Justia Insurance Law Opinion Summaries

In this case, a group of healthcare providers (Providers) sued the insurer Sanford Health Plan, Inc. (SHP) for excluding them from participating in some of its health benefit plans. The Providers argued that according to South Dakota’s “Any Willing Provider” law (SDCL 58-17J-2), they had the right to participate as panel providers in all of SHP's plans. The law stipulates that a health insurer cannot block patient choice by excluding a willing and qualified healthcare provider from its panel of providers if the provider is within the geographic coverage area of the health benefit plan. The circuit court determined that the law did not permit SHP to exclude a qualified and willing healthcare provider from participating in every health benefit plan it offered, granting summary judgment in favor of the Providers.The Supreme Court of the State of South Dakota affirmed the circuit court's decision. It interpreted the law as plan-specific, meaning an insurer may not exclude any willing and fully qualified provider from any of its plans or from any tier within a plan. It also clarified that an insurer may still exclude providers from plans if they do not meet the statutory requirements for participation as a panel provider. The court concluded that, according to the law, SHP could not exclude the Providers from participating in its TRUE Plan or Tier 1 of the PLUS Plan, thus affirming the circuit court's granting of summary judgment in favor of the Providers. View "Orthopedic Institute v. Sanford Health Plan, Inc." on Justia Law

In this case, the United States Court of Appeals for the Eighth Circuit affirmed the lower court's decision that the Pacific Life Insurance Company did not owe benefits to Katie Blevins, the beneficiary of a life insurance policy taken out by her late fiancé, Dr. Travis Richardson. Richardson applied for a life insurance policy and paid the first month's premium three days before he died. He did not sign the received policy or any required amendments. Blevins claimed that the policy was in effect at the time of Richardson's death, despite the policy not being physically delivered or formally accepted. Blevins also brought claims of bad faith, promissory estoppel, and apparent authority against the insurance company. In its decision, the court stated the policy was clear in its conditions, which required physical delivery and acceptance before the policy was in force. The court found these conditions were not met, as the policy was neither delivered nor accepted by Richardson before his death. Therefore, no death benefit was owed. As a result, Blevins' bad faith claim was also dismissed, as the insurer could not have acted in bad faith if there was no obligation to pay out the policy. View "Pacific Life Insurance Company v. Blevins" on Justia Law

Cynthia Bowen purchased an insurance policy from Farm Bureau Property & Casualty Insurance Company ("Farm Bureau") for her pick-up truck. She was injured when an employee of Menard, Inc. ("Menards") accidentally dropped a large board on her while helping load her truck at a store. Bowen sued Menards for damages, alleging negligence. Menards then filed an action against Farm Bureau seeking a declaratory judgment that it was entitled to a defense and indemnification from Farm Bureau under Bowen's insurance policy. The district court ruled in favor of Menards, finding that Menards and its employee were covered insureds under the policy and that no policy exclusion applied.On appeal, the United States Court of Appeals for the Eighth Circuit reversed the district court's decision. The court concluded that the policy's "Intrafamily Immunity" exclusion applied to the case. This exclusion stated that there was no coverage for any bodily injury to any "insured," which, in this case, included both Bowen and Menards. Therefore, the policy provided no liability coverage for Bowen's claim against Menards, another insured party. The court rejected the district court's reasoning that the term "intrafamily" limited the application of the exclusion, finding that the plain meaning of the operative policy provision prevailed. The court also rejected Menards' argument that Farm Bureau was estopped from asserting this defense to coverage. Consequently, the court reversed the district court's judgment, ruling that Farm Bureau was not obligated to provide defense and indemnification for Menards in connection with the lawsuit brought by Bowen. View "Menard, Inc. v. Farm Bureau P&C Ins. Co." on Justia Law

