Justia Insurance Law Opinion Summaries

The issue this case presented for the Eleventh Circuit's review centered on an insurance-coverage dispute that began in 2011 between Severin and Stephanie Hegel and The First Liberty Insurance Corporation. The Hegels claimed that First Liberty improperly denied their claim for a "sinkhole loss," defined under their homeowner's insurance policy as "structural damage to the building, including the foundation, caused by sinkhole activity." First Liberty argued that the damage to the Hegels' residence did not qualify as "structural damage," a term that was not defined in either the policy or the version of the Florida sinkhole-insurance statute applicable to their claim. The the district court granted summary judgment for the Hegels, finding that "structural damage" meant any "damage to the structure" and awarded them $166,518.17 in damages. First Liberty appealed. After review, the Eleventh Circuit reversed and remanded: the district court erred in equating the contractual term "structural damage" with any "damage to the structure." The case was remanded for further proceedings on whether there was a genuine dispute of material fact regarding how much, if any, structural damage to the Hegels' house (as properly defined) was due to sinkhole activity. The district court's determination on this issue will in turn lead to either a new grant of summary judgment for the appropriate party or to a trial on the merits. View "Hegel v. First Liberty Ins. Corp." on Justia Law

Wellmark, Inc., an Iowa-based health insurer that belongs to the national Blue Cross and Blue Shield (BCBS) network, contracted with health care providers in Iowa to provide services at certain reimbursement rates. Wellmark agreed to make those rates available both to self-insured Iowa plans that it administers and to out-of-state BCBS affiliates when those entities provide coverage for services provided in Iowa. Plaintiffs, a number of Iowa chiropractors, sued Wellmark, claiming that Wellmark had abused monopoly power in violation of the Iowa Competition Law. The Supreme Court affirmed the district court’s dismissal of some of the chiropractors’ antitrust claims and remanded on Plaintiffs’ remaining claims. On remand, Plaintiffs stipulated that their remaining antitrust claims regarding the agreements between Wellmark and both the self-insuring employers and the out-of-state BCBS affiliates were being asserted on a per se theory. The district court rejected Plaintiffs’ per se theories and entered summary judgment for Wellmark. The Supreme Court affirmed, holding that Wellmark’s arrangements with the self-insured employers and out-of-state BCBS licensees did not amount to per se violations of Iowa antitrust law. View "Mueller v. Wellmark, Inc." on Justia Law

