Justia Insurance Law Opinion Summaries

Plaintiff filed suit against Principal after it concluded that he was not eligible for long term disability benefits and denied his claim. The court concluded that Principal failed to properly consider plaintiff's subjective complaints and that Principal's request for objective evidence proving that he suffered from tinnitus was unreasonable. Therefore, the court held that Principal's denial of plaintiff's claim was arbitrary and capricious, and the court reversed the judgment of the district court, remanding for further proceedings. View "Miles v. Principal Life Ins. Co." on Justia Law

Paul Dyer held licenses as an insurance producer and consultant. Because of Dyer's alleged misconduct, the Bureau of Insurance filed a petition for enforcement against Dyer alleging that Dyer violated the Maine Insurance Code and seeking the revocation of his licenses and requesting civil penalties and restitution. After a hearing, the Superintendent of Insurance concluded that Dyer violated the identified provisions of the Insurance Code, revoked Dyer's licenses, and ordered him to pay civil penalties and restitution. Dyer appealed the judgment entered in the business and consumer docket affirming the Superintendent's decision. The Supreme Court affirmed, holding that the Superintendent did not err in interpreting the Insurance Code or in making factual findings and did not abuse his discretion by imposing penalties permitted in the statute. View "Dyer v. Superintendent of Ins." on Justia Law

William Shapley appealed the district court’s dismissal of his breach of contract and negligence claims against Centurion Life Insurance Company and Wells Fargo Financial. Shapley and his wife applied for credit life insurance with Centurion on the same day they closed on a real estate loan with Wells Fargo. The Shapleys were provided with a notice of insurance underwriting practices. The application papers stated that the Shapleys would receive insurance coverage only if Centurion approved their application. Centurion never had a chance to have a phone interview with Mrs. Shapley (a requirement for the policy). The day after the Shapleys closed on their loan, Mrs. Shapley suffered a brain hemorrhage from which she died four days later. Mr. Shapley contacted Centurion the same day to claim benefits in connection with Mrs. Shapley’s passing. Centurion denied the claim because it never issued an insurance policy on Mrs. Shapley. Because the interview never took place, Centurion issued insurance solely to Mr. Shapley. Mr. Shapley argued on appeal that the district court's dismissal was in error. Upon review, the Supreme Court affirmed the district court’s decisions, finding that while the district court incorrectly concluded that there must be a contract for estoppel to apply, the denial of Mr. Shapley’s motion to amend was appropriate because his estoppel claim was futile. View "Shapley v. Centurion Life Ins Co" on Justia Law

Plaintiff filed a complaint against State Farm, alleging that State Farm was intentionally engaging in delaying tactics to avoid paying on insurance policies. The court affirmed the district court's grant of summary judgment as to any breach of contract claim. Because plaintiff established, as a matter of law, that State Farm had no arguable or legitimate basis for certain periods of delay, she was entitled to present her compensatory damages claim to a finder of fact upon remand. The court reversed the district court's summary judgment as to plaintiff's bad faith claims and remanded for further proceedings. View "James v. State Farm Mutual Auto Ins. Co." on Justia Law

In 2006, Claimant Robert Brown tore the rotator cuff in his right shoulder while at work. The issue on appeal before the Supreme Court in this case centered on whether the workers' compensation laws precluded a certain impairment rating and associated award of permanent partial disability benefits for Complex Regional Pain Syndrome (CRPS) when the claimant was not diagnosed with CRPS, but an expert confirmed he had it. The Commissioner of the Department of Labor and the trial court both concluded that the applicable law denied the Commissioner discretion to assign the impairment rating and award benefits associated with CRPS when the diagnosis did not meet the diagnostic standards. Upon review of the matter, the Supreme Court concluded the Commissioner erred in his conclusion, and reversed and remanded for reconsideration. View "Brown v. W.T. Martin Plumbing & Heating, Inc." on Justia Law

Indigo and one of its employees filed suit against Advanced and Lile, alleging breach of contract, negligence, conspiracy, and violations of federal law on the theory that Advanced and Lile had intentionally delayed payments on valid insurance claims. Indigo argued on appeal that, despite receiving full reimbursement from the receiver, it suffered an injury because a monthly retention amount it had paid to Advanced was neither credited towards the employee's medical costs nor repaid by Indigo. The court agreed with the district court that Indigo failed to establish standing because Indigo failed to show how any injury had arisen, or might arise in the future, from the alleged conduct. View "Indigo LR LLC, et al. v. Advanced Ins. Brokerage, et al." on Justia Law

