Justia Insurance Law Opinion Summaries

Companies underwriting workers’ compensation insurance participate in a reinsurance pool administered by the National Workers Compensation Reinsurance Association. Insurers share in the pool’s profit or loss according to the volume of business they underwrite. When the pool is profitable, it is beneficial to have a larger book of business; when the pool loses money, a smaller book means that the underwriter needs to contribute less toward the losses. The class contends that AIG underreported the size of its business in losing years, causing the pool’s other members to bear a disproportionate share of the losses and sought$3.1 billion. Some of the insurers had independent claims against AIG. AIG advanced its own claims against Liberty Mutual. The district judge approved a settlement. Liberty Mutual appealed, arguing that its share would not compensate it adequately for its stand-alone claims against AIG and that the conflicts of interest within the reinsurance pool meant that the case never should have been certified as a class. After argument, Liberty Mutual settled with AIG. The Seventh Circuit dismissed the appeal, holding that the settlement does not jeopardize the interests of the unrepresented class members. View "Am. Int'l Grp. v. Liberty Mut. Ins. Co" on Justia Law

Judge, who worked as an airline baggage handler and ramp agent for 20 years, underwent surgery to repair an aortic valve and a dilated ascending aorta. He applied for disability benefits under a group insurance policy issued by MetLife. MetLife denied benefits, finding that Judge was not totally and permanently disabled under the terms of the Plan. After exhausting internal administrative procedures, Judge sued to recover benefits under 29 U.S.C. 1132(a)(1)(B), the Employee Retirement Income Security Act (ERISA). The district court granted judgment on the administrative record in favor of MetLife. The Sixth Circuit affirmed, rejecting arguments that MetLife applied the wrong definition of “total disability,” erred in failing to obtain vocational evidence before concluding that Judge was not totally and permanently disabled, erred in conducting a file review by a nurse in lieu of having Judge undergo independent medical examination, and that there was a conflict of interest because MetLife both evaluates claims and pays benefits under the plan. View "Judge v. Metro. Life Ins. Co." on Justia Law

A hotel worker fell and injured her back while cleaning a room. Her employer initially paid benefits, but it filed a controversion of benefits after its doctor doubted the accident’s occurrence and said any work injury was not the substantial cause of the worker’s continuing need for medical care. The Alaska Workers’ Compensation Board decided that the fall was the substantial cause of the worker’s disability, finding the worker’s testimony about the injury credible and the employer’s doctor’s testimony not credible. Based on the testimony of the worker and her treating physician, as well as an MRI showing a herniated disc, the Board decided that the injury was compensable. The Alaska Workers’ Compensation Appeals Commission reversed the Board’s decision because, in the its view, substantial evidence did not support the decision. Because the Commission incorrectly decided the substantial evidence question, the Supreme Court reversed the Commission’s decision. View "Sosa de Rosario v. Chenega Lodging" on Justia Law

Appellant was injured during the course of his employment with Employer. Appellant obtained a workers' compensation award that covered future medical treatment. Appellant subsequently underwent knee replacement surgery and sought a further award of benefits. The Workers' Compensation Court (WCC) denied the petition, finding that Appellant's knee replacement surgery was not established to be the product of the subject accident but, rather, was prompted by Appellant's preexisting degenerative knee condition. The Supreme Court affirmed, holding (1) the evidence provided sufficient competent evidence to support a finding that Appellant's knee replacement surgery was not the result of the work-related accident, and therefore, the WCC did not err in finding that Appellant's surgery was not compensable; and (2) in so holding, the WCC was not acting contrary to the original award but was enforcing the award's plain language. View "Pearson v. Archer-Daniels-Midland Milling Co." on Justia Law

Second Chance Investments, LLC (SCI) purchased a fire insurance policy from Auto-Owners Insurance Company (Auto-Owners) that covered a building with the limit of insurance set at $2,095,500. The building subsequently suffered extensive fire damage. SCI filed a proof of loss claiming the building was a total loss. Auto-Owners rejected the proof of loss, contending that it did not state the actual cash value of the loss as required by the policy or provide a written estimate of repair to support the claim. After a continued dispute over whether the property was a total loss, Auto-Owners ultimately filed a complaint in district court seeking an order compelling SCI to submit the issue of whether the building was a total loss to a binding determination by an appraisal panel. The district court denied Auto-Owners' motion to compel appraisal and dismissed its complaint. The court of appeals affirmed, concluding that a court, rather than an appraisal panel, is the appropriate forum to determine whether the property suffered a total loss. The Supreme Court affirmed, holding that a party to a fire insurance policy does not have the statutory right to have an appraisal panel decide whether a claim involves a total loss. View "Auto-Owners Ins. Co. v. Second Chance Invs., LLC" on Justia Law

