Justia Insurance Law Opinion Summaries

Annette McEachin, a human resources manager, was seriously injured in a car accident in 2017 and subsequently filed a disability claim with Reliance Standard Life Insurance Company. Reliance approved her for long-term disability benefits, which were later extended after another car accident worsened her condition. McEachin underwent multiple surgeries and treatments for her physical injuries and also received treatment for mental health issues, including depression and anxiety, exacerbated by her son's suicide in 2019. Reliance paid her benefits for nearly four years but stopped payments in April 2021, concluding that her physical health had improved sufficiently for her to return to work.The United States District Court for the Eastern District of Michigan found that McEachin no longer had a physical disability as of April 2021 but ruled that her mental health disabilities entitled her to two more years of benefits. Both parties appealed the decision. Reliance argued that the district court misinterpreted the insurance policy, while McEachin contended that her physical disabilities persisted beyond April 2021.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court held that McEachin's physical disabilities alone justified her disability benefits until April 2021, meaning the 24-month mental health limitation did not apply until then. The court affirmed the district court's finding that McEachin's physical disabilities no longer rendered her totally disabled as of April 2021. However, the court vacated the district court's decision regarding the mental health benefits and remanded the case to consider whether McEachin's post-April 2021 medical evidence could toll the 24-month mental health limitation period, potentially extending her eligibility for benefits beyond April 2023. View "McEachin v. Reliance Standard Life Ins. Co." on Justia Law

GEICO, a group of insurance companies, presented evidence that the defendants, collectively known as the Mayzenberg Defendants, paid third parties for referring patients eligible for no-fault insurance benefits to Mingmen Acupuncture, P.C. GEICO argued that this constituted an illegal kickback scheme, violating New York's rules of professional misconduct, and thus, under the Eligibility Regulation (11 N.Y.C.R.R. § 65-3.16(a)(12)), Mingmen was ineligible to receive no-fault payments. The Mayzenberg Defendants contended that paying for patient referrals might be professional misconduct but did not violate a "licensing requirement" under the Eligibility Regulation.The United States District Court for the Eastern District of New York granted summary judgment in favor of GEICO, agreeing that the Mayzenberg Defendants paid for patient referrals and that this conduct rendered Mingmen ineligible for no-fault benefits. The court also granted GEICO summary judgment on its common law fraud and RICO claims, based on the same conclusions about Mingmen’s ineligibility.The United States Court of Appeals for the Second Circuit reviewed the case and found that while the facts established that the Mayzenberg Defendants paid for patient referrals, the legal question of whether this conduct violated a "licensing requirement" under the Eligibility Regulation was unsettled. Given the lack of clear precedent from the New York Court of Appeals and the significant policy implications, the Second Circuit certified the question to the New York Court of Appeals to determine if paying for patient referrals in violation of New York Education Law § 6530(18) and 8 N.Y.C.R.R. § 29.1(b)(3) disqualifies a provider from receiving no-fault payments under the Eligibility Regulation. View "GEICO v. Mayzenberg" on Justia Law

A construction company chartered a barge and obtained insurance through a broker. Upon returning the barge, the owner discovered damage and sued the construction company in federal court. The construction company requested its insurer to defend it, but the insurer refused, citing lack of coverage. After the federal court awarded damages to the barge owner, the construction company sued the insurer and broker in state court, alleging breach of contract, insurance bad faith, and negligence.The Superior Court of Alaska denied the construction company's motion for summary judgment against the broker and insurer. The court granted summary judgment to the broker and insurer, finding that the construction company's claims were barred by the statute of limitations. The court held an evidentiary hearing and concluded that the construction company had not relied on any reassurances from the broker that would have delayed the filing of the lawsuit.The Alaska Supreme Court reviewed the case and affirmed the Superior Court's decision. The court held that the construction company's claims against the broker were time-barred, as the statute of limitations began to run when the insurer first denied coverage. The court also held that the construction company's claims against the insurer were time-barred, as the statute of limitations began to run when the insurer refused to defend the construction company in the federal lawsuit. The court concluded that the construction company's claims were untimely and affirmed the summary judgment in favor of the broker and insurer. View "Swalling Construction Company, Inc. v. Alaska USA Insurance Brokers, LLC" on Justia Law

