Justia Insurance Law Opinion Summaries

The Providers supply outpatient cardiac telemetry (OCT) services, used by doctors to monitor cardiac arrhythmias. The device differs from conventional technology in that it transmits electrocardiographic (EKG) data in real time to certified technicians, who forward the data to a physician. OCT is approved by the FDA, and has long been covered by Medicare and commercial insurers. CIGNA administers employer sponsored health benefit plans. CIGNA pays its in-network providers directly for the services rendered to patients. In 2007, the Providers joined CIGNA’s network by Agreements that set the reimbursement rate and define “Covered Services.” In 2012, CIGNA issued a statement that it would no longer cover OCT “for any indication because it is considered experimental, investigational or unproven.” The 2012 Policy acknowledged that this new position would be trumped by any conflicting language in the coverage policies themselves. In arriving at the new policy, CIGNA relied on the same medical literature it had previously relied upon in concluding that OCT should be covered. The Providers claim that CIGNA indicated that its motive was financial, but refused to reconsider the 2012 Policy. The district court found that the Providers’ claims fell within the arbitration clause of the Agreement. The Third Circuit vacated. The clause at issue is limited in scope to disputes “regarding the performance or interpretation of the Agreement” and the claims at issue do not relate to the performance or interpretation of the Agreement. View "Cardionet Inc v. Cigna Health Corp." on Justia Law

Dozens of suits were filed against Irving Oil Limited (IOL) alleging environmental contamination by methyl tertiary butyl ether (MTBE) occurring from 1979 to the present. At the time of this opinion, all of the MTBE suits against IOL had been settled. In 2009, IOL filed a complaint asking the superior court to declare that ACE INA Insurance (ACE) had a duty to defend and indemnify in the MTBE suits. The superior court granted IOL’s motion for summary judgment in part and denied it in part, concluding that it could not declare that IOL was entitled a judgment on the duty-to-defend count as a matter of law. IOL appealed. The Supreme Court dismissed IOL’s appeal and ACE’s cross-appeal, holding that although a decision that an insurer does not have a duty to defend its insured is ordinarily immediately appealable under the death knell exception to the final judgment rule, the exception did not apply in this case because there were no MTBE cases pending against IOL. View "Irving Oil Ltd. et al. v. ACE INA Ins." on Justia Law

A guest (“Guest”) at an apartment complex fell of a third-story apartment’s balcony, rendering him quadriplegic. Guest sued the apartment complex’s ownership (“Owner”) and management (“Manager”) under theories of joint and several liability. American Family Mutual Insurance Company held liability policies covering both Owner and Manager. Regent Insurance Company held liability policies covering Manager, but the parties disputed whether the policies also covered the “same risk” for Owner as an additional insured. American Family settled with Guest and sued Regent for equitable contribution toward the payment it made to Guest under the settlement agreement. The district court granted summary judgment in favor of American Family. The Supreme Court affirmed, holding that the district court did not err in its apportionment of the common obligation toward Guest’s settlement. View "Am. Family Mut. Ins. Co. v. Regent Ins. Co." on Justia Law

Dennis Hagenow was injured in an automobile accident with Betty Schmidt. Hagenow and his wife (Plaintiffs) filed an uninsured motorist claim with American Family Mutual Insurance Company. American Family denied the claim, determining that Schmidt’s vehicle was not an uninsured motor vehicle under Plaintiffs’ policy. Plaintiffs subsequently filed a breach of contract action against American Family. American Family moved for summary judgment, arguing (1) because Schmidt had automobile insurance at the time of the collision, she was not an uninsured motorist (UM) under the policy; and (2) Plaintiffs were not “legally entitled to recover” under the policy because a jury in Plaintiffs’ underlying action against Schmidt found Schmidt not liable for Plaintiffs’ damages. The district court denied the motion. The Supreme Court reversed, holding (1) Plaintiffs were not “legally entitled to recover” under Iowa law or their UM policy; and (2) Schmidt’s vehicle was not an uninsured motor vehicle under the terms of Plaintiffs’ UM provision. Remanded. View "Hagenow v. Am. Family Mut. Ins. Co." on Justia Law

Jennifer Lockwood was injured in a car accident caused by an uninsured drunk driver. Lockwood had car insurance through Geico General Insurance Company. After exhausting her policy's medical payments coverage, Lockwood sought payment under her uninsured motorist coverage. Geico offered $750 to settle the uninsured motorist claim, and Lockwood declined. Geico questioned Lockwood's "high" medical bills and refused to make additional medical payments outside of a total settlement of Lockwood's uninsured motorist claim. The parties eventually settled Lockwood's uninsured motorist claim for $25,000. Lockwood brought a tort claim against Geico for alleged breach of the duty of good faith and fair dealing implied in her insurance contract, arguing that Geico unreasonably delayed payment of Lockwood's uninsured motorist claim. The superior court granted summary judgment in favor of Geico on the bad-faith tort claim and awarded attorney's fees. Upon review of the matter, the Supreme Court reversed the superior court: because there was a genuine issue of material fact regarding whether Geico lacked a reasonable basis for delaying payment on Lockwood's uninsured motorist claim. The case was remanded for further proceedings. View "Lockwood v. Geico General Insurance Company" on Justia Law

