Justia Insurance Law Opinion Summaries

Hartford is the administrator of Wal-Mart’s Group Disability Plan, which is covered by the Employee Retirement Income Security Act. The policy requires any suit to recover benefits pursuant to ERISA, 29 U. S. C. 1132(a)(1)(B), to be filed within three years after “proof of loss” is due. Heimeshoff filed a claim for long-term disability benefits. Following mandatory administrative review process, Hartford issued a final denial. Almost three years after the final denial but more than three years after proof of loss was due, Heimeshoff sought judicial review under ERISA. The district court dismissed, reasoning that while ERISA does not provide a statute of limitations, the contractual limitations period was enforceable under state law and Circuit precedent. The Second Circuit affirmed. The Supreme Court affirmed, finding the limitations provision enforceable. A participant’s ERISA cause of action does not accrue until the plan issues a final denial, but it does not follow that a plan and its participants cannot agree to commence the limitations period before that time. The Court noted that contractual limitations provisions should ordinarily be enforced as written. The period at issue is not unreasonably short and does not undermine ERISA’s two-tiered remedial scheme by causing participants to shortchange the internal review process. If administrators attempt to prevent judicial review by delaying the resolution of claims in bad faith, the penalty for failure to meet regulatory deadlines is immediate access to judicial review for the participant and courts can apply waiver or estoppel. Plans offering appeals beyond what is contemplated in the internal review regulations must agree to toll the limitations provision during that time, 29 CFR 2560.503–1(c)(3)(ii). View "Heimeshoff v. Hartford Life & Accident Ins. Co." on Justia Law

Steve Sangwin, a State employee, was a qualified subscriber and beneficiary of the State of Montana Employee Benefits Plan (Plan), which was administered by Blue Cross and Blue Shield of Montana (BCBS). Steve's daughter, McKinley, was also a beneficiary under the Plan. This case arose after BCBS denied a preauthorization request for a medical procedure for McKinley on the grounds that the procedure was "experimental for research." Steve and his wife (collectively, the Sangwins) initiated this action by filing an amended complaint setting forth five counts, including a request for certification of a class action. The Sangwins defined class members as other beneficiaries of the Plan who had their employee benefits denied by the State based on the experimental exclusion for research in the past eight years. The district court granted the Sangwins' motion for class certification. The State appealed. The Supreme Court (1) affirmed the district court's order defining the class; but (2) reversed and remanded with respect to the question certified for class treatment, holding that the district court abused its discretion in specifying for class treatment the question of whether the State breached its contract of insurance with the plaintiffs. View "Sangwin v. State" on Justia Law

Safeway Insurance Company of Alabama, Inc. petitioned for a writ of mandamus to direct the Circuit Court to grant its Rule 12(b)(1) motion to dismiss a bad-faith claim against it for lack of subject-matter jurisdiction. Richard Kimbrough submitted a claim to Safeway for uninsured-motorist coverage when he was injured in an accident. A deer ran across the road, causing a truck in the southbound lane to swerve into the northbound lane, where Kimbrough was driving. According to Kimbrough, the truck struck his vehicle and ran him off the road and into a creek bed. The driver of the truck allegedly fled and was unknown. Kimbrough contended the driver of a "phantom vehicle" was an uninsured motorist. He sought the full policy limit of $50,000 because his expenses exceeded his coverage. The parties disputed whether Safeway denied the claim. After review of the matter, the Supreme Court disagreed with Safeway's argument that the Circuit Court lacked subject matter jurisdiction over the case. As such, Safeway did not demonstrate a clear legal right to the writ of mandamus. The Court therefore denied the petition. View "Kimbrough v. Safeway Insurance Company of Alabama, Inc." on Justia Law

In 1994, Norem purchased a “Flexible Premium Variable Life Insurance Policy” from Lincoln Benefit. With variable life insurance, part of the premium is allocated to the insurer’s investment funds, called subaccounts. Policyholders may move their investments within the subaccounts and the death benefit, which is guaranteed not to fall below a certain amount. With variable universal life, the policyholder may easily invest and alter insurance coverage. The policy is comprised of the policy value, which represents the investment component, and its net amount at risk, which represents the insurance component. Norem purchased his policy because he wanted both life insurance and an investment vehicle for the proceeds from the sale of his ownership of a medical business. The policy has a “cost of insurance” (COI) charge deducted monthly from the policy. The policy explains how the COI rate is calculated. Norem filed a putative class action on behalf of himself and other similarly situated policyholders, claiming that Lincoln Benefit breached the terms of its policies in its method of calculating the COI rate.Before deciding on class certification, the district court granted summary judgment to Lincoln Benefit, concluding that its calculation of COI rates did not breach the contract. The Seventh Circuit affirmed. View "Norem v. Lincoln Benefit Life Co." on Justia Law

The Standard Fire Insurance Company appealed a court of appeals' decision that reversed the trial court's grant of summary judgment in its favor, and finding respondents Thomas, Debra, and Christopher were entitled to stack underinsured motorist (UIM) coverage despite an exclusion in Standard Fire's policy purporting to limit an insured's ability to stack such coverage when the vehicles insured under the subject policy were not involved in the accident. After review of the trial and appellate court records, the Supreme Court found no reversible error and affirmed the appellate court's decision. View "Carter v. Standard Fire Insurance" on Justia Law

