Justia Insurance Law Opinion Summaries

Defendants appealed the district court's grant of summary judgment in favor of Nationwide, holding that defendants initially purchased a valid homeowner's insurance policy from Nationwide, but that subsequent renewals of that policy were void ab initio because they occurred after defendants lost ownership of their home to foreclosure. The court affirmed, concluding that, by renewing their homeowner's policy when they no longer owned their home, defendants made a misstatement of material fact that entitled Nationwide to rescind the policy. View "Nationwide Mutual Ins. Co. v. Baptist, et al." on Justia Law

As a Solvay employee Moyer participated in Solvay’s ERISA- governed Long Term Disability Plan. In 2005 MetLife initially approved Moyer’s claim for benefits. MetLife reversed its decision in 2007 after determining that Moyer retained the physical capacity to perform work other than his former job. In an administrative appeal, MetLife affirmed the revocation on June 20, 2008. Moyer’s adverse benefit determination letter included notice of the right to judicial review but failed to include notice that a three-year contractual time limit applied. The Summary Plan Description failed to provide notice of either Moyer’s right to judicial review or the applicable time limit. On February 20, 2012, Moyer sued MetLife, seeking recovery of unpaid plan benefits under 29 U.S.C. 1132(a)(1)(B). The district court held that the plan’s limitations period barred Moyer’s claim, noting that the plan documents—which were not sent to participants unless requested—stated that there was a three-year limitations period for filing suit, so that MetLife provided Moyer with constructive notice of the contractual time limit. The Sixth Circuit reversed. Exclusion of the judicial review time limits from the adverse benefit determination letter was inconsistent with ensuring a fair opportunity for review and rendered the letter not in substantial compliance.View "Moyer v. Metropolitan Life Ins. Co" on Justia Law

Plaintiff filed suit challenging the decision of an arbitrator that had denied his claim under a crop insurance policy obtained from ProAg. On appeal, ProAg challenged the district court's grant of plaintiff's motion to vacate the award and motion for summary judgment, vacating the arbitrator's decision. The court concluded that the district court erred in vacating the arbitrator's decision because the arbitrator was entitled to conclude that ProAg had the authority under the policy to set a reasonable deadline for the receipt of necessary documentation in support of the claim; plaintiff's failure to comply with the deadline was an adequate basis for ProAg's denial of his claim; the arbitrator was entitled to make his findings without first seeking a formal opinion of the FCIC; and plaintiff waived any argument based upon the arbitrator's failure to deliver his decision and award within the time limitations provided by the policy. Accordingly, the court reversed and remanded.View "Davis v. Producers Agricultural Ins." on Justia Law

Plaintiff-appellant Richard Salzer received medical care at an SSM Healthcare of Oklahoma (SSM) facility for injuries he sustained in an accident. At the time of his treatment, he had a health insurance plan (the "Plan"). Salzer entered into a contract with SSM to receive its services (the "Hospital Services Agreement"), under which he "authorized disclosure of [his] medical information for billing purposes and authorized [his] health insurance company to pay." SSM had an existing contract with Salzer's health insurance company (the "Provider Agreement") which required SSM to submit covered medical charges to Salzer's insurance company and accept discounted payment from the insurer. Although the Provider Agreement prohibited SSM from seeking payment for a covered charge from Salzer, SSM sought the non-discounted amount directly from him. Salzer sued SSM alleging breach of contract and other state law claims based on SSM's attempt to collect payment for medical care from Salzer instead of his health insurance company. SSM removed the case to federal district court. Salzer challenged the district court's denial of his motion to remand based on its determination that his claims were completely preempted by the Employee Retirement Income Security Act of 1974 (ERISA). Finding no reversible error, the Tenth Circuit affirmed the district court. View "Salzer v. SSM Health Care of Oklahoma" on Justia Law

Plaintiffs, employed by defense contractor Qinetiq to work on a military base in Iraq, were enrolled in Qinetiq’s Basic Long Term Disability, Basic Life, and Accidental Death and Dismemberment insurance policies, governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001, under a single contract with Prudential. Qinetiq paid the premiums. Plaintiffs also purchased, with their own funds, supplemental coverage under the same terms as the basic policies; there was a single summary plan description. An employee would file a single claim for basic and supplemental coverage benefits. The plan booklets provided that loss is not covered if it results from war, or any act of war, declared or undeclared. These exclusions applied to both the basic and supplemental policies. The plaintiffs were not otherwise uninsured for excluded injuries. Qinetiq obtained insurance required by the Defense Base Act, 42 U.S.C. 1651. After Prudential denied claims, the plaintiffs sued, alleging violations of the state consumer fraud acts and the Truth in Consumer Contract, Warranty, and Notice Act; breach of contract and breach of the implied covenant of good faith and fair dealing; and intentional or negligent misrepresentation or omission. They contended that Prudential fraudulently induced them to buy supplemental coverage knowing that any claim they filed would likely be subject to the war exclusions, rendering supplemental coverage effectively worthless. The district court dismissed, treating the basic and supplemental policies as components of a single plan, and holding that all state law claims were preempted by ERISA. The Third Circuit affirmed, holding that the supplemental coverage cannot be “unbundled” from ERISA coverage.View "Menkes v. Prudential Ins. Co. of Am." on Justia Law

