Justia Insurance Law Opinion Summaries

Van Dermark served in the Navy from 1963 until his 1976 honorable discharge. The VA found Van Dermark to be totally and permanently disabled due to service-connected injuries. Van Dermark received treatment in Thailand (where he lived) at non-VA facilities, from physicians and others not affiliated with VA, in 2016 and in 2018, both times for cardiac conditions not related to his service-connected disability. For each of the two instances of treatment abroad, Van Dermark filed a claim with VA under 38 U.S.C 1728 and 1725 seeking VA payment—to him or his medical creditors—for the surgical or other heart-related treatment he received abroad.VA Community Care denied both claims. The Board of Veterans’ Appeals maintained the denials. The Veterans Court and Federal Circuit affirmed. Section 1724(a) prohibits the VA from “furnish[ing] hospital . . . care or medical services” abroad, where the care or services are unrelated to the service-connected disability. The “furnishing” phrase encompasses the payment for a veteran’s hospital care or medical expenses abroad at issue here; sections 1728 and 1725 do not override that prohibition. View "Van Dermark v. McDonough" on Justia Law

This case arose out of a qui tam action against Prime Healthcare Services—Encino Hospital, LLC (Encino Hospital) and others to impose civil penalties for violation of the Insurance Fraud Prevention Act (IFPA), Insurance Code section 1871 et seq. The State of California and relator (Plaintiffs) appealed from a judgment entered after a bench trial in which the court found insufficient evidence to support their allegations that Defendants engaged in insurance fraud by billing insurers for services performed in a detox center for which they had no appropriate license, and by employing a referral agency to steer patients to the center.   The Second Appellate District affirmed the judgment. The court explained that, CDI alleged that Encino Hospital misrepresented to insurers that it was properly licensed to provide detox services when it was not. The trial court found no evidence suggesting that Defendants presented a false claim to any insurer. The court agreed, reasoning that no authority of which it is aware or to which it has been directed obligates Encino Hospital to hold any license other than its license as a general acute care hospital. Because Encino Hospital needed no separate license or approval, and no evidence showed it concealed any provider, the CDI’s cause of action for false claims failed for lack of a predicate. View "State of Cal. v. Encino Hospital Medical Center" on Justia Law

Plaintiff appealed the district court’s post-trial dismissal of his case for lack of subject-matter jurisdiction. A jury found that AXA Equitable Life Insurance Company negligently reported false medical information about Plaintiff to an information clearinghouse used by insurance companies, causing him to become uninsurable. Despite the fact that the parties satisfied the requirements for federal diversity jurisdiction, and the fact that both parties litigated the entire case through trial under North Carolina law, the district court decided that Connecticut law applied and found itself deprived of subject-matter jurisdiction by virtue of a Connecticut statute.   The Fourth Circuit found that the district court erred and concluded that choice of law is waivable and was waived here. And even if Connecticut’s law applied, it would not have ousted federal jurisdiction. Further, the court held that the district court also erred by concluding that Connecticut’s CIIPPA divested it of subject-matter jurisdiction despite that statute affecting only choice of law rather than choice of forum. AXA’s alternative argument for affirmance based on the nature of Plaintiff’s s injury and its causation was thoroughly briefed and argued before the court, and the court found it to be without merit. But because AXA’s argument for post-trial relief challenging the number of damages was neither raised nor briefed before this court, the court remanded to the district court to consider that issue in the first instance. View "Malcolm Wiener v. AXA Equitable Life Insurance Company" on Justia Law

Department of Labor regulations required the administrator of an employee benefit plan to give a claimant, “upon request,” copies of “all documents, records, and other information” that the administrator considered in making an adverse benefit determination. In 2018, the regulations were amended to eliminate “upon request” and require an administrator to provide such information “sufficiently in advance” of an adverse determination “to give the claimant a reasonable opportunity to respond.”Zall, a dentist for 20 years, sought long-term disability benefits in 2013 after pain and numbness forced him to stop working. His insurer, Standard denied the claim. In 2014, after considering additional medical information and consulting an orthopedic surgeon, Standard approved Zall’s claim, including retroactive payments. Less than a year later, Standard began reviewing his case to see if his condition was subject to a 24-month benefit limit applicable to any disability “caused or contributed to by … carpal tunnel or repetitive motion syndrome” or “diseases or disorders of the cervical, thoracic, or lumbosacral back and its surrounding soft tissue.” Standard ultimately terminated Zall’s benefits.Zall filed suit under the Employee Retirement Income Security Act, 29 U.S.C. 1001, arguing that the decision was arbitrary and capricious and that Standard violated ERISA’s procedural requirements by failing to afford him “a full and fair review.” The district court granted Standard summary judgment. The Seventh Circuit reversed and remanded. The plain language shows that the amended regulation applies; Standard failed to comply. View "Zall v. Standard Insurance Co." on Justia Law