A general contractor, Tocci Building Corporation, and its affiliates were involved in a dispute with their insurers, including Admiral Insurance Company, over coverage under a commercial general liability (CGL) insurance policy. The issue was whether the CGL policy covered damage to non-defective parts of a construction project caused by a subcontractor's defective work on another part of the project. Tocci sought defense and indemnity coverage under the Admiral policy for a lawsuit filed by Toll JM EB Residential Urban Renewal LLC, which alleged various issues with Tocci's work on a residential construction project.The United States District Court for the District of Massachusetts concluded that Admiral had no duty to defend Tocci. The court found that the lawsuit did not allege "property damage" caused by an "occurrence" as required for coverage under the policy. The court reasoned that the damage alleged was within the scope of the project Tocci was hired to complete and thus did not qualify as "property damage." Additionally, the court held that faulty workmanship did not constitute an "accident" and therefore was not an "occurrence" under the policy.The United States Court of Appeals for the First Circuit reviewed the case and affirmed the district court's decision, but for different reasons. The appellate court focused on the policy's exclusions, particularly the "Damage to Property" exclusion (j)(6), which excludes coverage for property that must be restored, repaired, or replaced because the insured's work was incorrectly performed on it. The court concluded that this exclusion applied to the entire project since Tocci was the general contractor responsible for the entire construction. The court also noted that Tocci did not meet its burden of showing that any exceptions to the exclusion applied, such as the "products-completed operations hazard," because Tocci's work was not completed or abandoned. Thus, the appellate court held that Admiral had no duty to defend Tocci in the underlying lawsuit. View "Admiral Insurance Company v. Tocci Building Corporation" on Justia Law

William Loomis was injured in a two-vehicle accident while driving a truck for his employer, XPO Logistics, Inc. The truck was registered in Indiana and garaged in New York. After recovering the full amount from the other vehicle’s liability insurer, Loomis sought additional recovery from ACE American Insurance Company, XPO’s insurer. ACE denied the claim, stating that the policy did not include underinsured motorist (UIM) coverage in Indiana or New York.Loomis sued ACE in New York state court, alleging breach of the insurance agreement. The case was removed to the United States District Court for the Northern District of New York. The district court granted Loomis’s motion, applying Indiana law, and concluded that the policy was not exempt from Indiana’s UIM statute. However, the court later granted ACE’s motion for summary judgment, determining that ACE’s obligation to provide UIM coverage was subject to the exhaustion of a $3 million retained limit. Both parties appealed, and the United States Court of Appeals for the Second Circuit certified two questions to the Indiana Supreme Court.The Indiana Supreme Court reviewed the case and concluded that the term “commercial excess liability policy” under Indiana law is ambiguous and must be construed in favor of the insured. Therefore, the policy in question is not exempt from the UIM coverage requirements. Additionally, the court found that the phrase “limits of liability” is also ambiguous and must be construed in favor of the insured, meaning that ACE’s statutory obligation to provide UIM coverage is not subject to the $3 million retained limit. The court answered both certified questions in the negative, ruling in favor of Loomis. View "Loomis v. ACE American Insurance Co." on Justia Law