The Montana Association of Counties Joint Powers Insurance Authority (MACo/JPIA) obtained catastrophic property insurance from Allianz Global Risks US Insurance Company to cover damages over $100,000. The Lincoln County Port Authority (Port) insured a building in its industrial facility through the MACo/JPIA self-insured risk pool. After the building's roof collapsed, MACo/JPIA informed the Port that it would no longer insure the building. The building was subsequently destroyed by a fire, and MACo/JPIA and Allianz refused to cover the loss. The Port filed this suit against Allianz. The district court concluded that the Allianz policy insured the Port and awarded $6,060,980 based on the findings of an appraisal panel. The Supreme Court (1) affirmed the district court's determination that Allianz's policy provided coverage for the building; (2) affirmed the district court's refusal to reform the Allianz policy; (3) reversed the district court's award of "replacement cost" for those portions of the building that the Port had slated for demolition; and (4) remanded to allow the district court to calculate post-judgment interest owed to the Port for the damages owed under the policy. View "Lincoln County Port Auth. v. Allianz Global Risks US Ins. Co." on Justia Law

Plaintiff was injured during the course of his employment when he was struck by a sheet of plywood that fell from a building under construction. Plaintiff received workers' compensation benefits for his injuries and then filed this personal injury action. Thereafter, the insurance carrier for Plaintiff's employer filed a motion to discontinue Plaintiff's workers' compensation benefits. An administrative law judge found Plaintiff had no further causally-related disability and that he had no further need for treatment. The Workers' Compensation Board Panel (Board) affirmed. Subsequently, in this negligence action, Defendants moved for an order estopping Plaintiff from relitigating the issue of causally-related disability. Supreme Court granted the motion. The Appellate Division reversed, concluding that the determination of the Board was one of ultimate fact and thus did not preclude Plaintiff from litigating the issue of his ongoing disability. The Court of Appeals affirmed, holding that Defendants failed to establish that the issue decided in the workers' compensation proceeding was identical to that presented in this negligence action. View "Auqui v. Seven Thirty One Ltd. P'ship" on Justia Law

John Johnson Jr. filed suit in state court against defendants, including Weeks Marine and Standard Concrete, for injuries he sustained when he fell from his crane while working on a project. This case concerned the terms of an indemnity agreement between Weeks Marine and Standard Concrete. Weeks Marine, the general contractor on the project, sought a declaration that Standard Concrete, Johnson's employer, was contractually obligated to defend and indemnify it in the underlying state court action. The court concluded that the indemnity agreement did not cover the underlying state court action and Weeks Marine pointed to no facts on appeal that lead the court to conclude otherwise. Accordingly, the court affirmed the district court's judgment in favor of Standard Concrete. View "Weeks Marine, Inc. v. Standard Concrete Products, Inc." on Justia Law

After Plaintiff filed a complaint for divorce from Dean Miller, Plaintiff and Dean executed a property settlement agreement providing that Dean would maintain life insurance for the benefit of the parties' four minor children until they reached the age of majority. Dean subsequently executed a service request form listing his children as the beneficiaries of his life insurance policy and instructing that beneficial interests be paid to and managed by Kristin Saunders as custodial trustee for the benefit of his minor children. After Dean died, funds from his life insurance policy were distributed to Saunders. Plaintiff filed a complaint seeking declaratory and injunctive relief asking the superior court to declare that Dean's four children were the sole beneficiaries of his life insurance policy. The court granted Defendants' motion for summary judgment, finding that Dean created a valid custodial trust pursuant to the Rhode Island Uniform Custodial Trust Act (RIUCTA) and that the trust was not inconsistent with Dean's obligations under the property settlement agreement. The Supreme Court affirmed, holding (1) Dean created a custodial trust pursuant to RIUCTA; and (2) Dean did not violate the property settlement agreement by designating Saunders as custodial trustee on the service request form. View "Miller v. Saunders" on Justia Law

In 2000, Rochow sold his interest in Universico to Gallagher and became President of Gallagher. As an employee of Gallagher, Rochow was covered under a LINA disability policy. In 2001, Rochow began to experience short term memory loss, chills, sweating, and stress at work. Gallagher demoted Rochow to Sales Executive-Account Manager. Because of his inability to perform his job, Gallagher forced Rochow to resign in January, 2002. In February 2002, Rochow experienced amnesia, was hospitalized, and was diagnosed with HSV-Encephalitis, a rare, severely debilitating brain infection. LINA repeatedly denied Rochow benefits stating that Rochow’s employment ended before his disability began. In 2004, Rochow sued Cigna, LINA’s parent company, alleging breach of fiduciary duty under ERISA, 29 U.S.C.1104(a). In 2007 the Sixth Circuit affirmed a decision that denial of Rochow’s claims was arbitrary, not the result of a deliberate, principled reasoning process, and did not appear to have been made solely in the interest of the participants and beneficiaries or the exclusive purpose of providing benefits to participants and beneficiaries as required by ERISA. Rochow died in 2008. In 2009, the district court ordered an equitable accounting of profits and disgorgement of $3,797,867.92 under an equitable theory of unjust enrichment. The Sixth Circuit affirmed. View "Rochowl v. Life Ins. Co. of N. America" on Justia Law