Justia Insurance Law Opinion Summaries

After Employee was injured in a car accident with a police officer, Employer's workers compensation carrier (Claimant) sought to bring this tort action against City. Claimant gave notice to City that it was pursuing a negligence claim against it, claiming damages in the amount of $19,590. Claimant then brought a lawsuit in the district court, requesting $19,590 in damages. Several months later, Claimant sought leave to amend its petition to raise the amount of alleged damages to $228,088. City objected, arguing that Claimant's notice did not include "a statement of the amount of monetary damages that is being requested" as required under Kan. Stat. Ann. 12-105b(d)(5). The district court granted Claimant's petition, finding that Claimant's statutory notice substantially complied with 12-105b(d). A divided court of appeals affirmed the district court's ruling that the notice was in substantial compliance with the law. The Supreme Court affirmed, holding (1) under the circumstances, Claimant's notice substantially complied with 12-105b(d), as the notice contained all the information required by the statute; and (2) when a notice conforms with section 12-105b(d), subsequent amendments to the pleadings are subject to an inquiry into a claimant's bad faith or misleading conduct. View "Cont'l W. Ins. Co. v. Shultz" on Justia Law

Several insureds filed a class action against the predecessor of Washington National Insurance Corporation concerning insurance policies that provide for reimbursement of certain home health care expenses. The district court granted summary judgment for the insureds, concluding that various provisions in the policy, including a certificate schedule, demonstrated an ambiguity concerning whether an automatic increase applied only to the daily benefit or also applied to the lifetime maximum benefit amount and the per occurrence maximum benefit amount. Because there was ambiguity in the policy, the court of appeal certified questions of law to the Florida Supreme Court, which held (1) because the policy was ambiguous, it must be construed against the insurer and in favor of coverage without consideration of extrinsic evidence; and (2) when so construed, the policy's automatic benefit increase applies to the daily benefit, the lifetime maximum benefit, and the per occurrence maximum benefit. View "Washington Nat'l Ins. Corp. v. Ruderman" on Justia Law

Plaintiff filed a claim with Defendant, his homeowner's insurance company, for fire damage on his home. Plaintiff's insurance policy with Defendant was a replacement cost policy. Defendant made a payment to Plaintiff that included costs of repair even though Defendant had not completed any repairs to the home. Defendant, however, refused to pay for a general contractor's overhead and profit because Plaintiff had not yet incurred those expenses. Plaintiff filed a breach of contract claim against Defendant, contending that, like the other costs of repair Defendant paid, Defendant was required to pay costs for overhead and profit. The trial court granted summary judgment for Defendant, and the court of appeal affirmed. The Supreme Court quashed the court of appeal's decision, holding (1) replacement cost insurance includes overhead and profit where the insured is reasonably likely to need a general contractor for repairs; and (2) the court of appeal erred in determining the Florida law and the insurance policy permitted Defendant to withhold payment of overhead and profit because Plaintiff had not actually incurred those costs. Remanded. View "Trinidad v. Fla. Peninsula Ins. Co." on Justia Law

After Insured sustained injuries in a car accident he sought MRIs from Virtual Imaging Services. Virtual Imaging obtained an assignment of personal injury protection (PIP) benefits under Insured's policy with GEICO and billed GEICO $3600 for the MRIs. GEICO paid the bill but limited its reimbursement to eighty percent of 200 percent of the applicable Medicare fee schedule in accordance with the formula described in Fla. Stat. 627.736(5)(a). This statutory provision became effective on January 1, 2008 as part of Florida's PIP statute. Virtual Imaging subsequently sued GEICO, alleging that GEICO's reimbursement was insufficient. The county court granted Virtual Imaging's motion for summary judgment. The court of appeal affirmed then certified a question of law to the Supreme Court, which answered by holding that GEICO was required to give notice to Insured by electing the permissive Medicare fee schedules in its policy before taking advantage of the Medicare fee schedule to limit reimbursements. View "Geico Gen. Ins. Co. v. Virtual Imaging Servs., Inc." on Justia Law

The issue on appeal to the Supreme Court in this case stemmed from district court decisions regarding an uninsured motorist claim between Plaintiffs-Appellants Sam and Deva Ferrell and Defendant-Respondent United Financial Casualty Company (United Financial, d.b.a. Progressive Insurance Company). The parties underwent arbitration, and the Ferrells subsequently filed a petition that sought confirmation of the arbitration award and an award of costs and attorney fees. The district court ordered confirmation of the arbitration award and interest based upon an agreement of the parties. On the issue of attorney fees, the district court found that arbitration began five months prior to the amendment of I.C. 41-1839 which explicitly allowed attorney fees in arbitration, and therefore the statute as it existed did not provide for attorney fees in this case. The Supreme Court reversed in part and remanded the case back to the district court. View "Ferrell v. United Financial Casualty Co." on Justia Law

