Justia Insurance Law Opinion Summaries

A plaintiff who was injured in an accident sought PIP benefits from an insurance carrier. The Superior Court applied Delaware's current three-part test and analyzed: (1) "whether the vehicle was an 'active accessory' in causing the injury," (2) "whether there was an act of independent significance that broke the causal link between use of the vehicle and the injuries inflicted," and (3) "whether the vehicle was used for transportation purposes." After concluding that the insured vehicle was not used for transportation purposes, the court granted the insurance carrier's motion for summary judgment. Upon reexamination of the statutory framework for PIP coverage, the Supreme Court concluded that the test's "transportation purposes" element should have been rejected. Therefore, the Court reversed the Superior Court judgment and remanded the case for further proceedings. View "Kelty v. State Farm Mutual Automobile Insurance Co." on Justia Law

Plaintiffs, insured under employer health plans, filed a proposed class action alleging that health-insurance companies violated Wisconsin law by requiring copayments for chiropractic care. The insurance code prohibits insurers from excluding coverage for chiropractic services if their policies cover the diagnosis and treatment of the same condition by a physician or osteopath. The policies at issue provide chiropractic coverage, although, like other services, it is subject to copayment requirements. The complaint cited provisions of the Employee Retirement Income Security Act for recovery of benefits due, 29 U.S.C. 1132(a)(1)(B) & 502(a)(3), and for breach of fiduciary duty, sections 1132(a)(3), 1104. The district court dismissed. The Seventh Circuit affirmed. Nothing in ERISA categorically precludes a benefits claim against an insurance company. The complaint alleges that the insurers decide all claims questions and owe the benefits; on these allegations the insurers are proper defendants on the 1132(a)(1)(B) claim. The complaint nonetheless fails to state a claim for breach of fiduciary duty; setting policy terms, including copayments, determines the content of the policy, and decisions about the content of a plan are not themselves fiduciary acts. View "Larson v. United Healthcare Ins. Co." on Justia Law

Plaintiffs Dorothy Harris and Tedeen Holbert were injured in separate automobile accidents caused by third-party tortfeasors. Plaintiffs were treated at Billings Clinic and St. Vincent Healthcare (Providers) for their injuries. Both Harris and Holbert were members of health plans administered by Blue Cross Blue Shield (BCBS), which entered into a preferred provider agreement (PPA) with the Providers pursuant to which Providers accepted payment from BCBS at a discounted reimbursement rate for certain medical services for BCBS insureds. Plaintiffs subsequently filed a complaint against Billings Clinic, asserting breach of contract and constructive fraud claims and requesting compensatory damages equal to the difference between the amount the third-party insurers paid to the Providers and the reduced reimbursement rates under the PPA with BCBS. Harris also filed similar claims against St. Vincent Healthcare. The district courts dismissed the claims for failure to state a claim upon which relief can be granted. The Supreme Court affirmed, holding that the district court did not err in determining that the Providers were entitled to collect from third-party insurers payment for the full amount of the billed charges for the medical treatment provided to Plaintiffs. View "Harris v. St Vincent Healthcare" on Justia Law

Portland General Electric Company (PGE) appealed a Court of Appeals decision that reversed and remanded a trial court order that denied Lexington Insurance Company's motion to set aside a default judgment entered in PGE's favor. Specifically, the issues were: (1) whether a default judgment awarding monetary relief violated ORCP 67C if the complaint did not specify amount of damages sought; and (2) if so, whether that omission rendered the judgment voidable or void. The Supreme Court held the judgment in question here did not violate ORCP 67C and that the judgment was not void. The case was remanded to the Court of Appeals for further proceedings. View "PGE v. Ebasco Services, Inc." on Justia Law

A construction company (Constructor) retained Defendant to arrange insurance for a new housing development. Defendant procured insurance from two insurance companies (Peerless and Hartford). Peerless denied coverage for a house destroyed by fire that was built on a lot not listed in Peerless's policy. Haynes claimed against Defendant for its negligent omission of the lot. Defendant gave notice of the loss to Plaintiff, from whom Defendant had purchased errors and omissions coverage. Defendant and Plaintiff settled with Constructor for $354,000. Constructor assigned its rights against Peerless and Hartford to Plaintiff and Defendant collectively. Defendant and Plaintiff then proceeded against the insurers for the $354,000. After the parties settled, $208,000 was deposited in an escrow account. Plaintiff sought a declaration that it was entitled to all of the escrow funds. Defendant counterclaimed for a declaration that, under Connecticut's make whole doctrine, it was entitled to recover the $150,000 deductible it contributed to the $354,000. The district court granted summary judgment for Plaintiff. The Supreme Court accepted certification from the appellate court and answered its questions by holding (1) the make whole doctrine is the default rule under Connecticut law; and (2) the make whole doctrine does not apply to insurance policy deductibles. View "Fireman's Fund Ins. Co. v. TD Banknorth Ins. Agency, Inc." on Justia Law

