Justia Insurance Law Opinion Summaries

Plaintiff filed suit against his former employer, Annett, alleging that the company acted in bad faith when it failed to provide medical care and refused to pay him healing-period benefits. Annett counter-claimed for fraud. The court concluded that the district court correctly ruled that plaintiff was required to exhaust his claim with the commissioner; under Iowa law, Annett had a reasonable basis to believe that it could request plaintiff to undergo an examination by the company's chosen physician and plaintiff's refusal to submit to the examination made the propriety of the company's denial of healing-period benefits at least fairly debatable; therefore, the district court properly granted summary judgment for Annett on plaintiff's bad-faith failure to pay benefits claim; and, under either Iowa law or federal law, Annett was judicially estopped from proceeding against plaintiff because Annett had admitted liability in plaintiff's alternate care petition. Accordingly, the court affirmed the judgment of the district court. Annett's motion to strike portions of plaintiff's supplemental appendix was denied as moot. View "Spencer v. Annett Holdings, Inc." on Justia Law

In 2004 Fox was charged with the sexual assault and murder of his three-year-old daughter. Detectives coerced a confession and delayed testing of DNA evidence, leaving Fox imprisoned for eight months, separated from his wife and son. His defense finally obtained the DNA evidence and had it tested at a private lab; the results excluded Fox and charges were dropped. Fox sued under 42 U.S.C. 1983 and state law alleging due process violations, malicious prosecution and intentional infliction of emotional distress. A St. Paul policy required the insurer to defend the detectives to its policy limit, $1 million. Will County also had excess liability policies for $5 million from AAIC (secondary) and Essex (tertiary). Under AAIC’s policy it was not required to assume “settlement or defense” until the underlying policy had been exhausted. None of the policies covered punitive damages. The detectives were represented by a firm retained by St. Paul. The jury awarded $15.5 million, including $6.2 million in punitive damages. Offers to settle for less, before and after the verdict, were rejected. St. Paul exhausted its policy limit; AAIC assumed the defense. The detectives assigned to the Foxes any claims against the insurers in exchange for a covenant not to seek punitive damages from the detectives’ personal assets. The Seventh Circuit upheld $8,166,000 of the damages awarded, including $3.4 million in punitive damages. Fox sought a declaratory judgment that AAIC breached its good faith duties to reasonably settle the claims and inform the detectives of their conflicts of interest. The district court dismissed, reasoning that AAIC, as excess insurer, never had any control over the defense before judgment and therefore had no duty to settle the claims or alert the detectives to any potential conflicts of interest. The Seventh Circuit affirmed View "Fox v. Am. Alt. Ins. Corp." on Justia Law

Plaintiffs challenged an insurance company's use of "retained asset accounts" (RAAs) as a method of paying life insurance benefits in the ERISA context. They presented the district court with two basic questions: (1) whether the insurer's method of paying death benefits in the form of RAAs constitute self-dealing in plan assets in violation of ERISA section 406(b); and (2) whether this redemption method offended the insurer's duty of loyalty toward the class of beneficiaries in violation of ERISA section 404(a). The district court answered the first question in favor of the insurer and the second in favor of the plaintiff class. The court then awarded class-wide relief totaling more than $12,000,000. Both sides appealed. Upon review, the First Circuit Court of Appeals agreed with the district court that the insurer's use of RAAs in this case did not constitute self-dealing in plan assets. However, the Court disagreed with the district court's answer to the second question and held that the insurer's use of RAAs did not breach any duty of loyalty owed by the insurer to the plaintiff class. View "Merrimon, et al v. Unum Life Insurance Company" on Justia Law

This case arose out of the sinking of a vessel owned by Hornbeck while at R&R's shipyard for repairs. R&R's liability insurer, National, filed suit to disclaim liability under its policy. Hornbeck counterclaimed. The district court found that R&R was negligent and that National was liable for the ensuing damages. The court concluded that the district court did not clearly err in finding that R&R was negligent under bailment law where the vessel was delivered to R&R afloat, R&R had full custody of the vessel, and the vessel sank while under R&R's care; even if the salvage company had been negligent, R&R would remain fully liable because this negligence was a foreseeable consequence of R&R's own negligence; under Rule 13(a), Hornbeck had standing to bring its counterclaim and the district court properly ruled on that claim after deciding R&R's liability; and the district court erred in the amount of damages it awarded and in applying an 18% interest rate. Accordingly, the court affirmed in part, reversed in part, and remanded for the entry of judgment and the appropriate assessment of interest on that judgment. View "National Liability & Fire Ins. Co. v. R & R Marine, Inc., et al." on Justia Law