Lambert Law Firm, LLC ("Lambert"), petitions the Supreme Court for a writ of mandamus to direct the Circuit Court to set aside an order awarding respondent Shawn Brechbill a portion of certain funds filed with the Circuit Court clerk. Brechbill, was represented by the law firm of Morris, Conchin & King. He sued State Farm Fire and Casualty Company seeking damages for breach of contract and bad-faith failure to pay an insurance claim. The law firm filed the initial complaint, prepared various pleadings, conducted discovery, engaged experts, and filed a response to a motion for a summary judgment filed by State Farm. Later, the law firm withdrew its representation of Brechbill. The trial court held a hearing and issued an order stating that the law firm would have a lien against any settlement or judgment that became payable to Brechbill arising from his claims against State Farm. Ultimately, the law firm's interest in the lien was assigned to Gary Conchin, a partner in the law firm. Brechbill hired Lambert to continue the litigation. Brechbill ultimately received a judgment against State Farm on his breach-of-contract and bad-faith claims. At some point after the judgment was entered, Lambert withdrew from further representation of Brechbill, and the trial court entered an order granting Lambert a lien on any recovery Brechbill might be awarded. State Farm elected to appeal the verdict on the bad-faith claim, but paid one-half of the amount of the verdict in satisfaction of the verdict on the breach-of-contract claim to the circuit court clerk. While State Farm's appeal was pending, both Conchin and Lambert moved to "condemn" the funds held by the circuit clerk. Brechbill also moved the trial court to release the funds to him. Upon review of the competing claims for the money, the Supreme Court concluded that the trial court clearly acted within its discretion in refusing, at the time of the hearing, to determine the amount of the liens at issue. "However, given the mandatory nature of section 34-3-61, the priority of the two liens in this case, and the limited funds to which the liens attached, the trial court must first determine the amount of the fees owed to ensure that any preliminary disbursement would not divest the fund of money in which, by law, another party would have a priority in interest." The Court held that Lambert demonstrated a clear legal right to relief, and therefore directed the trial court to vacate its May 30, 2013, order and to hold further proceedings. View "Brechbill v. State Farm Fire & Casualty Co." on Justia Law

Holder was an Illinois correctional officer since 2006. His wife began to suffer from mental health problems relating to opiate dependency. The Family and Medical Leave Act (FMLA) entitles eligible employees to 12 work weeks of leave during a 12-month period to care for a spouse with a serious medical condition, 29 U.S.C. 2612(a)(1). In October 2007, Holder submitted an FMLA certification form. His wife’s psychiatrist indicated that it would “be necessary for the employee to take off work only intermittently or to work less than a full schedule as a result of the condition,” and that the need for leave would continue for an “unknown” duration. The request was approved. The state never asked for additional medical documentation and paid its share of his health insurance premium until April 18, 2008. About 130 days of absence were recorded on a day-by-day basis. On April 18, 2008, Holder was advised that his FMLA leave had expired and that additional leave would be under the Illinois Family Responsibility Leave program, which allows up to a year of unpaid leave; the state only covers insurance premiums for six months. In April-June 2008, Holder took 29 absences, citing the state program. The Warden disapproved requests for June 8-9 and on the denied form, Holder wrote “last one!!!” Eight months later Central Management Services informed Holder that the state had mistakenly paid for his health insurance premiums beyond his entitlement and began deducting 25% of his earnings until he had refunded $8,291.83. Holder sued, claiming interference with FLMA rights. The jury returned a verdict in favor of the state, but the judge entered judgment awarding Holder $1,222.10 for January 2008, but entered a judgment for the state for the rest of the months. The Seventh Circuit affirmed. View "Holder v. IL Dep't of Corrs." on Justia Law

This case arose out of dispute over the administration of a workers’ compensation self-insurance plan (“Plan”) administered by Herkimer County. Dozens of municipalities participated in the Plan, including the Village of Herkimer. In 2005, the County passed a resolution to terminate the plan. To ensure funding for outstanding workers’ compensation claims, the County created an Abandonment Plan that allowed municipalities to withdraw from the plan and pay a lump sum withdrawal fee. Several of the participating municipalities, including the Village, filed an action challenging the Plan and Abandonment Plan based on alleged mismanagement by the County. The County counterclaimed for breach of contract, seeking to recover the withdrawal liability. The County prevailed on summary judgment as to the liability on its counterclaim for breach of contract against the Village. After a trial on damages, the jury awarded the full amount of damages sought by the County against the Village. The Appellate Division affirmed the damages award. The Court of Appeals affirmed as modified, holding that the fee for the Village’s withdrawal from the Plan reflected benefits to be paid in the future and therefore should have been discounted to its current value as of the date it was due. View "Village of Ilion v. County of Herkimer" on Justia Law

Workforce Safety and Insurance appealed a district court judgment affirming an administrative law judge's order finding William Snook and other similarly situated welders were independent contractors. The Supreme Court affirmed, concluding the ALJ's findings of fact were supported by a preponderance of the evidence and the conclusions of law were supported by those facts. View "WSI v. Larry's On Site Welding" on Justia Law

Dennis Whedbee appealed a district court judgment affirming Workforce Safety and Insurance's ("WSI") binding dispute resolution denying Whedbee's request for a myoelectric prosthesis and approving a body-powered prosthesis. Whedbee argued the binding dispute resolution was an abuse of discretion and violated his due process rights. He argued that WSI should have selected an independent medical examiner located closer to his residence and that his treating physician's opinion should have been given controlling weight. Finding no reversible error, the Supreme Court affirmed. View "Whedbee v. WSI" on Justia Law