Justia Insurance Law Opinion Summaries

Appellant, an over-the-road truck driver, filed a claim for workers’ compensation benefits, alleging that he sustained injuries in the form of deep vein thrombosis and pulmonary embolism in an accident that occurred during the course and scope of his employment. The compensation court applied a split test of causation used in heart attack cases, which requires proof of both legal and medical causation. The court then dismissed Appellant’s claim for failure to establish the medical cause prong. The Supreme Court affirmed the dismissal of Appellant’s claim, holding (1) the split test was properly applied to Appellant’s injuries in this case, as deep vein thrombosis and pulmonary embolism present the same difficulties in attributing the cause of a heart attack to a claimant’s work and are similar in origin to a heart attack; and (2) the compensation court’s finding as to causation was not clearly wrong. View "Wingfield v. Hill Bros. Transp., Inc." on Justia Law

Hi-Lex has about 1,300 employees. Blue Cross Blue Shield of Michigan (BCBSM) served as a third-party administrator (TPA) for Hi-Lex’s Health and Welfare Benefit Plan since 1991. Under the Administrative Services Contracts (ASCs) between the parties, BCBSM agreed to process healthcare claims for Hi-Lex employees and grant those employees access to BCBSM’s provider networks. BCBSM received an “administrative fee” set forth in ASC Schedule A on a per-employee, per month basis. In 1993, BCBSM implemented a new system, “retention reallocation,” to retain additional revenue. Regardless of the amount BCBSM was required to pay a hospital for a given service, it reported a higher amount that was then paid by the self-insured client. Hi-Lex allegedly was unaware of the retention reallocation until 2011, when BCBSM disclosed the fees in a letter and described them as “administrative compensation.” Hi-Lex sued, alleging breach of fiduciary duty under the Employee Retirement Income Security Act, 29 U.S.C. 1104(a). The court awarded Hi-Lex $5,111,431 in damages and prejudgment interest of $914,241. The Sixth Circuit affirmed that: BCBSM was an ERISA fiduciary and breached its fiduciary duty under ERISA section 1104(a), that BCBSM conducted “self-dealing” in violation of section 1106(b)(1), and that Hi-Lex’s claims were not time-barred. View "Hi-Lex Controls, Inc. v. Blue Cross Blue Shield of MI" on Justia Law

In 2009, Plaintiff’s floral shop was destroyed by a fire. State Farm Casualty Insurance Company, with whom Plaintiff had an insurance policy for her business, paid Plaintiff the maximum amount available under her policy, which was approximately $21,105. Plaintiff filed suit against State Farm and insurance agent Shawn Ori, alleging that Ori, acting as State Farm’s agent, had a professional duty to ascertain or advise her of the adequate amount of coverage for her business and that his failure to do so constituted professional negligence. State Farm and Ori jointly moved for summary judgment on the ground that Plaintiff failed to name an expert witness to establish the standard of care applicable to an insurance agent. The district court granted summary judgment in favor of Defendants, concluding that expert testimony was required to establish the standard of care to which Ori was required to conform. The Supreme Court affirmed, holding that Plaintiff’s failure to obtain an expert witness resulted in an insufficiency of proof regarding duty and thus prevented Plaintiff from establishing a prima facie claim of negligence. View "Dulaney v. State Farm Fire & Cas. Ins. Co." on Justia Law

United filed a declaratory judgment action against Titan, seeking a declaration that United did not owe a duty to defend or indemnify Titan against a pending state-court lawsuit because the policy's absolute pollution exclusion barred coverage for the claims raised in the lawsuit. Titan counter-claimed for relief. The district court granted Titan's motion and denied United's, entering a judgment declaring that United owed a duty to defend and indemnify Titan against the state-court lawsuit. The court concluded that an ordinary person of average understanding purchasing the policy would consider TIAH, an acrylic concrete sealant, to fall unambiguously within the policy's definition of "pollutant." Because the district court premised its denial of United's motion for summary judgment exclusively on the erroneous conclusion that TIAH does not constitute a pollutant, the court vacated the district court's order. The court declined to direct the entry of summary judgment in favor of United. The court remanded for further proceedings. View "United Fire & Casualty Co. v. Titan Contractors Service, Inc." on Justia Law