Central States, an employee benefit plan governed by the Employee Retirement Income Security Act, provides health insurance for Teamsters and their families. Guarantee Trust provides sports injury insurance for student athletes. Each of 13 high school and college athletes, all children of Teamsters, holds general health insurance from Central and sports injury insurance from Guarantee. Each suffered an injury while playing sports (most often football) between 2006 and 2009, and sought coverage from both companies. Each time Guarantee refused to pay the athlete’s medical expenses, and each time Central paid the bill under protest. The district court entered a declaratory judgment under ERISA, 29 U.S.C. 1132(a)(3)(B), that, when coverage of student athletes overlap, Guarantee must pay, and ordered Guarantee to reimburse Central for the payouts to the 13 students. The Sixth Circuit, affirmed in part characterizing the case as a “you first” paradox, or ‘gastonette.” An ERISA plan may coordinate benefits with another policy, but may not redefine the coverage of another policy. Absent the Central plan, the Guarantee policy would cover the sports injuries at issue without question. An ERISA plan must keep doing what it would do in another plan’s absence. That amounts to coordinating benefits, not redefining coverage. View "Cent St, SE & SW Areas Health & Welfare Fund v. First Agency, Inc." on Justia Law

In this diversity case, the court considered whether Mid-Continent was obligated under Texas law to pay for damage caused by one of its insureds, Arrow, when Arrow failed to promptly correct work in the home that it had constructed for plaintiffs and which failed to conform to the requirements of the construction contract into which Arrow and plaintiffs had entered. The court concluded that, consistent with Texas law and considering the Texas Supreme Court's decisions in Gilbert Texas Construction, L.P. v. Underwriters at Lloyd's London, and Ewing Construction Co. v. Amerisure Insurance Co., Mid-Content has demonstrated that an exclusion from coverage applied and that the insureds have failed to show that an exception to that exclusion applies. The district court committed no error in granting summary judgment to Mid-Content. Accordingly, the court affirmed the judgment of the district court. View "Crownover, et al. v. Mid-Continent Casualty Co." on Justia Law

Department of Health and Human Services (HHS) regulations implementing the 2010 Patient Protection and Affordable Care Act (ACA) require that employers’ group health plans furnish preventive care and screenings for women without cost sharing requirements, 42 U.S.C. 300gg–13(a)(4). Nonexempt employers must provide coverage for 20 FDA-approved contraceptive methods, including four that may have the effect of preventing a fertilized egg from developing. Religious employers, such as churches, are exempt from the contraceptive mandate. HHS has effectively exempted religious nonprofit organizations; an insurer must exclude contraceptive coverage from such an employer’s plan and provide participants with separate payments for contraceptive services. Closely held for-profit corporations sought an injunction under the 1993 Religious Freedom Restoration Act (RFRA), which prohibits the government from substantially burdening a person’s exercise of religion even by a rule of general applicability unless it demonstrates that imposing the burden is the least restrictive means of furthering a compelling governmental interest, 42 U.S.C. 2000bb–1(a), (b). As amended by the Religious Land Use and Institutionalized Persons Act of 2000 (RLUIPA), RFRA covers “any exercise of religion, whether or not compelled by, or central to, a system of religious belief.” The Third Circuit held that a for-profit corporation could not “engage in religious exercise” under RFRA and that the mandate imposed no requirements on corporate owners in their personal capacity. The Tenth Circuit held that the businesses are “persons” under RFRA; that the contraceptive mandate substantially burdened their religious exercise; and that HHS had not demonstrated that the mandate was the “least restrictive means” of furthering a compelling governmental interest.The Supreme Court ruled in favor of the businesses, holding that RFRA applies to regulations that govern the activities of closely held for-profit corporations. The Court declined to “leave merchants with a difficult choice” of giving up the right to seek judicial protection of their religious liberty or forgoing the benefits of operating as corporations. Nothing in RFRA suggests intent to depart from the Dictionary Act definition of “person,” which includes corporations, 1 U.S.C.1; no definition of “person” includes natural persons and nonprofit corporations, but excludes for-profit corporations. “Any suggestion that for-profit corporations are incapable of exercising religion because their purpose is simply to make money flies in the face of modern corporate law.” The Court rejected arguments based on the difficulty of ascertaining the “beliefs” of large, publicly traded corporations and that the mandate itself requires only insurance coverage. If the plaintiff companies refuse to provide contraceptive coverage, they face severe economic consequences; the government failed to show that the contraceptive mandate is the least restrictive means of furthering a compelling interest in guaranteeing cost-free access to the four challenged contraceptive methods. The government could assume the cost of providing the four contraceptives or could extend the accommodation already established for religious nonprofit organizations. The Court noted that its decision concerns only the contraceptive mandate, not all insurance-coverage mandates, e.g., for vaccinations or blood transfusions. View "Burwell v. Hobby Lobby Stores, Inc." on Justia Law