R.I. Pools appealed from the district court's grant of summary judgment in favor of Scottsdale, which insured R.I. Pools under commercial general liability policies. Scottsdale brought this action seeking declaratory judgment that it had no obligations under the policies with respect to suits brought against R.I. Pools by purchasers of swimming pools for damage the purchasers sustained when cracks developed in their pools. Because the district court erred in ruling that defects in R.I. Pool's work were not within the scope of an "occurrence" and never considered the crucial question whether the defects come within the subcontractor exception to the express exclusion of R.I. Pools's own work, the court vacated the judgment and remanded for further proceedings. Because the duty to defend existed up until the point at which it was legally determined that there was no possibility for coverage under the policies, Scottsdale had not shown entitlement to any reimbursement for defense costs it previously expended. View "Scottsdale Ins. Co. v. R.I. Pools Inc." on Justia Law

Plaintiffs, 91 current and former special investigators (SIs) employed by Nationwide Mutual Insurance claimed that Nationwide improperly classified SIs as administrative employees exempt from the overtime requirements of the Fair Labor Standards Act, 29 U.S.C. 207 and 213(a)(1)) and analogous provisions of New York and California law. The district court entered partial summary judgment in favor of Nationwide, then ruled in the company’s favor following trial on other issues. The Sixth Circuit affirmed. A reference to investigators, 29 C.F.R. 541.3(b)(1), read in context, pertains to law enforcement and public safety personnel and not to the Sis employed by Nationwide. Plaintiffs perform work “directly related” to Nationwide’s “general business operations.” The district court properly found that their investigations, with the purpose of resolving the indicators of fraud and the legitimacy of the suspicious claims, are unlike the narrower more formulaic background investigations into facts and records that have been found to not involve the exercise of discretion and independent judgment with respect to matters of significance. View "Foster v. Nationwide Mut. Ins. Co" on Justia Law

Two employees of Connections CSP, Inc. were killed in an automobile collision during the course and scope of their employment. Connections owned the vehicle and had purchased underinsured motorist insurance (UIM) for the vehicle and also worker's compensation insurance which covered the employees. The UIM insurer paid its policy limit of $1,000,000. The worker's compensation insurer also paid benefits to the representatives of the decedents. The worker's compensation insurer then sought to enforce a lien upon the UIM payment equal to the worker's compensation benefits it paid. But the UIM policy specifically excluded the direct or indirect benefit of any insurer or self-insurer under a worker's compensation claim. Notwithstanding this exclusion, the Superior Court enforced the lien based upon its interpretation of 19 Del. C. 2363(e), which allows reimbursement of a worker's compensation carrier "from the third party liability insurer." The UIM insurer appealed. Upon review, the Supreme Court held that General Assembly eliminated the ability of a worker's compensation insurer to assert a lien against the UIM payments made pursuant to the employer's UIM policy. Because the Superior Court erred as a matter of law in enforcing a lien, the Supreme Court reversed its decision and remanded the case for further proceedings. View "Simendinger v. National Union Fire Insurance Co." on Justia Law

Plaintiff was injured in an automobile accident and received medical treatment at Benefis Health System, Inc. Plaintiff had healthcare coverage as a TRICARE beneficiary and also had medical payments coverage through his insurance carrier, Kemper. Plaintiff's medical treatment costs totaled $2,073. Benefis accepted $662 from TRICARE as payment in full satisfaction of the bill pursuant to a preferred provider agreement (PPA) between Blue Cross Blue Shield and Benefis. Benefis subsequently received $1,866 from Kemper, upon which Benefis reimbursed TRICARE's payment in full. Plaintiff filed an individual and class action complaint, claiming that he was entitled to the additional $1,204 that Benefis received from Kemper over and above the TRICARE reimbursement rate. Plaintiff filed a motion for judgment on the pleadings, asking the district court to find Benefis breached its contract with TRICARE and that Benefis was liable for Plaintiff's damages. The district court converted the motion into a motion for summary judgment and granted summary judgment to Plaintiff. The Supreme Court reversed the grant of summary judgment, holding (1) Plaintiff was not entitled to pocket the difference between the TRICARE reimbursement rate and the amount Benefis accepted from Kemper; and (2) Plaintiff failed to establish any damages that resulted from the alleged breach. View "Conway v. Benefis Health Sys., Inc." on Justia Law

The issue before the Supreme Court in this case was one of first impression: whether the Louisiana Workers’ Compensation Law (specifically La. R.S. 23:1036) as the exclusive remedy for a volunteer firefighter in claims for personal injury against the "fire company," similarly applies to claims for personal injury against fellow volunteer members. After reviewing the record and the law, the Court found the defendant failed to establish that the Workers’ Compensation Law granted immunity to fellow volunteer members of a volunteer fire company from suits in tort. Accordingly, the Court affirmed the decisions of the lower courts in denying the defendants’ motion for summary judgment. View "Champagne v. American Alternative Ins. Corp." on Justia Law