Plaintiff Higby Crane Service, LLC (Higby) entered into a Contract with Defendant DCP Midstream, LP that covered crane work to be done at the gas processing plant of DCP's wholly owned subsidiary National Helium, LLC (collectively, "DCP"). A fire negligently started by DCP damaged Higby's crane. The other Plaintiff, National Interstate Insurance Co. had issued Higby a commercial inland marine (CIM) policy covering direct physical loss to certain property. National paid Higby under the policy, and Plaintiffs then sued DCP for the loss. DCP counterclaimed that Higby had breached the contract by failing to obtain a commercial general liability (CGL) policy that would have indemnified DCP for its negligence and therefore Higby should bear the loss from the damage to the crane. The United States District Court for the District of Kansas granted summary judgment to Plaintiffs, and DCP appealed. Upon review, the Tenth Circuit reversed and remanded for further proceedings to determine whether the required CGL policy would have protected DCP from liability. View "National Interstate Insurance, et al v. National Helium, et al" on Justia Law

In 2004, Appellant fell while working and strained her back. Appellant was awarded worker’s compensation benefits. In 2009, Appellant slipped and fell at work and injured her ankle. In 2010, Appellant sought temporary total disability and medical pay benefits from the Workers Compensation Division, which denied Appellant’s requests. After a contested case hearing, the Office of Administrative Hearings (OAH) upheld the Division’s denial of Appellant’s request for benefits, concluding Appellant did not meet her burden of proving that she suffered aggravation of a preexisting back condition as a result of a work related injury or that she suffered a second compensable injury. The district court affirmed. The Supreme Court affirmed, holding that the OAH did not err by failing to find a causal connection between the 2009 workplace incident and Appellant’s delayed back pain. View "Hirsch v. State ex rel. Wyo. Workers' Safety & Comp. Div." on Justia Law

In 2009, Appellant suffered injuries to both of his knees in a work-related accident. Appellant filed a request for loss of earning compensation. The Workers’ Compensation Court concluded that, notwithstanding findings of permanent impairment, because no permanent physical restrictions were specifically assigned by an expert for Appellant’s left knee, the court could not perform a loss of earning capacity calculation authorized under the third paragraph of Neb. Rev. Stat. 48-121(3) and that Appellant was thus limited to scheduled member compensation. The Supreme Court reversed, holding that the compensation court erred as a matter of law in concluding that there must be expert opinion of permanent physical restrictions as to each injured member in order to perform a loss of earning capacity calculation under section 48-121(3). Remanded. View "Rodgers v. Neb. State Fair" on Justia Law

Plaintiff sought insurance coverage for gastric lap band surgery. Defendant, a health-care insurer that covered Plaintiff by virtue of Plaintiff’s husband’s employment with the federal government, refused to cover the full cost of the surgery. Plaintiff brought tort and breach of contract claims against Defendant in the Puerto Rico Court of First Instance. Defendant removed the action to the federal district court, asserting, inter alia, that the Federal Employees Health Benefits Act of 1959 (FEHBA) completely preempted Plaintiff’s local-law claims, thus conferring original jurisdiction on the federal court. Defendant then moved to dismiss the case, arguing that the FEHBA demanded exhaustion of administrative remedies. Plaintiff, in the meantime, requested that the district court remand the case to the Court of First Instance. The district court (1) denied Plaintiff’s motion to remand, holding that the FEHBA completely preempted Plaintiff’s claims and, thus, federal jurisdiction attached; and (2) dismissed the action for Plaintiff’s failure to exhaust administrative remedies. The First Circuit Court of Appeals reversed the district court’s judgment of dismissal and its order denying remand, holding that the court erred in concluding that the FEHBA afforded complete preemption. View "Lopez-Munoz v. Triple-S Salud, Inc. " on Justia Law