Imperial Premium Finance LLC was implicated in a life insurance scheme. Imperial’s primary business involved stranger-originated life insurance (STOLI), yet its business was not a STOLI in its purest form: instead of buying a policy on a person's life outright, Imperial provided financing for life insurance premiums in the form of loans whose terms allowed Imperial to foreclose on the policy and become the policy owner if the borrower defaulted. Seeking to evade "insurable interest" requirements, Imperial drafted its loan agreements to require that during the term of the loan the policy be held in irrevocable trust (with a trustee chosen by Imperial) for the benefit of the insured’s relatives. In late 2007, Florida resident Barton Cotton met with an insurance agent to buy a multimillion-dollar life insurance policy and finance the premium payments. Cotton was ultimately referred to Imperial about financing the premium payments. Cotton and an irrevocable trust in his name applied to Lincoln National Life Insurance Company for an $8 million life insurance policy. The beneficiaries of the trust were Cotton’s wife and children. Cotton falsely stated on the insurance application that he was not buying the policy for resale and that he would not use a third party to finance the premium payments. Lincoln issued Cotton a $5 million policy, which became an asset of the Cotton trust. Premium payments were advanced to the trust until Imperial lent the trust $335,000. The trust used that money to repay the advance and to continue making the premium payments. Because of the high interest rate and an “origination fee," after less than two years, Imperial’s $335,000 loan to the Cotton trust had ballooned to more than $557,000. Cotton was diagnosed with esophageal cancer. The loan used to finance the policy reached maturity and became due, and Cotton died two months after that. At the time of his death the trust had not paid back Imperial for the loan, but Imperial had not yet foreclosed on it, which left the trust for the benefit of Cotton’s family as the record owner of the policy. After learning of Cotton’s death, Lincoln launched an investigation which turned up the fact that Imperial had financed the purchase of the policy on Cotton’s life under a STOLI scheme. Lincoln refused to pay the death benefit. In April 2011 the Cotton trustee sued Lincoln for the benefit. Lincoln counterclaimed, alleging fraud, negligent misrepresentation, and civil conspiracy. Imperial asked its outside counsel to represent the trust. During discovery, Lincoln sought to depose Imperial under Rule 30(b)(6) of the Federal Rules of Civil Procedure. Because the topics included in Lincoln’s subpoena touched on subjects related to the criminal investigation, Imperial’s managers and employees exercised their individual Fifth Amendment rights and all refused to testify in the Rule 30(b)(6) deposition in the Lincoln case. Imperial's proffered expert witness was unable to answer questions at the deposition or at trial specific to the facts of the Cotton trust case. The jury later returned a verdict in favor of the trust, finding that though Cotton and others conspired to commit an unlawful act, Lincoln had not relied on or been damaged by the misrepresentations, and therefore not injured by the conspiracy. The court notified the parties that it was considering sanctions against Imperial and its proffered expert due to the witness' poor "performance" and lack of preparation at trial. After a hearing, the court assessed sanctions against Imperial. Imperial appealed that sanctions order. Finding that the district court's findings were not clearly erroneous and its imposition of sanctions was not an abuse of discretion, the Eleventh Circuit affirmed the sanctions order. View "Lincoln National Life Insurance Company v. Imperial Premium Finance Company, LLC" on Justia Law

In November 2005, petitioner Barbara Shepard was working for the Oklahoma Department of Corrections when she was injured. The Workers' Compensation Court found that Shepard had sustained a permanent partial disability. The court ordered the respondent Department of Corrections and/or its insurance carrier "to provide the claimant with reasonable and necessary continuing medical maintenance limited to prescription medications and four (4) visits per year to monitor same with Dr. M." There was no limit imposed on the doctor's exercise of a medical judgment as to which prescriptions were needed by Shepard, except those that were medically reasonable and necessary. The court also directed payment of reasonable and necessary medical expenses incurred by Shepard as a result of her injury. In 2010, Shepard moved to reopen her claim based upon a change of condition for the worse. In 2011, the Workers' Compensation Court reopened the claim and determined that Shepard had a change of condition for the worse and allowed additional compensation for the worsening of her left shoulder. The order of the Workers' Compensation Court en banc stated that respondent/insurance carrier "shall pay all reasonable and necessary medical expenses incurred by claimant as a result of said injury through the date of this order." The previous award of continuing medical maintenance was not disturbed by the order that reopened her claim. The order on reopening was appealed to the Court en banc which affirmed in part and modified in part the previous order. In 2011, the Court en banc modified a provision relating to temporary total disability, and two provisions of attorney's fees. The award of reasonable and necessary medical expenses was not modified. The previous award of continuing medical maintenance was not disturbed. In 2012, Respondents sought a hearing to "discuss prescriptions." They objected one of Dr. M.'s medical reports. The court ordered Shepard to submit to a medical examination by Dr. Y., and directed this doctor to determine whether Shepard needed pain management and the nature and extent of necessary continuing medical maintenance. The order also directed Dr. Y. to determine if Shepard's current continuing medical maintenance by Dr. M. was within the Oklahoma Treatment Guidelines. The court also directed Dr. Y. to determine whether Shepard's continuing medical maintenance was within the Oklahoma Treatment Guidelines; and if not, to advise whether her continuing medical maintenance in her best interest. Respondents then sought an order that would have the effect of terminating Shepard's medical prescriptions. In June 2014, the Workers' Compensation Court of Existing Claims ordered that Dr. M. could provide continuing medical maintenance to the Shepard. In July 2014, Shepard sought review of this decision by by the Supreme Court, arguing that respondents made an impermissible retroactive application of a new workers' compensation law. Respondents argued that application of the new law to medical benefits currently being provided was not a retroactive application, and that even if the application was a retroactive application, such application was permissible. The Supreme Court held that 85 O.S.2011 section 326(G) and the statutorily incorporated Guidelines were unconstitutionally applied retroactively to employee's previous award for medical treatment that predated section 326. View "Shepard v. Dept. of Corrections" on Justia Law