Tennessee resident Lombard acquired a 1997 Lincoln Town Car in 2004. The car was partially manufactured, and its final assembly completed, in 1996 at Ford’s Wixom, Michigan plant. In March 2007, the Lincoln, which was licensed, registered, and insured in Tennessee, allegedly caught fire in Lombard’s driveway, causing damage to the car, Lombard’s residence, and personal property. Lombard’s insurers reimbursed Lombard for his losses and, as subrogees, sued Ford, asserting products liability, breach of warranty and negligence claims, alleging that the fire was due to a defective cruise control system. The district court dismissed, finding that Tennessee law governed and that Tennessee’s statute of repose for products liability actions bars the claims. The Sixth Circuit affirmed, after examining Michigan choice of law rules. The conclusion that Michigan’s interests do not “mandate” that Michigan law be applied despite Tennessee’s interests was not erroneous. View "Std. Fire Ins. Co. v. Ford Motor Co." on Justia Law

In an insurance coverage dispute with a policyholder, Cincinnati appealed the district court's adverse summary judgment rulings. The policyholder sought a claim of total loss for a vertical lathe that it purchased from a manufacturer in Taiwan and that was destroyed in Los Angeles. Cincinnati denied coverage, claiming that the coverage extension for newly acquired property did not apply. The court concluded that the extension of coverage to "any location you acquire" was ambiguous and, under Iowa law, the court construed that ambiguity in the policyholder's favor. The court also concluded that the district court did not err in awarding prejudgment interest under Iowa law. Accordingly, the court affirmed the judgment of the district court. View "Amera-Seiki Corp. v. The Cincinnati Ins. Co." on Justia Law

The plant’s union and TRW negotiated collective bargaining agreements, which included provisions for healthcare benefits for retirees. The last CBA became effective in 1993 and was scheduled to expire in 1996. The plant closed in 1997. TRW and the union entered into a termination agreement that provided that any beneficiary, who is receiving or entitled to receive any payment and/or benefit under the CBA, “shall continue to receive or be entitled to receive such payment and/or benefit as though the CBA and Pension Plan had remained in effect.” In 2011, TRW terminated prescription drug coverage for Medicare-eligible retirees, replacing it with an annual contribution to a health reimbursement account. Plaintiffs claimed that this change modified their benefits in violation of TRW’s contractual obligation and filed a purported class action under the Labor Management Relations Act, 29 U.S.C. 185(a), and a claim for benefits under the Employment Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B). The district court granted TRW’s motion to compel arbitration. The Sixth Circuit affirmed as to the two named Plaintiffs, declining to address the rights of hypothetical plaintiffs. View "VanPamel v. TRW Vehicle Safety Sys., Inc." on Justia Law

Michelle and Tony Tweten brought an action against COUNTRY Preferred Insurance Company and American National Property and Casualty Company ("ANPAC"), seeking the full amount of underinsured motorist coverage from both insurance companies. The United States District Court for the District of North Dakota certified a question to the North Dakota Supreme Court that called for an interpretation of the Twetens' policies under North Dakota law. The federal court asked whether the Twetens as a divorced couple with separate insurance policies, were foreclosed from recovering up to the full amount of underinsured motorist benefits from their respective policies under the 'other insurance' clause contained in each policy and the statutory anti-stacking provisions of NDCC Ch. 26.1-40 following the death of their son in a car accident. The North Dakota Supreme Court answered the question "Yes." View "Tweten v. COUNTRY Preferred Insurance Company" on Justia Law

Petitioner Allen Davenport appealed a judgment affirming a Workforce Safety and Insurance ("WSI") decision to terminate benefits on his claim for treatment of his cervical spine and left shoulder and denying his claims for benefits for treatment of his anxiety and depression and lower back condition. He argued his anxiety and depression and his cervical spine, left shoulder and back conditions were "compensable injuries." Upon further review, the Supreme Court concluded Davenport failed to establish by a preponderance of the evidence that work incidents subject to this claim substantially accelerated the progression of, or substantially worsened the severity of, his existing conditions and that his physical injury caused at least 50 percent of his anxiety and depression. View "Davenport v. WSI" on Justia Law