Engleson, vice president of an Akron insurance agency, suffered from medical conditions, including Crohn’s disease and depression. He resigned in 2001 and sought long-term disability benefits from the company’s group plan, managed by Unum. Unum denied his claim weeks later, reasoning that Engleson’s clinical documentation did not establish that his symptoms were so debilitating that he was precluded from working. Unum denied an appeal in October, 2001 and a second appeal with additional supporting information in November, 2001. In 2007, Engleson returned to Ohio and to the agency, but in August, 2008, he filed another claim for disability benefits. Unum granted his request, with the date of disability denoted as August 5, 2008. Unum would not provide additional appeal review of the 2001 claim. Engleson filed suit in 2009, under 29 U.S.C. 1132(a)(1)(B) and the Employee Retirement Income Security Act, alleging that he was not afforded a full and fair review of his claim and that Unum breached its fiduciary duties. The district court held that the three-year contractual limitations period barred the suit with respect to his 2001 claim. The Sixth Circuit affirmed, holding that the untimely filing was not excusable. View "Engleson v. UNUM Life Ins. Co. of Am." on Justia Law

Plaintiffs filed a class action suit against Auto-Owners, alleging breach of contract and bad faith. On appeal, Auto-Owners challenged the district court's certification of a class for those policy owners whose policies were issued in North Dakota. The court reversed, concluding that the certified class did not meet the predominance requirement of Rule 23 where the reasonableness of any claim payment may have to be individually analyzed and, therefore, the district court abused its discretion in certifying the class. View "Halvorson, et al. v. Auto-Owners Ins. Co., et al." on Justia Law

Defendant's employer had insurance through American States Insurance Policy (ASIC). After Defendant was involved in a car accident, Defendant sent ASIC written notice of a potential claim under ASIC's uninsured/underinsured (UM/UIM) coverage. ASIC did not formally deny the claim but, rather, responded with a declaratory-judgment action, asserting that because Defendant had failed to undertake legal action or to make a written demand for arbitration against ASIC within three years from the date of the accident, her UIM claim against ASIC was time-barred. The U.S. district court entered judgment on the pleadings in favor of ASIC, determining that the three-year limitations period set forth in the policy did not violate public policy. On appeal, the court of appeals certified a question of law to the Rhode Island Supreme Court, which answered by holding that Rhode Island would not enforce the contractual limitations clause in this case because it began to run on the date of the accident rather than the date the insurance contract was breached and was shorter than the statutory limitations period. View "Am. States Ins. Co. v. LaFlam" on Justia Law

The Oklahoma Supreme Court accepted a certified question of state law from the Tenth Circuit federal appellate court. Two excess insurers for the Grand River Dame Authority (GRDA) had a dispute concerning the application of equitable subrogation. The question centered on whether a second-level excess insurer could invoke equitable subrogation to recover money it became liable to pay because of an agreement GRDA had with its first-level insurer. GRDA and the first-level insurer agreed to include losses under a policy that was outside that policy's year and that triggered the second-level insurer's coverage for that year. Upon review, the Oklahoma Court held that the second-level insurer could invoke equitable subrogation notwithstanding GRDA's release of the first level insurer. View "Steadfast Insurance Co. v. Agricultural Ins. Co" on Justia Law

In 2009, respondent Adrian Melton suffered an on-the-job accident while working for his employer, Joe Brown Company, Inc. He was awarded eleven weeks of temporary total disability, granted permanent partial disability, and a psychological overlay. The employer appealed the award, which vacated some parts and sustained others. In 2011, the employer appealed to the Court of Civil Appeals (COCA) which vacated the permanent partial impairment award because it failed to comply with the AMA Guides (5th Edition), and that an "any competent evidence" standard of review was inconsistent with 85 O.S. 2011 sec. 340, so the court used the "against the clear weight of the evidence" standard which had recently been revised. Respondent petitioned the Supreme Court for review of the COCA decision, arguing that the appellate court should have used the "any competent evidence" standard. Upon review of the matter, the Supreme Court concluded that because respondent's injury happened before the new standard went into effect, the "any competent evidence" standard should have been applied. With regard to respondent's awards of disability, the Court found that psychological overlay was not supported by appropriate expert testimony. Accordingly, the benefits as they related to the overlay were vacated. View "Joe Brown Company, Inc. v. Melton" on Justia Law