Wisconsin’s notice-prejudice statutes provide that an insured’s failure to furnish timely notice of a claim as required by the terms of a liability policy will not bar coverage unless timely notice was reasonably possible and the insurer was prejudiced by the delay. Plaintiffs sued their former attorney (“Attorney”) for legal malpractice. Attorney’s professional liability insurer ("Insurer") intervened in the lawsuit and sought summary judgment declaring that the insurance policy it issued to Attorney did not cover Plaintiffs’ suit. At issue in this case was whether the notice-prejudice statutes superseded Insurer’s policy requirement that claims be reported during the policy period. Plaintiffs’ claim against Attorney was made during the policy period, but Attorney did not report the claim during the policy period. The circuit court granted the Insurer’s motion for summary judgment, but the court of appeals reversed. The Supreme Court reversed, holding that the notice-prejudice statutes did not supersede Insurer’s policy requirement that claims be reported within the policy period. View "Anderson v. Aul" on Justia Law

Fire Insurance Exchange (FIE) insured Defendant’s home in Clancy, Montana. When Defendant’s home was broken into and robbed, Defendant made a claim under her homeowner’s policy. FIE paid Defendant $22,602, representing property damage and actual cash value for the items Defendant claimed were stolen from the home. Defendant then submitted a supplemental claim in the amount of $23,102 for personal property she asserted she had replaced. When FIE concluded that the receipts Defendant provided to substantiate her replacement claims were fraudulent, FIE made a referral for criminal charges. Defendant subsequently pleaded guilty to felony insurance fraud and theft. The district court ordered Defendant to pay restitution to FIE in the amount of $22,602. The Supreme Court affirmed, holding that the district court did not err when it ordered Defendant to pay restitution to FIE even where Defendant’s initial claim was legitimate because Defendant’s subsequent fraudulent replacement value claim voided her policy, and FIE suffered a pecuniary loss in the amount of Defendant’s initial claim. View "State v. Henderson" on Justia Law

Plaintiff filed a putative class action against EquiTrust, alleging that EquiTrust's marketing of the sale of annuities violated the Racketeer Influenced and Corrupt Organizations (RICO) Act, 18 U.S.C. 1962(c), and Arizona law. The district court granted EquiTrust's motion for summary judgment but declined to award costs. In this case, plaintiff's complaint is based entirely on the language of the annuity contract and the EquiTrust marketing materials. The district court found, and the court agreed, that there were no actionable predicate acts regarding the premium bonus, the market value adjustment, nor the nonforfeiture law. The court concluded, however, that the district court must explain a denial of an award of costs to the prevailing party. Because the district court failed to do so here, the court vacated the order denying costs and remanded for further proceedings. The court affirmed the grant of summary judgment. View "Harrington v. EquiTrust Life Ins." on Justia Law