Petitioner Robert Smitter applied for workers' compensation benefits after being injured on the job working as a firefighter for Thornapple Township. At the time of his injury, Petitioner also worked for General Motors. He earned eleven percent of his income from the township and 89 from GM. The township did not reduce its workers’ compensation obligation by coordinating Petitioner's benefits with his disability benefits under MCL 418.354(1)(b). The township sought reimbursement from the Second Injury Fund under the dual-employment provisions for the entirety of Petitioner's wage-loss benefits. The fund agreed to pay the amount it would have owed if the township had coordinated Petitioner's benefits. The township filed an application for a hearing with the Worker’s Compensation Board of Magistrates, seeking reimbursement from the fund for the uncoordinated amount. The magistrate ordered the fund to reimburse the township for 89 percent of Petitioner's uncoordinated benefits. The Workers’ Compensation Appellate Commission (WCAC) affirmed. The Court of Appeals denied the fund’s application for leave to appeal. After its review, the Supreme Court concluded that when the injury employment provided less than 80 percent of the employee’s wages, the fund is required to reimburse its portion of the coordinated amount of benefits. Because the Township did not coordinate in this case, the appellate court erred in its analysis. Accordingly the appellate court was reversed and the case remanded to the magistrate for further proceedings. View "Smitter v. Thornapple Township" on Justia Law

The Providence School Board (Board) provided health insurance to active employees and retirees. In 2006, the Providence Teachers Union (Union) filed a grievance protesting a difference in the increase of premium costs for retirees compared with a more modest increase in premium costs for active employees. The Union argued that the Board's action violated three provisions of the collective bargaining agreement (CBA) between the board and the union. An arbitrator ruled in the Union's favor, concluding that the Board violated the CBA by failing to include retirees and active employees in a single group when it calculated the healthcare premium rates. The trial justice vacated the arbitration award, concluding (1) the Union did not have standing to pursue a grievance on behalf of retirees, and (2) the issue of the calculation of the group premium rate was not arbitrable. The Supreme Court affirmed, holding (1) pursuant to Arena v. City of Providence and City of Newport v. Local 1080, the Union could not pursue this grievance on behalf of the retirees; and (2) because the Union had no standing to pursue this particular grievance, the grievance was not arbitrable. View "Providence Sch. Bd. v. Providence Teachers Union, Local 958" on Justia Law

Workforce Safety & Insurance (WSI) appealed a district court's judgment reversing its denial of worker's compensation benefits to claimant Brenda Albright. Albright submitted her claim to WSI for a work-related back injury. Albright had a history of back problems; an independent medical records review of Albright's case showed she had "well-documented multilevel degenerative disk pathology" which contributed to the claim at issue here. The ALJ hearing Albright's case concluded her injury was not the result of a single incident, and denied her application for benefits. Finding that the evidence in the record supported the ALJ's decision to deny Albright's application for benefits, the Supreme Court reversed the district court, affirmed the ALJ and reinstated WSI's order denying benefits. View "Albright v. ND Workforce Safety & Ins" on Justia Law

Plaintiff filed suit seeking interest on benefits she received under an Accidental Death and Dismemberment (ADD) insurance policy issued by Hartford. The parties disagreed on whether Tennessee law or Missouri law applied. Plaintiff did not dispute Hartford's argument that under Missouri law and the policy language, Hartford paid the benefit to her when it was payable. Accordingly, the court concluded that plaintiff was not entitled to interest under Missouri law. Assuming Tennessee law applied, the court relied on Performance Sys., Inc. v. First Am. Nat'l Bank, to conclude that the Tennessee Supreme Court would likely construe "due" in Tenn. Code Ann. 7-14-109(b) to mean the time of payment designated in the policy, not the date of loss. In this instance, Hartford paid the benefit to plaintiff within the time of payment designated in the policy and, therefore, plaintiff was not entitled to interest under subsection (b). Accordingly, the court affirmed the judgment. View "Williamson v. Hartford Life & Accident, etc." on Justia Law