In the case before the Supreme Court of the State of Hawai‘i, the issue was whether a subrogee insurance company, which timely intervened pursuant to HRS § 386-8(b), has an independent right to continue to pursue claims and/or legal theories against a tortfeasor that were not asserted by the subrogor employee, after summary judgment has been granted against the subrogor employee, on the subrogor employee’s claims. This case involved Hyun Ju Park, a bartender who was shot by an off-duty Honolulu Police Department officer while at work. Park sued the City and County of Honolulu, alleging negligence and other claims. Dongbu Insurance Co., Ltd., the workers' compensation insurance carrier for Park's employer, intervened in the case, alleging additional negligence claims that Park had not raised. The City moved to dismiss all of Park’s claims and some of Dongbu's claims, which the court granted, leaving two of Dongbu's claims - negligent supervision and negligent training - remaining. The City then moved for summary judgment against Dongbu, arguing that since Park's claims were dismissed, Dongbu's claims also failed.The Supreme Court of Hawai‘i held that a subrogee insurance company, which timely intervened, does have an independent right to continue to pursue claims and/or legal theories against a tortfeasor that were not asserted by the subrogor employee, even after summary judgment has been granted against the subrogor. The court reasoned that an affirmative answer protects subrogation, aligns with Hawai‘i’s workers’ compensation subrogation law, and does not undermine employers’ and insurers’ intervention rights. The court also rejected the City's claim preclusion argument, stating that Dongbu's remaining claims for negligent supervision and negligent training had not yet been decided and were not barred by res judicata. Therefore, Dongbu may continue to pursue its non-dismissed claims. View "Park v. City and County of Honolulu" on Justia Law

This case involves a dispute between a homeowner, Mario Rodriguez, and his insurance company, Safeco Insurance Company of Indiana. After a tornado damaged Rodriguez's home, Safeco issued a payment of $27,449.88, which Rodriguez accepted. Rodriguez's counsel then informed Safeco that it owed an additional $29,500 and threatened to sue. Rodriguez sued Safeco, bringing several claims, including breach of contract and statutory claims under the Insurance Code. Safeco invoked the insurance policy’s appraisal provision and subsequently issued a check to Rodriguez for $32,447.73, which it viewed as full payment of the appraisal amount due under the policy. Safeco also paid an additional $9,458.40, which it claimed would cover any interest possibly owed on the appraised amount.The Supreme Court of Texas was asked to answer a certified question from the United States Court of Appeals for the Fifth Circuit: “In an action under Chapter 542A of the Texas Prompt Payment of Claims Act, does an insurer’s payment of the full appraisal award plus any possible statutory interest preclude recovery of attorney’s fees?” The Supreme Court of Texas held that the answer is yes. When an insurer has fully discharged its obligations under the policy by voluntarily paying the appraised amount, plus any statutory interest, in compliance with the policy’s appraisal provisions, section 542A.007 of the Insurance Code prohibits an award of attorney’s fees. This is because there is no remaining “amount to be awarded in the judgment to the claimant for the claimant’s claim under the insurance policy,” which means no attorney’s fees are available under section 542A.007(a)(3)’s formula. View "RODRIGUEZ v. SAFECO INSURANCE COMPANY OF INDIANA" on Justia Law

This case involves American Coastal Insurance Company ("American Coastal") and San Marco Villas Condominium Association, Inc. ("San Marco"). American Coastal issued San Marco a policy covering the condominium complex against various perils, including hurricanes. When Hurricane Irma struck Marco Island, San Marco's buildings sustained damage and submitted a claim to American Coastal. After an investigation, American Coastal estimated San Marco’s losses to be $356,208.82 and paid $192,629.75, reflecting depreciation and application of policy deductibles. San Marco, however, obtained an estimate showing damages exceeding eight million dollars, leading to a disagreement over the amount of loss, which San Marco sought to resolve by invoking the appraisal provision in the policy.American Coastal refused, arguing that an appraisal was premature since its investigation was ongoing. San Marco subsequently sued American Coastal, seeking the court to compel an appraisal. American Coastal contested, arguing that appraisal was inappropriate because they had completely denied coverage based on a policy condition that voids coverage when the insured commits fraud or makes material misrepresentations about the insurance. The trial court sided with San Marco and ordered an appraisal. The Second District Court of Appeal affirmed the trial court's decision, and the Supreme Court of Florida granted review based on the certified conflict.The Supreme Court of Florida held that a trial court has discretion in determining the order in which coverage and amount-of-loss issues are resolved. It rejected American Coastal’s argument that coverage issues must be resolved before an appraisal can be ordered. The court found that the policy’s retained-rights provision contemplates appraisals occurring prior to resolution of coverage issues. Therefore, the court approved the decision of the Second District Court of Appeal and disapproved the certified conflict cases to the extent they are inconsistent with this opinion. View "American Coastal Insurance Company v. San Marco Villas Condominium Association, Inc." on Justia Law