Hayssen and its employees were parties to a Plant Closing Agreement that promised medical benefits upon retirement. In 1996, Bemis acquired Hayssen and assumed its obligations. Bemis reduced benefits under the Agreement: increasing co-pays and deductibles and eliminating its prescription drug program. Former employees sued under the Employee Retirement Income Security Act, 29 U.S.C. 1132, and the Labor-Management Relations Act, 29 U.S.C. 185(a). The court certified a class, but granted summary judgment to Bemis, reasoning that the Agreement did not establish a lifetime interest in a certain level of benefits. About a month later, Bemis eliminated all medical benefits under the Agreement. The Seventh Circuit reversed, concluding that the parties intended to provide lifetime medical coverage. On remand, the court granted a preliminary injunction forcing Bemis to restore the benefits eliminated in 2009 and provide a basic Medicare Part D drug benefit. The court awarded fees and costs, finding that the company’s position was not substantially justified. The judge struck billing entries that were vague or for time not reasonably expended on the case, concluded that the lawyers’ billing rates were reasonable, and calculated the lodestar amount to reach an award of $403,053.75, for four years of advocacy, including an appeal and trial preparation. The Seventh Circuit affirmed.View "Temme v. Bemis Co., Inc." on Justia Law

Reva Merrill appealed a Superior Court judgment that affirmed the Board of Trustees for the Maine Public Employees Retirement System's decision to deny her request for a waiver of past-due life insurance premiums. Merrill contended on appeal that the Board erred in interpreting 5 M.R.S. 17103(6)(2008) to prohibit it from waiving past-due payments for the non-mandatory Group Life Insurance Program, and that the Board's administrative procedures violated her right to due process. Because the Supreme Court agreed with Merrill that the Board had the authority to waive back premiums, the Court vacated the Board's decision and remanded the case for the Board to decide finally whether to waive Merrill's required payments. View "Merrill v. Maine Public Employees Retirement System" on Justia Law

Plaintiff filed suit against Mid-Continent, alleging that Mid-Continent breached the insurance contract by denying coverage to plaintiff in an underlying lawsuit arising from a subcontractor's faulty workmanship during construction of a home. The court affirmed the district court's dismissal of the claim because faulty workmanship on the home was not an "occurrence" within the meaning of the policy under Essex Ins. Co. v. Holder. The district court did not err by denying plaintiff leave to amend because plaintiff seeks to extend coverage to subcontractor negligence through a claim of estoppel. Under Arkansas law, the doctrine of waiver of estoppel cannot be given the effect of enlarging or extending the coverage as defined in the contract.View "J-McDaniel Construction Co v. Mid-Continent Casualty Co., et al." on Justia Law

In 2011, Michigan passed the Health Insurance Claims Assessment Act, Mich. Comp. Laws 550.1731–1741, to generate revenue needed to fund its obligations under Medicaid. The Act functions by imposing a one-percent tax on all “paid claims” by “carriers” or “third party administrators” to healthcare providers for services rendered in Michigan for Michigan residents. “Carriers” include sponsors of “group health plan[s]” set up under the strictures of the Employee Retirement Income Security Act, 29 U.S.C. 1002–1461. On top of the tax, every carrier and third-party administrator paying the tax must submit quarterly returns with to the Michigan Department of the Treasury and “keep accurate and complete records and pertinent documents as required by the department.” Every carrier and third-party administrator must also “develop and implement a methodology by which it will collect the [tax]” subject to several conditions. SIIA sought a declaratory judgment that ERISA preempted the Act, and an injunction, to prevent implementation and enforcement of the Act against the ERISA-covered entities. The district court dismissed, concluding that the Act did not offend ERISA’s express preemption clause because the Act did not “relate to” an ERISA-governed benefit plan. The Sixth Circuit affirmed, finding that the statute escapes the preemptive reach of ERISA.View "Self-Ins. Inst. of Am., Inc. v. Snyder" on Justia Law

Plaintiff Progressive Casualty Insurance Company insured the vehicle involved in the accident at issue in this case. Given the number of victims, the policy’s liability coverage did not fully compensate at least one of the injured passengers. The parties disputed whether the injured passenger was therefore entitled to UIM benefits under Progressive’s policy. Progressive argued that coverage was barred by certain exclusions in its policy. The trial court found Progressive’s exclusions unenforceable as inconsistent with the definition of an "underinsured vehicle" set forth in 23 V.S.A. 941(f). Progressive appealed, arguing that its exclusions should be enforced, and that it should not have to provide both liability and UIM benefits to the injured passenger. The Supreme Court agreed with Progressive after its review of the case, and therefore, reversed the trial court’s decision.View "Progressive Casuality Insurance Co. v. MMG Insurnace Co." on Justia Law