Lisa Davis and her son, Brandon Zoladkiewicz, were involved in a car accident with an uninsured drunk driver, resulting in Davis's death and Brandon's serious injuries. Davis and her husband, Mark Ginsberg, had separate but nearly identical insurance policies from the same carrier, each with uninsured motorist coverage of $100,000 per person and $300,000 per accident. Ginsberg, individually and as executor of Davis's estate, and Ron Zoladkiewicz, as guardian ad litem for Brandon, sought coverage from both policies. The insurance carrier agreed to pay the coverage limit for one policy but refused to combine or stack the two policies.The Superior Court of Delaware dismissed the plaintiffs' complaint, agreeing with the insurance carrier that the Delaware Insurance Code limited coverage to one policy when the policies were issued by the same insurer to insureds in the same household. The court found that the statute allowed anti-stacking provisions and that the policies' provisions were not ambiguous enough to permit stacking.The Supreme Court of Delaware reversed the Superior Court's decision. The court held that the Delaware Insurance Code does not prohibit stacking of underinsured/uninsured motorist coverage policies issued by the same carrier to insureds in the same household. Instead, the Code requires that the court limit coverage to the highest limit of liability set by either insurance policy. The court found that the policies were ambiguous because they contained conflicting provisions regarding stacking. Interpreting the ambiguity in favor of the insureds, the court allowed stacking of the policies. Additionally, the court determined that the releases signed by Ginsberg and Brandon Zoladkiewicz did not preclude recovery under the Ginsberg Policy. The case was remanded to the Superior Court to determine the amount recoverable under the Ginsberg Policy. View "Ginsberg v. Harleysville Worcester Insurance Company" on Justia Law

The case involves the Police Jury of Calcasieu Parish, a political subdivision of Louisiana, which suffered property damage from Hurricanes Laura and Delta in 2020. The Police Jury had insurance policies with a syndicate of eight domestic insurers. The insurers sought to compel arbitration in New York under New York law for the approximately 300 property damage claims. The Police Jury alleged underpayment and untimely payments by the insurers and filed suit in state court, which was later removed to the United States District Court for the Western District of Louisiana.The Western District Court granted the Police Jury's motion to certify three questions of Louisiana law to the Louisiana Supreme Court. The questions concerned the validity of arbitration clauses in insurance policies issued to Louisiana political subdivisions, particularly in light of a 2020 amendment to La. R.S. 22:868 and the applicability of La. R.S. 9:2778, which bars arbitration clauses in contracts with the state or its political subdivisions.The Louisiana Supreme Court addressed the certified questions. First, it held that the 2020 amendment to La. R.S. 22:868, which allowed forum or venue selection clauses in certain insurance contracts, did not implicitly repeal the prohibition of arbitration clauses in all insurance contracts under La. R.S. 22:868(A). Second, the court determined that La. R.S. 9:2778 applies to all contracts with political subdivisions, including insurance contracts, thereby prohibiting arbitration outside Louisiana or the application of foreign law. Third, the court held that a domestic insurer cannot use equitable estoppel to enforce an arbitration clause in another insurer’s policy against a political subdivision, as it would contravene the positive law prohibiting arbitration clauses in La. R.S. 22:868(A)(2).The Louisiana Supreme Court answered all three certified questions, maintaining the prohibition of arbitration clauses in insurance policies issued to Louisiana political subdivisions and affirming the applicability of La. R.S. 9:2778 to such contracts. View "POLICE JURY OF CALCASIEU PARISH VS. INDIAN HARBOR INSURANCE CO." on Justia Law

In 2019, Huberto Martinez's vehicle slid off an icy highway in Shreveport, Louisiana, and was subsequently struck by a tractor-trailer driven by Salah Dahir and owned by Starr Carriers, LLC. Martinez and his passengers, Ada Licona, Rosa Rivera, and Salvador Flores, filed lawsuits against Dahir, Starr Carriers, and their insurer, American Transportation Group Risk Retention Group, Inc. (ATG), which had a policy limit of $1,000,000. Martinez settled his claims before trial, but the jury awarded substantial damages to the remaining plaintiffs, exceeding ATG's policy limit.The First Judicial District Court, Parish of Caddo, denied the defendants' post-trial motions and rendered a final judgment in favor of the plaintiffs for $2,802,054.66 plus interest and costs. The defendants sought a suspensive appeal and requested a bond less than the entire judgment, citing their inability to secure such a bond. The trial court set the bond at the full judgment amount. ATG posted a bond for its remaining policy limits plus interest and costs. The Second Circuit Court of Appeal denied ATG's request for supervisory review.The Supreme Court of Louisiana reviewed the case and held that an insurer is not required to post a bond exceeding its policy limits to secure a suspensive appeal. The court determined that requiring ATG to post a bond for the entire judgment would impair the contractual limits of liability and violate the contract clause of the state constitution. The court allowed ATG to post a bond up to its policy limits for a suspensive appeal and to devolutively appeal the remainder of the judgment. The case was remanded for further proceedings consistent with this holding. View "MARTINEZ VS. AMERICAN TRANSPORT GROUP RISK RETENTION GROUP, INC." on Justia Law

