Justia Insurance Law Opinion Summaries

In consolidated appeals, petitioners, both recipients of home-based long-term care benefits through Vermont's Medicaid-funded Choices for Care (Choices) program, appealed decisions of the Human Services Board disallowing deductions for personal care services from their patient-share obligation under federal and state Medicaid laws. Upon review of the cases, the Supreme Court concluded that to the extent the services in question were medically necessary, expenses for those services must be deducted from petitioners’ patient-share obligation even if they are of a type generally covered by Medicaid. Furthermore, the Court rejected the State’s claim that the decision of the Department of Disabilities, Aging and Independent Living not to provide the personal care services in question under the Choices program constituted a conclusive finding that the services were not medically necessary. View "In re Brett" on Justia Law

The Commission appealed the district court's order preliminarily enjoining him from enforcing several provisions of the Georgia Code as preempted by Section 514 of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1144(a). The court found that AHIP had standing to challenge Section 4, 5, and 6 of the Insurance Delivery Enhancement Act of 2011 (IDEA), O.C.G.A. 33-24-59.5; AHIP's suit was not barred by the Tax Injunction Act, 28 U.S.C. 1341; AHIP was likely to succeed on the merits of its claims where the challenged IDEA provisions were preempted by ERISA Section 514; and the district court did not abuse its discretion in concluding that AHIP met its burden to show irreparable injury and that the balance of equities weighed in favor of a preliminary injunction. Accordingly, the court affirmed the judgment of the district court. View "America's Health Ins. Plan v. Hudgens" on Justia Law

Plaintiff had a $1 million insurance policy from Defendant on an office building. On February 23, 2007, the building was severely damaged in a fire. Defendant paid Plaintiff the actual cash value of the destroyed building in the amount of $757,812 but withheld the cost of replacing the destroyed property until Plaintiff could replace the property. The replacement building was completed in October 2010. Plaintiff brought an action against Defendant seeking payment of the unpaid portion of the policy limits. The U.S. district court granted Defendant’s motion to dismiss, concluding that the policy barred any suits commenced more than two years after the date of the damage and that the two-year limitation period was reasonable. The Court of Appeals answered a question from the Second Circuit Court of Appeals and held that such a contractual limitation period, applied to this case in which the property could not reasonably be replaced in two years, was unreasonable and unenforceable. View "Executive Plaza, LLC v. Peerless Ins. Co." on Justia Law

VP & PK purchased an insurance policy from Lexington Insurance Company for work on a construction site. Kila Kila, one of VP & PK’s subcontractors, purchased an insurance policy from Nautilus Insurance Company. Both policies contained an “other insurance” provision and included duties to defend and indemnify. When VP & PK and Kila Kila were sued for damages resulting from the construction, Nautilus funded the defense of both Kila Kila and VP & PK. Lexington satisfied the judgment against VP & PK but did not contribute to the defense costs. Nautilus filed a complaint seeking (1) a declaration that Lexington owed VP & PK a duty to defend, which it breached; and (2) equitable contribution from Lexington for defense costs. The U.S. district court granted summary judgment for Lexington, holding that Lexington’s policy was in excess to Nautilus’s policy, and therefore, Lexington’s duty to defend was not triggered. The Hawaii Supreme Court accepted certified questions from the court of appeals and held, inter alia, that (1) an “other insurance” clause purporting to release an otherwise primary insurer of the duty to defend if the insurer becomes excess as to liability is enforceable, but only as between two or more insurers seeking to allocate or recover defense costs; and (2) an otherwise primary insurer who becomes an excess insurer by operation of an “other insurance” clause has a duty to defend as soon as a claim is tendered to it and there is the mere possibility that coverage of that claim exists under its policy. View "Nautilus Ins. Co. v. Lexington Ins. Co." on Justia Law

Machon Lyons suffered severe injuries as the result of an automobile accident. The accident occurred when a vehicle operated by Roderick Holliday left the road and collided with a tree. As a result, Lyons obtained a default judgment of $72,500 against Holliday. Holliday's mother, Daisy Lang, insured the vehicle through Direct General Insurance Company of Mississippi. Lang's policy included a provision specifically excluding Holliday from any coverage under the policy. Accordingly, Direct denied coverage for the judgment. Lyons sought a declaratory judgment, asking the Circuit Court to hold that Lang's policy covered the judgment against Holliday. Lyons acknowledged the policy exclusion, but argued that Lang's policy covered the judgment against Holliday because Mississippi law required minimum-liability coverage for all permissive drivers, and because Lang's insurance card failed to mention any permissive-driver exclusions. The circuit court granted summary judgment in favor of Direct, finding that the policy clearly and specifically excluded coverage of Holliday. The Court of Appeals reversed, finding that 63-15-4(2)(a) required liability insurance for all vehicles operated in Mississippi and that Mississippi Code Section 63-15-43 required that the liability insurance policy "pay on behalf of the named insured and any other person, as insured, using any such motor vehicle or motor vehicles with the express or implied permission of such named insured." Although the Court of Appeals reached the right result, it cited as its authority the incorrect statute, so the Supreme Court granted certiorari. The Court concluded the policy exclusion violated Mississippi law: even though Holliday was an excluded driver under the Direct General policy issued to Daisy Lang, the exclusion did not operate to eliminate liability coverage in the minimum amounts required by statute. The trial court's grant of summary judgment was reversed and the case remanded for further proceedings. View "Lyons v. Direct General Insurance Company of Mississippi " on Justia Law