This case arose from a contract between Roanoke Healthcare Authority (doing business as Randolph Medical Center) and Batson-Cook Company, a general contractor, to renovate the medical center, located in Roanoke. Batson-Cook received written notice from Roanoke Healthcare that work on the renovation project had been suspended. Batson-Cook notified one of its subcontractors, Hardy, of the suspension and stated that "[t]he contract has been suspended by [Roanoke Healthcare] through no fault of Batson-Cook ... or its subcontractors. [Roanoke Healthcare] is currently out of funding and has subsequently closed the facility while seeking a buyer." Liberty Mutual, the project's insurer, alleged in its answer that Roanoke Healthcare failed to pay Batson-Cook $241,940.51 for work performed pursuant to the contract. Batson-Cook sent Hardy a change order the change order deducted from the subcontract the $147,000 in equipment and materials another subcontractor Hardy hired, Johnson Controls, Inc. (JCI), had furnished for the renovation project and for which it has not received payment. JCI notified Liberty Mutual, Roanoke Healthcare, Batson-Cook, and Hardy by certified letters of its claim on a payment bond. The letters identified Batson-Cook as the general contractor and Hardy as the debtor. Liberty Mutual denied the claim. JCI sued Liberty Mutual, alleging JCI was entitled to payment on the payment bond Liberty Mutual had issued to Batson-Cook. Upon review, the Supreme Court concluded JCI was a proper claimant on the payment bond. Therefore, the circuit court erred in entering a summary judgment in favor of Liberty Mutual and denying JCI's summary judgment motion. View "Johnson Controls, Inc. v. Liberty Mutual Insurance Company " on Justia Law

Alfa Life Insurance Corporation ("Alfa") and Brandon Morris, an agent for Alfa, appealed a judgment entered against them following a jury verdict for Kimberly Colza, the widow of Dante Colza. In 2010, Morris met with Dante to assist him in completing an application for a life-insurance policy. There was disputed evidence as to whether Morris asked Dante whether he had had a moving traffic violation, a driver's license suspended, or an accident in the prior three years, it was undisputed that Morris entered a checkmark in the "No" box by that question. The evidence indicated that Dante applied for the Preferred Tobacco premium rate. Dante named Kimberly as the beneficiary under the policy. At the close of the meeting, Kimberly wrote a check payable to Alfa for $103.70, the monthly Preferred Tobacco premium rate. Kimberly testified at trial that Morris informed them that Dante would be covered as soon as they gave Morris the check. Dante was later examined by the medical examiner. During the examination, Dante informed the examiner that his family had a history of heart disease and that he had had moving traffic violations within the past five years. The day after he had his medical examination, Dante was killed in an accident. Two days later, Alfa received the medical examiner's report, which indicated that Dante's family had a history of heart disease, that Dante's cholesterol was above 255, and that Dante had had moving traffic violations in the past five years. In light of the report, Alfa's underwriters determined that Dante was not eligible for the Preferred Tobacco rate for which he had applied; rather, the proper classification would have been the Standard Tobacco rate (which had a higher premium). Additionally, in light of the moving vehicle violations, Dante was a greater risk to insure and a "rate-up" of $2.50 per $1,000 worth of coverage was required. Alfa notified Kimberly by letter that no life-insurance coverage was available for Dante's death "because no policy was issued and the conditions of coverage under the conditional receipt were not met." Kimberly sued Alfa seeking to recover under the terms of the conditional receipt (an acknowledgment of the policy). She alleged, among other claims, that Alfa had breached the contract and had acted in bad faith when it refused to pay life-insurance benefits on Dante's death. Kimberly also sued Morris, alleging, among other claims, that he had negligently failed to procure insurance coverage for Dante. After a trial, the jury found that Alfa had breached the contract and had in bad faith refused to pay the insurance benefits due, and that Morris had negligently failed to procure insurance. Upon review, the Supreme Court concluded Alfa and Morris were entitled to a judgment as a matter of law on those claims, and the trial court erred by submitting the claims to the jury for consideration. View "Alfa Life Insurance Corporation v. Colza " on Justia Law