Justia Insurance Law Opinion Summaries

In 1990, Employee was working for Employer when she injured her left ankle. By 2009, Employee had multiple surgeries and was taking approximately fourteen medications. That same year, a Dr. Randolph concluded Employee required no further medical treatment for her 1990 industrial injury and other allowed conditions in her claim and that her current medications were no longer necessary. Employee subsequently filed a motion with the Industrial Commission for the loss of use of her left arm. Based on Dr. Randolph's addendum to his original report, a hearing officer denied Employee's motion for compensation for the loss of use of her arm. Employee filed a complaint for a writ of mandamus, which the court of appeals denied, concluding that Dr. Randolph's second and third reports, issued as addenda to his original report, constituted some evidence upon which the Commission could rely to support its decision denying Appellant's claim. The Supreme Court affirmed, holding that because the addenda of Dr. Randolph constituted some evidence to support the Commission's decision to deny Employee's request for compensation for the loss of use of her left arm, the Commission did not abuse its discretion, and the court of appeals properly denied the writ. View "State ex rel. Kish v. Kroger Co." on Justia Law

Michael Jassek appealed a district court judgment that affirmed the binding dispute resolution decision of Workforce Safety and Insurance ("WSI") that denied payment for a myoelectric prosthesis. Upon review of the matter, the Supreme Court concluded the district court did not have subject matter jurisdiction, and therefore vacated the judgment. Jassek contended that because WSI failed to explain its reasons for disregarding the medical evidence favorable to Jassek, its binding dispute resolution decision was arbitrary, and that WSI's binding dispute resolution procedure violated his right to due process because it failed to provide a formal hearing. The language of N.D.C.C. 65-02-20 unambiguously provides that "[a] dispute resolution decision under this section requested by a medical provider concerning . . . a request for . . . treatment is not reviewable by any court." The statute based appealability on the identity of the party who requests binding dispute resolution, not on who appeals the binding dispute resolution decision. Jassek’s orthotist was a "medical provider," and this dispute concernd "a request for diagnostic tests or treatment," specifically the determination of an appropriate prosthetic device. Accordingly, WSI's decision on the medical provider’s request for binding dispute resolution was not reviewable by the district court, the district court was without subject matter jurisdiction, and the judgment affirming WSI's decision was void. View "Jassek v. Workforce Safety and Insurance" on Justia Law

Defendant-Appellant Lloyds of London Syndicate 2003 ("Lloyds") appealed the district court's denial of its summary judgment motion and subsequent grant of summary judgment in favor of Plaintiff-Appellee Brecek & Young Advisors, Inc. ("BYA") in an action arising out of a professional liability insurance contract. The district court concluded Lloyds failed to pay sufficient indemnity to BYA for claims brought against BYA in an arbitration before the National Association of Securities Dealers. The underlying suit alleged BYA agents mismanaged and unlawfully "churned" the investment accounts of its clients. The court concluded the claims brought in the arbitration did not relate back to earlier claims brought outside the policy period and, therefore, rejected Lloyds' argument coverage was precluded altogether. Additionally, the court rejected BYA's argument that Lloyds was equitably estopped from denying coverage due to its course of conduct in receiving and defending the claims. Upon review, the Tenth Circuit concluded that the district court erred in its interpretation of the law of the case, and therefore abused its discretion in making its judgments in this case. Accordingly, the district court's decisions were reversed and the case remanded for further proceedings. View "Brecek & Young Advisors, Inc. v. Lloyds of London Syndicate 2003" on Justia Law

Plaintiff, an insurance company, filed an equitable action in the U.S. district court for Rhode Island seeking a declaratory judgment that a life insurance policy was rescinded ab initio due to the fraudulent misrepresentations of Defendant, an irrevocable trust. Plaintiff also sought to retain the premium paid by the trust as an offset against the damages it had suffered in connection with the policy. The district court (1) found that Defendant, by and through its trustee, had made false representations to induce Plaintiff to issue the policy and that this fraud caused Plaintiff damages that would not be fully compensated by rescission alone; and (2) allowed Plaintiff to retain the policy premium paid by Defendant. The First Circuit Court of Appeals affirmed, holding that the district court (1) did not err, under Rhode Island law, in allowing Plaintiff to both rescind the policy and retain the premium; (2) did not err in finding that Plaintiff was a victim of a fraudulent insurance scheme; and (3) appropriately exercised its equity powers. View "PHL Variable Ins. Co. v. Bowie 2008 Irrevocable Trust " on Justia Law

Employee was injured while working for Employer and was awarded permanent partial disability benefits. Employee subsequently petitioned to review-reopen his workers' compensation claim, seeking additional workers' compensation benefits, seeking reimbursement for additional postarbitration medical expenses, requesting a determination of the amount of workers' compensation benefits still owed by Employer and its insurer, and asking the court to decide whether the workers' compensation commissioner needed to enter an additional order compelling payment to enforce an arbitration award for the unpaid benefits. The district court (1) rejected Employee's petition for review as untimely; (2) affirmed denial of reimbursement for some of Employee's medical expenses; and (3) did not provide the requested calculation but ruled that a compel-payment order was unnecessary because Employee could seek a judgment to enforce the award. The Supreme Court (1) reversed as to the statute of limitations for a petition for review-reopening; and (2) affirmed as to the judgment regarding which medical expenses were causally connected to the work-related injury. Remanded to the district court for it to remand the matter to the commissioner with directions to decide the issues regarding the amount still owed to Employee by Employer and its insurer under the arbitration award. View "Coffey v. Mid Seven Transp. Co." on Justia Law