When the ACA’s mandate and SRP were still in effect, a husband and wife (“Taxpayers”) did not maintain the minimum insurance coverage required by the ACA. The taxpayers did not include their $2409 SRP when they filed their 2018 federal tax return. The Taxpayers filed for Chapter 13 bankruptcy protection in the Eastern District of North Carolina. The IRS filed a proof of claim for the unpaid SRP and asserted that its claim was entitled to priority as an income or excise tax under Section 507 of the Bankruptcy Code. The Taxpayers objected to the government’s claim of priority. The bankruptcy court granted the objection, concluding that, for purposes of the Bankruptcy Code, the SRP is a penalty, not a tax, and therefore is not entitled to priority under Section 507(a)(8). The government appealed to the district court, which affirmed the bankruptcy court’s decision. The district court held that even if the SRP was generally a tax, it did not qualify as a tax measured by income or an excise tax and thus was not entitled to priority. The government thereafter appealed.   The Fourth Circuit reversed and remanded. The court concluded that that the SRP qualifies as a tax under the functional approach that has consistently been applied in bankruptcy cases and that nothing in the Supreme Court’s decision in NFIB requires the court to abandon that functional approach. Because the SRP is a tax that is measured by income, the government’s claim is entitled to priority under 11 U.S.C. Section 507(a)(8)(A). View "US v. Fabio Alicea" on Justia Law

Five months after being sued in Oregon for trademark infringement, Jacob Rieger & Co., LLC provided notice to its liability insurer, Cincinnati Insurance Company. Due to Rieger’s delay, Cincinnati refused to reimburse Rieger’s legal fees for the five months that Cincinnati was unaware of the lawsuit. The Oregon case was ultimately dismissed for lack of jurisdiction. Instead of waiting to be sued in a court that did have jurisdiction, Rieger’s parent company, GSP Licensing LLC, filed a new suit in Missouri as the plaintiff. GSP was not named under Rieger’s insurance policy, so Cincinnati denied coverage for the Missouri case. Cincinnati then filed this lawsuit, seeking a declaration of coverage. The district court granted summary judgment to Cincinnati.   The Eighth Circuit reversed in part the district court’s grant of summary judgment to Cincinnati. The court affirmed the dismissal of Rieger’s tort claims and the imposition of sanctions. The court explained that under Missouri law, a tort claim is independent of a contract claim if the tort claim can succeed without regard to the outcome of the contract claim. In other words, the tort claim could succeed regardless of the outcome of the contract claim. Here, Rieger admits that its tort claims would fail if its contract claim succeeded. By Rieger’s own admission, the court found that the district court properly dismissed Rieger’s tort claims. View "Cincinnati Insurance Company v. Jacob Rieger & Co., LLC" on Justia Law

Sandstone operated large-scale swine farms in Scott County. Its owner also owned Red Oak. In 2007-2008, Westfield insured Sandstone. After 2008, Indemnity insured Sandstone. Star provided insurance to Red Oak. Sandstone was named as an additional insured under Star’s policy in 2009. In 2010, neighbors brought private nuisance claims against Sandstone in Illinois state court (“Marsh action”). Sandstone notified the three insurance companies. Each agreed to defend Sandstone, subject to a reservation of rights. Indemnity, citing a coverage exclusion for claims involving ”pollutants,” sought a declaratory judgment that it had no duty to defend. Sandstone withdrew its tender of defense to Indemnity, which dismissed its suit without prejudice. Star and Westfield split the defense of the Marsh action. An Illinois appellate court held that odor claims involving a hog facility are not “traditional environmental pollution” and are not excluded under insurance policy pollution exclusions, which foreclosed Indemnity’s earlier argument. Sandstone notified Indemnity, which filed another federal declaratory judgment action. In the Marsh action, a jury returned a verdict in favor of Sandstone. Westfield and then sought reimbursement of their defense costs.Reversing the district court, the Seventh Circuit ruled in favor of Indemnity. Its insurance is "excess" and Star had a duty to defend, so Indemnity’s “other insurance” provision relieves it of any duty to defend Sandstone. Indemnity is not estopped from asserting that defense because it promptly responded to Sandstone’s tender of defense. View "Indemnity Insurance Co. of North America v. Westfield Insurance Co." on Justia Law