The plaintiffs, Shane and Maura Pelissier, insured their automobile through GEICO General Insurance Company. They sought underinsured motorist benefits four and a half years after a motor vehicle accident with an underinsured driver. GEICO moved for summary judgment, citing a policy provision requiring lawsuits for underinsured motorist benefits to be filed within three years of the accident. The trial court denied the motion and transferred three interlocutory appeal questions to the Supreme Court of New Hampshire.The trial court found that the contractual limitations provision was unenforceable because it could require insureds to file suit before a justiciable cause of action exists. It also found that using the date of the accident as the triggering event for the limitations period was contrary to public policy and that there was a material factual dispute regarding the plaintiffs' ability to discover the tortfeasor’s policy limits before the limitations period expired. The trial court denied GEICO’s motion for reconsideration but granted an interlocutory appeal.The Supreme Court of New Hampshire reviewed whether the contractual limitations provision violated public policy. The court held that the provision was unenforceable because it could force insureds to file suit before their cause of action for underinsured motorist benefits had accrued, thus restricting their ability to recover damages. The court noted that the provision contravened the public policy underlying New Hampshire’s uninsured motorist statute, RSA 264:15, which aims to place insured persons in the same position as if the offending motorist had adequate liability insurance. The court affirmed the trial court’s decision in part, did not address the second interlocutory question, and remanded the case for further proceedings. View "Pelissier v. GEICO Gen. Ins. Co" on Justia Law

State Farm Mutual Automobile Insurance Company and State Farm Fire and Casualty Insurance Company (collectively, “State Farm”) provide automobile insurance in New York and are required to reimburse individuals injured in automobile accidents for necessary health expenses under New York’s No-Fault Act. State Farm alleges that several health care providers and related entities engaged in a scheme to fraudulently obtain No-Fault benefits by providing unnecessary treatments and services, and then pursued baseless arbitrations and state-court proceedings to seek reimbursement for unpaid bills.The United States District Court for the Eastern District of New York granted State Farm’s motion for a preliminary injunction in part, enjoining the defendants from proceeding with pending arbitrations and from initiating new arbitrations and state-court proceedings, but denied an injunction of the pending state-court proceedings. The district court found that State Farm demonstrated irreparable harm due to the fragmented nature of the proceedings, which obscured the alleged fraud, and the risk of inconsistent judgments and preclusive effects.The United States Court of Appeals for the Second Circuit reviewed the case and affirmed the district court’s decision to grant the preliminary injunction in part. The appellate court held that the district court did not abuse its discretion in finding that State Farm demonstrated irreparable harm, serious questions going to the merits, a balance of hardships tipping in its favor, and that the injunction was in the public interest. The court also concluded that the Federal Arbitration Act did not bar the injunction of the arbitrations because the arbitrations would prevent State Farm from effectively vindicating its RICO claims.Additionally, the appellate court reversed the district court’s decision not to enjoin the pending state-court proceedings, finding that the Anti-Injunction Act’s “expressly-authorized” exception applied. The court determined that the state-court proceedings were part of a pattern of baseless, repetitive claims that furthered the alleged RICO violation, and that enjoining these proceedings was necessary to give RICO its intended scope. The case was remanded for further proceedings consistent with this opinion. View "State Farm Mutual v. Tri-Borough" on Justia Law