Baldwin Mutual Insurance Company appealed a circuit court order certifying the action filed against it by Gloria McCain as a class action. McCain owned a house in Montgomery on which she held a homeowner's insurance policy issued by Baldwin Mutual. That policy provided that any covered property losses would be settled "at actual cash value at the time of loss but not exceeding the amount necessary to repair or replace the damaged property." In July 2005, McCain's house was damaged as the result of a windstorm. She filed a claim with Baldwin Mutual, and Baldwin Mutual thereafter retained an independent adjuster to examine McCain's damaged property and to prepare an estimate to repair the damage. Baldwin Mutual paid McCain's claim in accordance with the estimate prepared by the adjuster. Pursuant to a work-authorization form signed by McCain, Baldwin Mutual paid the funds directly to McCain's contractor. In June 2006, McCain filed another claim after her house suffered damage as a result of a lightning strike. After the same adjuster prepared an estimate, Baldwin Mutual paid the new claim in accordance with the adjuster's estimate. The genesis of the claims underlying this suit was that Baldwin Mutual had wrongfully been reducing the amount paid on claims made on actual-cash-value polices inasmuch as its practice was to deduct some amount for depreciation not only of the damaged materials and the labor costs of initially installing those damaged materials (based on their condition prior to the covered damage and their expected life span), but also of the labor costs associated with the removal of the damaged materials. It was improper and impossible to depreciate those labor costs, McCain argued, because they had not previously been incurred at some defined time in the past; rather, they were being incurred at the time of the current repair. Noting that hundreds or thousands of Baldwin Mutual policyholders were likely negatively affected by Baldwin Mutual's practices in this regard, McCain sought class action certification of her claims. The Alabama Supreme Court reversed the class certification, finding that the trial court here exceeded its discretion with a definition proposed by McCain without giving Baldwin Mutual the opportunity to oppose the certification of the proposed class at a hearing conducted for that purpose pursuant to statute. The case was remanded for further proceedings. View "Baldwin Mutual Ins. Co. v. McCain" on Justia Law

Tuzzolino and his law firm represented Coletta. Coletta alleged that, in litigation, Tuzzolino failed to timely disclose expert witnesses; failed to retain needed expert witnesses; advised Coletta to settle for an amount far less than Coletta’s losses; told Coletta that negotiations were continuing after dismissal; and signed settlement documents without informing Coletta. According to Coletta, Tuzzolino offered to pay $670,000 to settle any potential malpractice claim, but never paid. Three months later, shortly before the expiration of the firm’s 2007-08 malpractice policy with ISBA Mutual, Tuzzolino completed a renewal application. In response to: “Has any member of the firm become aware of a past or present circumstance(s), act(s), error(s) or omission(s), which may give rise to a claim that has not been reported?” Tuzzolino checked “no.” Mutual issued the policy. Tuzzolino’s partner, Terpinas, learned of Tuzzolino’s malfeasance a month later, when he received a lien letter from Coletta’s attorney. Terpinas reported the claim to Mutual, which sought rescission and other relief. The circuit court entered summary judgment against Tuzzolino and rescinded the policy, finding that Mutual had no duty to defend Terpinas or the firm against Coletta’s action. The appellate court reversed as to Terpinas, citing the common law “innocent insured doctrine.” The Illinois Supreme Court reinstated the rescission, citing 215 ILCS 5/154, which allows rescission in cases involving misrepresentations “made by the insured or in his behalf,” with an actual intent to deceive or that “materially affect the acceptance of the risk or hazard assumed by the insurer.” View "Ill. State Bar Ass'n Mut. Ins. Co. v. Law Office of Tuzzolino & Terpinas" on Justia Law

After a subsurface water main abutting Plaintiffs’ property ruptured, causing water to flood into and damage their home’s basement, Plaintiffs made a claim under their homeowners’ insurance policy issued by Defendant, Allstate Indemnity Company. Allstate disclaimed coverage based on a provision in the policy excluding coverage for loss caused by water on or below the surface of the ground, including water that seeps through any part of the residence premises. Plaintiffs commenced this action alleging that Allstate had improperly disclaimed coverage because their claim fell within the exception to the water loss exclusion. Supreme Court declared that Plaintiffs’ loss was covered under the policy and that Allstate was required to pay the claim. The Appellate Division modified the order by vacating the declaration and otherwise affirmed, concluding that the policy was ambiguous and should be construed in favor of Plaintiffs. The Court of Appeals reversed, holding that the policy’s unambiguous language excluded from coverage the water damage to Plaintiffs’ home, and the exception did not nullify the water loss exclusion or render it ambiguous. View "Platek v. Town of Hamberg" on Justia Law