Justia Insurance Law Opinion Summaries

Plaintiffs filed suit to recover losses sustained after a fire damaged their home. On appeal, plaintiffs challenged the district court's grant of summary judgment to Allstate. Plaintiffs claimed that the jury instructions misstated Missouri law and the elements of the claims and defenses. The court concluded that the jury instruction was not obviously erroneous and that any imprecision in this instruction was not the sort of egregious error that might warrant relief on plain error review in a civil case. Accordingly, the court affirmed the judgment of the district court.View "Young, et al. v. Allstate Ins. Co." on Justia Law

Baum filed suit against Twin City, its insurer, over a dispute regarding coverage of an IRS investigation. Reviewing the choice of law question in light of sections 188 and 187 of the Restatement (Second) of Conflict of Laws, the court predicted that the Missouri Supreme Court would apply New York law to this dispute; the court concluded that the policy provided coverage where Twin City's insurance agreement was ambiguous regarding any timely notice requirement applicable to later liabilities arising from a timely original claim; although the district court erred by applying Missouri law, the court affirmed the judgment of the district court; and the court affirmed the district court's declaration that a $3 million self-insured retention applied to the derivatives litigation because the litigation was sufficiently related to Baum's business underwriting and selling municipal bonds. View "George K. Baum & Co. v. Twin City Fire Ins. Co." on Justia Law

Warner, insured by State Farm, was involved in an automobile accident. Following the accident, Michigan Spine provided Warner with about $26,000 of neurological treatment. State Farm denied coverage, stating that Warner’s condition was the result of a preexisting condition. Michigan Spine submitted the claim to Medicare, which approved a conditional payment of $5,000 under the Medicare Secondary Payer Act, 42 U.S.C. 1395y. Michigan Spine sued State Farm under Michigan’s No-Fault Act and the Medicare Secondary Payer Act, which permits private causes of action against primary plans that fail to pay medical expenses for which they are responsible. The district court dismissed, holding that a private party can recover under the Secondary Payer Act only if a “primary plan” has failed to provide appropriate reimbursement only because the planholder is entitled to Medicare benefits, and State Farm did not deny coverage on that basis. The Sixth Circuit reversed and remanded. Although the text of the Secondary Payer Act is unclear as to whether a private cause of action is available against a non-group health plan that denies coverage on a basis other than Medicare eligibility, accompanying regulations and congressional intent indicate that the requirement applies only to group health plans and not to non-group health plans. Michigan Spine may pursue its claim under the Secondary Payer Act. View "MI Spine & Brain Surgeons, PLLC v. State Farm Mut. Auto Ins Co" on Justia Law

Velicia Carter was injured in an automobile collision with Jeova Oliviera. It was alleged that Oliviera was under the influence of alcohol at the time. Oliviera had an auto liability insurance policy with GEICO General Insurance Company with a $30,000 per person liability limit. Carter was insured by Progressive Mountain Insurance Company, including uninsured/underinsured motorist (UM) coverage of $25,000 per person. Carter sued Oliviera and served Progressive as her UM carrier, and entered into a settlement in which GEICO paid the $30,000 limit of Oliviera's policy, and Carter executed a limited liability release. It allocated $29,000 of GEICO's payment to punitive damages and $1,000 to compensatory damages. Progressive answered the suit as Carter's UM carrier and sought summary judgment on the UM claim, which the trial court granted, ruling that, by imposing the condition that $29,000 of the liability coverage limit be allocated to the payment of punitive damages, Carter failed to meet a prerequisite for recovery of the UM benefits. The Court of Appeals affirmed, finding that, by allocating a portion of the payment to punitive damages, rather than allocating all of the payment to compensatory damages, Carter failed to exhaust the limits of Oliviera's liability policy, and, therefore, forfeited the ability to make a claim on her UM policy. The Supreme Court granted a writ of certiorari to the Court of Appeals to determine if that Court properly applied the motor vehicle insurance limited liability release provision of OCGA 33-24-41.1. Finding that the Court of Appeals erred, the Supreme Court reversed that Court's judgment. View "Carter v. Progressive Mountain Ins." on Justia Law

Expedia (and several other hotel booking websites, collectively, "Petitioners") has been subject to approximately 80 underlying lawsuits by states, counties, and municipalities (collectively, taxing authorities) for purportedly failing to collect the right amount of local occupancy taxes from its hotel customers. Expedia tendered most of the suits to its insurer, Zurich, although some were tendered late. Zurich refused to defend Expedia on a number of grounds, including late tender and that the underlying suits may be excluded from the policies' coverage. The trial court declined to make a determination of Zurich's duty to defend Expedia, instead ordering discovery that Expedia claimed was prejudicial to the underlying actions. Petitioners sought adjudication of their summary judgment motion concerning their respective insurers' duty to defend them in cases brought by local taxing authorities. They further requested a stay of discovery in the coverage action that could prejudice them in the underlying litigation. Upon review of the matter, the Washington Supreme Court held that the trial court erred by delaying adjudication of Zurich's duty to defend Expedia. Accordingly, the Court vacated the trial court's order. The case was remanded to the trial court to determine Zurich's duty to defend Expedia in each of the 54 underlying cases subject to Expedia's motion. The trial court was furthermore ordered to stay discovery in the coverage action until it could make a factual determination as to which parts of discovery are potentially prejudicial to Expedia in the underlying actions. View "Expedia, Inc. v. Steadfast Ins. Co." on Justia Law