Plaintiff Lancaster Hospital Corporation (Lancaster) operates an inpatient rehabilitation facility that provides services for Medicare beneficiaries. The Department of Health and Human Services (HHS) denied Plaintiff’s request for reimbursement because the provider failed to submit information in a form that could be audited. The district court granted summary judgment to HHS.   The Fourth Circuit affirmed. The court explained that Lancaster asserts that—even if some reductions were warranted—the Board erred by denying its entire 1997 reimbursement request. There appears no doubt Lancaster provided services to Medicare beneficiaries in 1997, and denying all reimbursement for that year may seem harsh. But the principle that people “must turn square corners when they deal with the Government” “has its greatest force when a private party seeks to spend the Government’s money.” However, the court explained that under Heckler v. Community Health Servs. of Crawford Cnty., Inc., “As a participant in the Medicare program,” Lancaster “had a duty to familiarize itself with the legal requirements for cost reimbursement,” including the need to provide cost data in a form “capable of being audited.” Thus, the Board’s decision to deny reimbursement for the fiscal year 1997 was neither arbitrary nor capricious and was supported by substantial evidence. View "Lancaster Hospital Corporation v. Xavier Becerra" on Justia Law

Humphrey was a Riteway driver. His trips began in Illinois, often ending in another state. In 2013 Humphrey drove a truck to Indiana. After he delivered the freight, Riteway directed him to another site in Fort Wayne. While driving to the pickup site, Humphrey’s truck collided with Wright's car. After cooperating with the police, Humphrey picked up his load and delivered it to Illinois. Wright sued Riteway in Indiana state court and obtained a default judgment. Riteway's Prime Insurance policy contained an endorsement that provides payments to an injured party even when the insurer need not defend or indemnify its client. A federal court determined that Riteway had forfeited the benefit of Prime’s policy but reserved questions about whether Wright could recover under the endorsement. The Indiana judiciary declined to allow Prime to attack the default judgment.Prime sought a declaratory judgment that the endorsement did not apply. The endorsement applies to any judgment “resulting from negligence ... subject to the financial responsibility requirements of Sections 29 and 30 of the Motor Carrier Act of 1980.” Those statutes have been repealed but the parties stipulated that 49 U.S.C. 31139(b)(1) applies and provides that all motor freight transportation from a place in one state to a place in another is covered. The district court ordered Prime to pay. The Seventh Circuit affirmed. Humphrey was engaged in interstate freight transportation under the statutory definition regardless of intent, whether a truck was carrying freight, or the “totality” of the circumstances. View "Prime Insurance Co. v. Wright" on Justia Law

Lawsuits brought by governmental bodies and health clinics alleged that Quest, a wholesale pharmaceutical distributor, engaged in misconduct that contributed to a nationwide epidemic of opioid abuse. The plaintiffs plead violations of the RICO Act and state statutes, common law public nuisance, and negligence, seeking damages for “significant expenses for police, emergency, health, prosecution, corrections, rehabilitation, and other services.” Some complaints clarify that the claims “are not based upon or derivative of the rights of others” and that the plaintiffs “do not seek damages for death, physical injury to person, emotional distress, or physical damages to property[.]”Quest's insurance policies covered "damages because of 'bodily injury' or 'property damage'" and explain that “[d]amages because of ‘bodily injury’ include damages claimed by any person or organization for care, loss of services or death resulting at any time from the ‘bodily injury.’” “Bodily injury” is defined as “bodily injury, sickness or disease sustained by a person, including death resulting from any of these at any time.”The insurers sought declaratory judgments that they had no duty to defend or indemnify Quest. The district court granted the insurers summary judgment. The Sixth Circuit affirmed. Based on the plain language of the policies and their overall context and purpose, the court concluded that the Kentucky Supreme Court would find that the insurers have no duty to defend because the lawsuits do not seek damages “because of bodily injury” and claim only economic damages. View "Westfield National Insurance Co. v. Quest Pharmaceuticals, Inc." on Justia Law