Employee, who was injured while working for Employer, sought enforcement of an arbitration award he received from the workers' compensation commissioner against Employer and Employer's insurer. Employee requested the district court to determine the amount Employer and its insurer (collectively, Appellees) owed him under the arbitration award in light of Employee's claim that Appellees failed to pay all of the medical benefits, mileage reimbursements, and interest due under the arbitration decision. Appellees claimed a credit against any amount they owed Employee due to his third-party settlements. After a hearing, the district court declined to answer the issues raised by the parties and declined to determine the amount still owed to Employee under the arbitration decision, concluding that addressing the issues in Employee's petition required the district court to exceed its authority. The Supreme Court reversed and remanded to the district court for the court to remand the matter to the commissioner with directions to decide the issues Employee raised in his petition for judgment. View "Coffey v. Mid Seven Transp. Co." on Justia Law

A minor plaintiff commenced a civil action against the Roman Catholic Diocese of Brooklyn and one of its priests alleging sexual molestation by the priest. The Diocese settled the action for $2 million and additional consideration. At issue on appeal was a dispute between the Diocese and one of its insurance carriers (National Union) regarding the Diocese's demand for reimbursement for the settlement. The Diocese sought a declaratory judgment that National Union was required to indemnify the Diocese for the settlement and certain defense costs and fees. Supreme Court granted summary judgment for the Diocese. At issue on appeal was whether the incidents of sexual abuse constituted a single occurrence or multiple occurrences that spanned several years and several policy periods. The Appellate Division reversed, concluding that the alleged acts of sexual abuse constituted multiple occurrences and that the settlement amount should be allocated on a pro rata basis over the seven policy periods. The Court of Appeals affirmed, holding that the incidents of sexual abuse constituted multiple occurrences and that any potential liability should be apportioned among the several insurance policies, pro rata. View "Roman Catholic Diocese of Brooklyn v. Nat'l Union Fire Ins. Co. of Pittsburgh" on Justia Law

This matter arose from the suicide of a sixteen-year-old girl, who was residing at the Spring Creek Lodge Academy at the time of her death. Following the girl's death, her mother, Plaintiff, brought an action against the owner of the school, its on-site directors, including Teen Help, and various related entities. Claims against Teen Help were settled before trial, and the settlement was later reduced to a judgment. While Newman I proceeded to trial, Newman filed this declaratory judgment and breach of contract action against Teen Help's two insurers to collect on the settlement and judgment, arguing that the insurers breached their obligation to defend and indemnify Teen Help in Newman I. The district court determined the insurers were severally liable for the underlying judgment and awarded attorney's fees and interest on the underlying judgment. The Supreme Court (1) affirmed the district court's judgment as it pertained to the insurers, its award of interest on the underlying judgment, and its application of Montana law; and (2) reversed the court's ruling on attorney's fees. Remanded for recalculation of reasonable attorney's fees. View "Newman v. Scottsdale Ins. Co." on Justia Law

Claimant-appellant Stephen Arrants appealed a superior court order that affirmed an Industrial Accident Board's order granting employer-appellee Home Depot's petition to terminate appellant's total disability benefits. Appellant raised two claims on appeal: (1) the Board's decision was in error because all experts agreed that his condition had not improved since the 2007 Board finding of total disability; and (2) the Board's decision was not supported by competent evidence in the record. Upon review, the Supreme Court concluded that both arguments were without merit, and affirmed the superior court. View "Arrants v. Home Depot" on Justia Law

Phillips was beneficiary of a life insurance policy purchased by her fiancé, Strang, issued by Prudential. When Strang died, Prudential informed Phillips that the default method of payment was the “Alliance Account settlement option,” under which the insurer, instead of paying a lump-sum benefit, creates an interest-bearing account for the beneficiary and sends her checks that can be used to draw the funds, in part or in whole, at any time. The funds are held in Prudential’s general investment account, which allows Prudential to profit from the spread between its investment returns and interest paid to the beneficiary, in Phillips’s case, three percent. In a putative class action, Phillips claimed that establishment of the Alliance Account as the default payment method and her enrollment in it breached the insurance policy and unreasonably delayed payment of benefits in violation of the Illinois Insurance Code and that Prudential breached a fiduciary duty by not disclosing information regarding investments made with her funds and by keeping investment profits. The district court dismissed. The Seventh Circuit affirmed. “Whether this practice is disreputable is open to debate,” but It did not breach the policy, did not effect an unreasonable delay, and did not breach any fiduciary duty. View "Phillips v. Prudential Ins. Co." on Justia Law