Justia Insurance Law Opinion Summaries

In a commercial general liability policy (GCL) coverage case, the United States Court of Appeals for the Eleventh Circuit certified two questions to the Georgia Supreme Court: (1) whether, for an "occurrence" to exist under a standard CGL policy, Georgia law requires there to be damage to "other property;" and (2) if "no" to the first question, whether for an "occurrence" to exist under a standard CGL policy, Georgia law requires that the claims being defended not be for breach of contract, fraud, or breach of warranty from the failure to disclose material information. The Supreme Court answered the first question in the negative, and the second in the affirmative to fraud, but negative as to breach of warranty. View "Taylor Morrison Services, Inc. v. HDI-Gerling America Insurance Co. " on Justia Law

After receiving a work-related injury during his employment by Employer, Employee applied for worker's compensation benefits. An ALJ ordered that further medical procedures were required to determine whether Employee was permanently and totally disabled, but the Labor and Industry Review Commission (LIRC) proceeded to award benefits to Employee for his permanent total disability. Employer filed a complaint seeking judicial review of LIRC's decision. The circuit court affirmed. The court of appeals reversed, concluding that the circuit court was required to dismiss Employer's complaint for lack of competency based on Employer's failure to name its insurer (Insurer) as an "adverse party" pursuant to Wis. Stat. 102.23(1)(a). The Supreme Court reversed and remanded with instructions to affirm LIRC's decision, holding (1) the circuit court had competency to adjudicate Employer's complaint notwithstanding Employer's omission of Insurer because Insurer was not an "adverse party" for purposes of section 102.23(1)(a); and (2) LIRC did not exceed its authority in awarding Employee permanent total disability benefits, and its finding that Employee was entitled to benefits on an odd-lot basis was supported by credible and substantial evidence. View "Xcel Energy Servs., Inc. v. Labor & Ind. Review Comm'n " on Justia Law

Appellant received treatment at Hospital for injuries she sustained in an automobile accident. Appellant granted two statutory liens to Hospital on settlement proceeds she obtained from the tortfeasor for hospital services rendered. Appellant subsequently settled her case against the tortfeasor, and the tortfeasor's insurer (Insurer) agreed to pay Appellant $1.3 million in exchange for Appellant's agreement to indemnify Insurer from all healthcare provider liens. Hospital subsequently sued Insurer, and Appellant tendered to Hospital all money it asserted was due. Appellant then filed a complaint against Hospital, alleging that Hospital overcharged her pursuant to Nev. Rev. Stat. 439B.260(1), which provides that hospitals must reduce charges by thirty percent to inpatients who lack insurance "or other contractual provision for the payment of the charge by a third party." The district court entered judgment in favor of Hospital, finding that Appellant's settlement agreement with the tortfeasor rendered Appellant ineligible for the thirty percent statutory discount. The Supreme Court reversed in part, holding that a patient's eligibility is determined at the commencement of hospital services, and therefore, a later settlement agreement with a third party for the payment of such services does not disqualify the patient for the statutory discount. View " Bielar v. Washoe Health Sys., Inc." on Justia Law

Karla Brown brought a lawsuit against Deutsche Bank and others seeking rescission of a note and first mortgage securing that note, alleging that she was the victim of a predatory lending scheme. The mortgage was originated by Deutsche Bank's predecessor in interest in connection with the purchase of Brown's home. Deutsche Bank requested that First American Title Insurance Company defend Deutsche Bank's mortgage interest pursuant to the terms of its title insurance policy. First American refused coverage, claiming the lawsuit did not trigger its duty to defend because Brown was claiming she was misinformed as to the terms of the note rather than challenging that she granted the mortgage. Deutsche Bank subsequently brought this action seeking a judgment declaring First American had a duty to defend it in Brown's lawsuit. The superior court granted summary judgment in favor of First American. The Supreme Court affirmed, holding that the allegations in Brown's complaint did not trigger First American's duty to defend because the complaint's claims were not specifically envisioned by the terms of the title insurance policy. View "Deutsche Bank Nat'l Ass'n v. First Am. Title Ins. Co." on Justia Law

Doctor, a licensed podiatrist, was driving alone in her husband's vehicle when she was injured in a collision caused by an underinsured motorist. Doctor sought payment from Peerless Indemnity Insurance Co. and Peerless Insurance Co. (collectively, Peerless), who issued business owner's and excess/umbrella policies to Doctor's podiatric practice (Lake Region). Peerless sought a declaratory judgment in federal district court that it had no duty to pay for Doctor's injuries or damages. The district court granted summary judgment for Peerless. The First Circuit Court of Appeals affirmed, holding that Maine's uninsured/underinsured motorist statute did not apply to the Peerless policies issued to Lake Region, thus precluding Doctor's recovery from Peerless. View "Peerless Indem. Ins. Co. v. Frost " on Justia Law