In a case concerning the Senior Health Insurance Company of Pennsylvania ("SHIP"), the Supreme Court of Pennsylvania upheld a rehabilitation plan devised by the Pennsylvania Insurance Commissioner. SHIP, which sold long-term care policies in multiple states, became insolvent due to the high cost of care against inadequate premiums. The rehabilitation plan was designed to correct the company’s financial condition by adjusting the premiums and benefits of the existing policies. However, insurance regulators from Maine, Massachusetts, and Washington ("Regulators") objected to the plan, arguing that it exceeded the Insurance Commissioner's statutory authority and violated their states' regulatory authority over rates. The court rejected these claims, finding that the plan did not exhibit a "policy of hostility" to the public acts of other states and thus did not violate the Full Faith and Credit Clause of the U.S. Constitution. The court concluded that the Commonwealth Court, holding exclusive jurisdiction over the distribution of SHIP's assets, did not abuse its discretion by approving the plan. View "In Re: Senior Health Ins. Co. of PA" on Justia Law

The Supreme Court of Pennsylvania ruled that a "regular use" exclusion in a motor vehicle insurance policy does not violate the Motor Vehicle Financial Responsibility Law (MVFRL), thereby reversing the order of the Superior Court. The case involved Matthew Rush, a detective, who was injured in a motor vehicle accident while driving a city-owned car insured under the city's policy. Rush had his personal vehicles insured with Erie Insurance. When Rush's injuries exceeded the liability insurance limits of the other drivers involved in the accident and the underinsured motorist (UIM) coverage limits of the city's policy, he filed a claim for UIM benefits under his Erie policies. Erie denied coverage based on the "regular use" exclusion in the Erie Policies. The Supreme Court of Pennsylvania held that the "regular use" exclusion was valid and enforceable, and did not violate the MVFRL. The court reasoned that UIM coverage was not universally portable and could, therefore, be subject to policy exclusions. View "Rush v. Erie Insurance Exchange" on Justia Law

In this case, a woman was severely injured while moving an inoperable airplane owned by her husband. She sought recovery from her husband's homeowner's insurance policy. The insurance policy, however, excluded injuries "arising out of" the ownership, maintenance, use, loading or unloading of an aircraft. The woman argued that the policy should cover her injury because, in her view, the aircraft had become mere "parts" after her husband removed the wings, elevators, and tail rudder. The lower court disagreed and concluded that her injuries were not covered by the policy. The woman appealed this decision.The Supreme Court of the State of Alaska agreed with the lower court’s interpretation of the homeowner's insurance policy exclusion. The court maintained that regardless of whether the airplane was considered an aircraft or a collection of airplane “parts” when it injured the woman, the injury arose out of the husband’s ownership of the airplane. This interpretation was supported by the clear language of the policy which excluded coverage for bodily injury arising out of ownership or maintenance of an aircraft. As a result, the court affirmed the lower court’s decision. View "Thompson v. United Services Automobile Association" on Justia Law

The case in question arose from a multi-million-dollar loss suffered by Westlake Chemical Corporation and Axiall Corporation (the respondents) at their chlorine manufacturing plant in Natrium, West Virginia. The loss occurred when 90 tons of liquid chlorine leaked from a rupture in a railroad tanker car that had been recently repaired by third-party contractors. The liquid chlorine vaporized into a cloud or plume that caused corrosion damage to the equipment at the plant. The respondents claimed the damage costs from their insurance companies (the petitioners). However, the insurance companies denied coverage based on three exclusions in the insurance policies relating to corrosion, faulty workmanship, and contamination. The case reached the Supreme Court of Appeals of West Virginia, which was asked to review three orders of the Circuit Court of Marshall County, West Virginia, Business Court Division. The lower court had granted partial summary judgment to the respondents, finding that none of the three exclusions barred the respondents’ coverage claims. The Supreme Court of Appeals of West Virginia concluded that the lower court's orders were not final orders subject to appeal at this stage of the proceedings. This was due to unresolved issues of causation and damages, and because the orders did not conclusively determine the disputed controversy, resolve an important issue completely separate from the merits of the action, or were effectively unreviewable on appeal from a final judgment. Therefore, the court dismissed the appeal, without prejudice. View "NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. v. WESTLAKE CHEMICAL CORPORATION" on Justia Law