Retired Employees and their spouses filed suit against the County, alleging that the Retired Employees have an implied vested right to the pooling of their health care premiums with those of current employees ("pooled premiums"). The court affirmed the district court's order granting the County's motion for summary judgment, concluding that Retired Employees failed to raise a genuine issue of material fact where they did not show any link to Retired Employees' claim of an implied right to an ongoing pool premium; a practice or policy extended over a period of time did not translate into an implied contract without clear legislative intent to create that right - and intent that Retired Employees has not demonstrated in this case; Retired Employees' assertions that its involvement in negotiations with the County revealed an implied contract right to the pooled premium also lacked evidentiary support; and the nature of Retired Employees' evidence underscored the absence of any definitive intent or commitment on the part of the County to provide for the pooled premium. Accordingly, the court affirmed the district court's grant of the County's motion for summary judgment. View "REAOC v. County of Orange" on Justia Law

Richard worked for GPI for 25 years until his 2009 death. He had a basic life insurance policy through GPI’s health and welfare plan and paid for an optional supplemental life insurance policy through GPI for several years. His wife, Maureen, was the beneficiary of both policies. At the end of 2008, Richard’s supplemental life insurance policy was cancelled. Richard’s pay stubs reflected the change, beginning in January 2009. When Richard died a few months later, GPI’s insurer, ABC, paid benefits on the basic life insurance policy. Richard had been diagnosed with stage 4 cancer in September 2008. Soon after Richard’s death, Maureen’s attorney requested information regarding Richard’s supplemental life insurance policy. The company refused the request, citing its confidentiality policy, indicating that the information would only be produced in response to a subpoena. Almost two years later, Maureen filed suit, claiming that either GPI or ABC breached the policy by terminating it without Richard’s consent, in violation of the Employee Retirement Income Security Act, 29 U.S.C. 1001. The district court awarded the defendants summary judgment. The Seventh Circuit affirmed. There was no material issue of fact as to whether Richard cancelled his supplemental policy. Although Maureen speculated that someone other than Richard terminated the policy, she presented no evidence to support her assertion. View "Herzog v. Graphic Packaging Int'l, Inc." on Justia Law

Appellant, Century Indemnity Company (CIC) appealed a Superior Court order that granted Respondent Roger Sevigny, Commissioner of Insurance and Liquidator of the Home Insurance Company (Home) an award of statutory prejudgment interest on certain monies owed to Home by CIC. Home is an insurance company, organized under the laws of New Hampshire, which was declared insolvent and placed in liquidation in 2003. CIC is an insurance company organized under the laws of Pennsylvania. CIC and Home have a set of co-insurance and reinsurance relationships. In prior litigation, the Supreme Court held that an asserted $8 million setoff claim by CIC, which had been waived and then reacquired by CIC in a pair of settlement agreements with PECO, was impermissible under New Hampshire law. The New Hampshire Court explicitly declined, without prejudice, to decide the issue at issue here: whether Home’s estate was entitled to prejudgment interest on the payments CIC wrongfully withheld based upon setoff. The Court denied CIC’s motion for reconsideration in the "Home IV" appeal; after remand, the Liquidator filed a motion in superior court for interest on amounts withheld by CIC based upon improper setoff, to which CIC objected. CIC removed the PECO setoff from its monthly statement to Home and paid the previously withheld $8 million to the Liquidator. The trial court entered an order granting the motion and finding that Home was entitled to prejudgment statutory interest under RSA 524:1-a (2007) accruing from October 2007 (the date of the Liquidator’s letter notifying CIC of his determination to disallow the PECO setoff). This appeal followed. Finding no reversible error in the Superior Court's order, the Supreme Court affirmed. View "In the Matter of the Rehabilitation of the Home Insurance Company" on Justia Law

This appeal presented the final set of issues arising from claims of negligent construction of a condominium project in south Mississippi. The district court held that a subcontractor's Commercial General Liability (CGL) insurer breached its duty to defend the general contractor. The court concluded that the district court erred in holding that there was a duty to defend where the CGL insurer was not on notice of a claim under the policy. Consequently, the remaining appellate issues concerning the calculation and allocation of the costs of the alleged failure to defend were moot. Accordingly, the court reversed and remanded. View "Carl E. Woodward, L.L.C., et al. v. Travelers Indemnity Co. of CT" on Justia Law

In 2009, plaintiff Craig Mulford filed a complaint against his employer Union Pacific Railroad (UP) seeking relief under the Federal Employer’s Liability Act (FELA). Plaintiff alleged he sustained injury to his knees as a result of UP's negligence. The case went to trial in 2012. The jury reached its verdict, unanimously concluding that UP was not negligent. The district court issued its final judgment and dismissed plaintiff's claims. In this appeal, plaintiff claimed that the district court erred on two separate grounds: (1) failing to disqualify a juror for cause; and (2) admitting evidence that he received disability benefits from the Railroad Retirement Board (RRB) to impeach statements made by plaintiff on direct examination. Finding no reversible error, the Supreme Court affirmed. View "Mulford v. Union Pacific Railroad" on Justia Law