Petitioner was traveling home from work in his personal vehicle when he sustained back injuries in a car accident. Petitioner applied for workers' compensation benefits, but his application was denied under the "going and coming rule," which deems injuries occurring during a work commute outside the course of employment and thus not compensable. Petitioner appealed, arguing that in light of the benefits his employer received through various work-related uses of his vehicle, he was "in the course of employment" during the accident. The labor commission and court of appeals rejected Petitioner's claim that he qualified under the "instrumentality" exception of the going and coming rule. The Supreme Court affirmed, holding that Petitioner fell within the rule and not the exception. View "Jex v. Utah Labor Comm'n" on Justia Law

States participating in Medicaid in a managed care environment are required to make, at least every fourth month, supplemental “wraparound” payments to federally-qualified health centers (FQHCs) equal to the difference between a rate set by statute multiplied by the number of Medicaid patient encounters, and the amount paid to FQHCs by managed care organizations (MCOs) for all Medicaid-covered patient encounters, 42 U.S.C.1396. Concerned that gaps in FQHC claim verification led to overpayments, the New Jersey Department of Human Services changed its calculation: instead of basing wraparound payments solely on the number of Medicaid encounters and total MCO receipts as self-reported by FQHCs, the state would rely on data reported by MCOs absent receipt of certain additional data from the FQHCs. Because MCOs report only encounters that they have approved and paid, prior MCO payment would be a prerequisite to wraparound reimbursement under the new system. An association of FQHCs sued, claiming that the change violated their due process rights as well as state and federal law, resulting in budget shortfalls. The district court granted the association summary judgment and a preliminary injunction. The Third Circuit affirmed the holding that the requirement that wraparound payments be contingent on prior MCO payment violated the Medicaid statute’s requirement that FQHCs receive timely full wraparound payment for all Medicaid-eligible claims. View "NJ Primary Care Assoc. v. NJ Dep't of Human Servs." on Justia Law

This case stemmed from a dispute involving a Master Services Agreement (MSA) between BHP and Deep Marine. At issue on appeal was whether Underwriters could enforce BHP's contractual insurance, defense, and indemnity obligations to Deep Marine after Deep Marine's bankruptcy discharge. The court concluded that, even assuming arguendo that the MSA required indemnification against liability and that Deep Marine will eventually be held liable, Underwriters still could not prevail because BHP's indemnification obligation runs only to Deep Marine; Deep Marine would not, and could not, incur any loss in the Duval action, so Underwriters could not seek indemnification from BHP; because BHP had agreed to continue providing Deep Marine with a nominal defense, Underwriters would not have a breach of contract claim against BHP; the additional insured and primary insurance requirements do not apply BHP's self-insurance; BHP's only obligation was an indemnification obligation to Deep Marine; unlike Underwriters, it had no secondary liability to injured tort victims, like Duval; and Duval had no claim against BHP and, therefore, tender under Federal Rule of Civil Procedure 14(c) was improper. Accordingly, the court affirmed the judgment. View "Duval v. Northern Assurance Co." on Justia Law

The Wehrles were struck by drunk-driver Barth. Robert Wehrle’s injury claim exceeded $750,000 and his wife's claim exceeded $1.5 million. Barth’s auto insurance policy included a $100,000 per-person liability limit. Each recovered that amount from Barth’s insurer. The Wehrle’s own policy, issued by Cincinnati, included underinsured-motorist coverage, for up to $1 million. Cincinnati paid $800,000, reasoning that the Wehrles’ policy reduces its $1 million maximum payout “by all sums paid by anyone who is legally responsible,” and that the Wehrles had recovered $200,000 from Barth’s insurer. The Wehrles claimed that the $100,000 that they each received from the drunk-driver’s insurer should reduce their individual claims. The district court ruled in favor of the insurer. The Seventh Circuit affirmed, holding that the policy language unambiguously supported the insurer’s interpretation and was consistent with the gap-filling purpose of underinsured-motorist insurance. View "Wehrle v. Cincinnati Ins. Co." on Justia Law

In 2006, Kevin and his wife Marjorie moved to Indiana, to manage car dealerships owned by Savoree. In 2007 Savoree proposed selling the dealerships to the couple through a series of stock purchases to be financed by a $3.5 million loan from CSB. After negotiating the loan with CSB, Kevin took out a life insurance policy with Cincinnati Life that named Marjorie as the beneficiary. Two months later, Kevin assigned that policy to CSB. The couple eventually declared bankruptcy and litigation between all of the parties ensued. Kevin died of cancer in 2010. Cincinnati Life deposited the proceeds, $3 million, with the clerk of court and sought judicial determination of ownership. The district court dismissed Marjorie’s claims with prejudice for failing to meet pleading standards and entered summary judgment for CSB. The Seventh Circuit affirmed, finding that Marjorie did not present any evidence to create a genuine disputed issue of material fact. She identified lack of consideration for the assignment as a potential disputed fact, but the assertion was made and repeated without any support or citation to evidence. View "Cincinnati Life Ins. Co. v. Beyrer" on Justia Law