Employee was injured at work and underwent surgery. Employee’s health insurer covered the surgery’s costs at a discounted rate. After the Department of Labor found Employer liable for Employee’s condition Employer accepted Employee’s claim and reimbursed Employee for his out of pocket expenses and reimbursed Employee’s insurer for payments it made on Employee’s behalf. Employee challenged the payment, arguing that Employer was required to pay the full medical expense without the health insurance discount. The Department concluded that Employer fulfilled its obligation. The circuit court reversed and found Employer liable for the full medical expense billed before adjustments. Employer appealed. The Supreme Court reversed the circuit court and reinstated the Department’s order, holding that the Department correctly applied the law in determining that Employer satisfied its statutory reimbursement obligation. View "Whitesell v. Rapid Soft Water & Spas, Inc." on Justia Law

An employee (Isack) was injured during the course and scope of his employment with his employer. Acuity, the employer’s workers’ compensation insurer, paid workers’ compensation benefits to Isack. Isack then retained attorney John Knight for legal representation in a suit against the tortfeasor and his employer. In turn, Acuity retained an attorney to represent its statutory rights of recovery and offset in Isack’s claim. Isack and the tortfeasor’s employer reached a litigation settlement. The trial judge subsequently awarded Knight one-third of Acuity’s recovery and offset award. Acuity appealed, arguing that the circuit court erred by giving Knight a thirty-three percent contingent fee from Acuity’s settlement portion because Acuity retained its own attorney to represent its interests. The Supreme Court affirmed, holding that the circuit court’s application of S.D. Codified Laws 62-4-39 and its allocation of the entire contingent fee to Knight was not clearly erroneous.View "Isack v. Acuity" on Justia Law

Public Act 97-695 (eff. July 1, 2012), amended section 10 of the State Employees Group Insurance Act of 1971, 5 ILCS 375/10, by eliminating the statutory standards for the state’s contributions to health insurance premiums for members of three of the state’s retirement systems. The amendment requires the Director of Central Management Services to determine annually the amount of the health insurance premiums that will be charged to the state and to retired public employees. It is not limited to those who become annuitants or survivors on or after the statute’s effective date. The amendment was challenged by members of the affected entities: State Employees’ Retirement System (SERS), State Universities Retirement System (SURS), and Teachers’ Retirement System (TRS), as violation the pension protection clause, the contracts clause, and the separation of powers clause of the Illinois Constitution. Certain plaintiffs added common-law claims based on contract and promissory estoppel. The Illinois Supreme Court, on direct review, reversed dismissal, stating that health insurance subsidies are constitutionally protected by the pension protection clause and rejecting an argument that only the retirement annuity itself is covered. View "Kanerva v. Weems" on Justia Law

The Louisiana Supreme Court granted this writ application to determine whether a plaintiff had a private right of action for damages against a health care provider under the Health Care and Consumer Billing and Disclosure Protection Act. Plaintiff Yana Anderson alleged that she was injured in an automobile accident caused by a third party. She received medical treatment at an Ochsner facility. Anderson was insured by UnitedHealthcare. Pursuant to her insurance contract, Anderson paid premiums to UnitedHealthcare in exchange for discounted health care rates. These reduced rates were available pursuant to a member provider agreement, wherein UnitedHealthcare contracted with Ochsner to secure discounted charges for its insureds. Anderson presented proof of insurance to Ochsner in order for her claims to be submitted to UnitedHealthcare for payment on the agreed upon reduced rate. However, Ochsner refused to file a claim with her insurer. Instead, Ochsner sent a letter to Anderson’s attorney, asserting a medical lien for the full amount of undiscounted charges on any tort recovery Anderson received for the underlying automobile accident. Anderson filed a putative class action against Ochsner, seeking, among other things, damages arising from Ochsner’s billing practices. Upon review of the matter, the Supreme Court found the legislature intended to allow a private right of action under the statute. Additionally, the Court found an express right of action was available under La. R.S. 22:1874(B) based on the assertion of a medical lien. View "Anderson v. Ochsner Health System" on Justia Law

An insurance company appealed a decision on the issue of coverage under a claims-made-and-reported policy. The appellate court found that, under the Direct Action Statute, an insurer could not use the policy’s claim-reporting requirement to deprive an injured third party of a right that vests at the time of injury. After considering the applicable law, the Supreme Court found that the reporting provision in a claims-made-and-reported policy was a permissible limitation on the insurer’s liability as to third parties and did not violate the Direct Action Statute. Accordingly, the Court reversed that portion of the court of appeal’s decision relating to the claim of the injured third party, and reinstated the trial court’s judgment, finding no coverage.View "Gorman v. City of Opelousas" on Justia Law