The Patient Protection and Affordable Care Act, 42 U.S.C. 18002, provides $5 billion to reimburse employers and their proxies for outlays on early retirees’ medical care. WEA, which administers health-care programs on behalf of Wisconsin school districts, told them that it would collect on their behalf. It decided to use the money to reduce future premiums. The school districts claim that WEA should have rebated premiums for the years in which the retirees received the medical care that led to the federal payments. The difference matters to school districts that want to switch carriers. WEA’s plan to cut future rates, rather than provide rebates, gave it a competitive advantage. Districts filed suit, characterizing WEA’s choice to allocate no money to districts, that switch carriers as a form of conversion. All of the claims arise under state law and all litigants are citizens of Wisconsin. WEA removed to federal court, contending that the Act and its implementing regulations are the crux of the litigation. The Seventh Circuit ordered the case returned to state court, reasoning that the suit does not necessarily raise any issue of federal law and that the McCarran-Ferguson Act, 15 U.S.C. 1011–15, gives states preeminence in the domain of insurance regulation. View "Hartland Lakeside Joint No. 3 Sch. Dist. v. WEA Ins. Corp." on Justia Law

The Club is a non-profit provider of protection and indemnity insurance. The Club's Rules include a choice-of-law provision selecting New York law and a two-year statute of limitations for claims against the Club. The Club filed a civil action against defendant alleging that it breached the insurance contract by failing to reimburse the Club for a shortfall and by failing to pay the overdue insurance premiums. The court agreed with the district court, and precedent, that an otherwise valid choice-of-law provision in a maritime contract is enforceable and may require application of a jurisdiction's statute of limitations, in lieu of the doctrine of laches, to govern issues regarding the timeliness of claims asserted under that agreement. Accordingly, the court held that the district court correctly applied New York's six-year statute of limitations to the Club's claims arising under its maritime insurance contract with plaintiff. Therefore, the court affirmed the judgment of the district court. View "American Steamship Owners v. Dann Ocean Towing, Inc." on Justia Law

Mark Hansen was a former vice president of Wilcox Industries Corp. After Hansen left Wilcox, he founded his own company, Advanced Life Support Technologies. Wilcox filed a complaint against Hansen, alleging that Hansen stole Wilcox’s customers and spread false and damaging information about Wilcox’s products. Hansen tendered his defense to Wilcox’s insurer, Sentry Insurance Company. Sentry denied coverage, stating that it did not have a duty to defend or indemnify Hansen against Wilcox’s claims. Hansen subsequently filed suit seeking a declaration that Sentry owed a duty to defend and indemnify him with respect to Wilson’s complaint. The district court granted summary judgment for Wilcox, concluding that Hansen did not qualify as an “insured” under Wilcox’s policy. The First Circuit affirmed, holding (1) Sentry owed no duty to defend or indemnify Hansen in the underlying litigation; and (2) there was no evidence in the record that would permit a reasonable jury to find that Sentry breached any contract with Hansen. View "Hansen v. Sentry Ins. Co." on Justia Law