right to have its motion to realign the parties granted and to allow it to opt out of the underlying litigation. No authority is cited requiring that, in order to make the permitted election, Alfa must first release the right of subrogation to which it was also clearly entitled. View "Ex parte Alfa Mutual General Insurance Company." on Justia Law

Kaady, a mason, filed suit against Mid-Continent after Mid-Continent denied Kaady's claim for indemnification under its commercial liability insurance policy. The district court granted summary judgment to Mid-Continent based on the ground that Kaady's claim was barred by the policy's known-loss provision. The court concluded that MidContinent has offered no reason to treat the insured’s work and the work of others as different property in every provision of the policy except the known-loss provision. Thus, the known-loss provision also distinguishes between them. The insured’s knowledge of damage to his own work doesn’t automatically constitute knowledge of damage to the components of the structure furnished by others. Further, an insured’s knowledge of one type of damage to property doesn’t automatically constitute knowledge of any and all damage to the property; the claimed damage must be related to the known damage. In this case, Kaady’s knowledge of the cracks in the masonry before he bought the policy doesn’t constitute knowledge of the claimed “property damage” to the structural components. The court concluded that the correct inquiry is whether the claimed damage to the structural components was a “continuation, change or resumption” of the cracks. If it was, Kaady’s knowledge of the cracks would bar coverage of the claimed damage; if not, his knowledge of the cracks wouldn’t bar coverage. In this case, without any record evidence connecting the cracks in the masonry that Kaady observed before he bought the policy to the damage to the wooden components for which Kaady claims coverage, summary judgment was inappropriate. Accordingly, the court reversed and remanded. View "Kaady v. Mid-Continent Cas. Co." on Justia Law

Plaintiff is a health insurance company that offers a choice of federal government-regulated alternatives to Medicare known as Medicare Advantage plans. These plans allow Medicare-eligible individuals to purchase health insurance from private insurance companies. Those companies are reimbursed by the government for health care services provided to the plans’ members. Before the Supreme Judicial Court was Plaintiff’s demand for indemnification to cover losses resulting from health care claims for unprovided services paid through Plaintiff’s computer system. At issue was the coverage available to Plaintiff pursuant to Rider #3 of a financial institution bond issued by Defendant. The bond insured Plaintiff against various losses, and the Rider amended the bond to provide indemnification specifically for computer systems fraud. When Plaintiff suffered more than $18 million in losses for payment for fraudulent claims for services never actually performed under its Medicare Advantage plans, Plaintiff sought payment from Defendant for its post-deductible losses. Defendant denied coverage, and Plaintiff sued. Supreme Court granted summary judgment for Defendant. The Court of Appeals affirmed, holding that the Rider applies to losses resulting directly from fraudulent access, not to losses from the content submitted by authorized users. View "Universal Am. Corp. v Nat’l Union Fire Ins. Co. of Pittsburgh, PA" on Justia Law

Plaintiffs filed suit against USAA, seeking to recover a portion of their insurance premium payments because they would have elected to pay for building ordinance and law (BOL) insurance covering only 25% of their home's value. On appeal, plaintiffs challenged the dismissal of their complaint. The court agreed with the district court that the plain language of Florida Statutes 627.7011(2) does not require an insurer to obtain a policyholder’s written consent on a form approved by the Florida Office of Insurance Regulation before issuing BOL coverage greater than 25%. Further, Florida Statutes 627.418(1) bars plaintiffs' suit because the only remedy available for providing extra insurance coverage is to enforce the contract as written. In this case, plaintiffs freely contracted to buy 50% coverage, that is exactly what they received, and no legal basis exists for reducing their premium payments. Accordingly, the court affirmed the judgment. View "Allen v. U.S. Automobile Assoc." on Justia Law

The Patient Protection and Affordable Care Act (42 U.S.C 18001) includes “guaranteed issue” and “community rating” requirements, which bar insurers from denying coverage or charging higher premiums based on health; requires individuals to maintain health insurance coverage or make a payment to the IRS, unless the cost of buying insurance would exceed eight percent of that individual’s income; and seeks to make insurance more affordable by giving refundable tax credits to individuals with household incomes between 100 per cent and 400 percent of the federal poverty line. The Act requires creation of an “Exchange” in each state— a marketplace to compare and purchase insurance plans; the federal government will establish “such Exchange” if the state does not. The Act provides that tax credits “shall be allowed” for any “applicable taxpayer,” only if the taxpayer has enrolled in an insurance plan through “an Exchange established by the State under [42 U.S.C. 18031],” An IRS regulation interprets that language as making credits available regardless of whether the exchange is established by a state or the federal government. Plaintiffs live in Virginia, which has a federal exchange. They argued Virginia’s Exchange does not qualify as “an Exchange established by the State,” so they should not receive any tax credits. That would make the cost of buying insurance more than eight percent of their income, exempting them from the coverage requirement. The district court dismissed their suit. The Fourth Circuit and Supreme Court affirmed. Tax credits are available to individuals in states that have a federal exchange. Given that the text is ambiguous, the Court looked to the broader structure of the Act and concluded that plaintiffs’ interpretation would destabilize the individual insurance market in any state with a federal exchange. It is implausible that Congress meant the Act to operate in that manner. Congress made the guaranteed issue and community rating requirements applicable in every state, but those requirements only work when combined with the coverage requirement and tax credits. View "King v. Burwell" on Justia Law