LOS ANGELES - In an unpublished July 15 opinion, a California appeals court affirmed a health insurance company's demurrer without leave to amend in a health care reimbursement suit, finding that there was no contractual agreement requiring the insurer to pay the provider its usual and customary rate (Orthopedic Specialists of Southern California v. California Public Employees' Retirement System, No. B248535, Calif. App., 2nd Dist.; 2014 Cal. App. Unpub. LEXIS 4955).
ST. CROIX, Virgin Islands - A Virgin Islands federal judge on July 15 issued a memorandum opinion detailing his reasons for granting summary judgment in favor of an insurer in December in a coverage dispute over a personal injury lawsuit against a nail salon insured, finding that the negligence claim against the insured falls under the policy's professional services and grooming and therapy exclusions (Certain Underwriters at Lloyds Of London v. Johnny Le d/b/a Nails Time, No. 2013-40, D. Virgin Islands, 2014 U.S. Dist. LEXIS 95988).
DETROIT - A federal judge in Michigan on July 14 denied a motion for partial summary judgment filed by plaintiffs claiming that State Farm Fire & Casualty Insurance Co. wrongfully denied their claim for personal property losses resulting from a November 2010 fire, ruling that the insurance company presented sufficient evidence for a jury to determine if the plaintiffs materially misrepresented what was destroyed in the fire (Roderick Gillison, et al. v. State Farm Fire and Casualty Insurance Company, No. 12-15620, E.D. Mich.; 2014 U.S. Dist. LEXIS 95123).
BOSTON - The Massachusetts Appeals Court on July 16 overturned a defendant's guilty verdict in an automobile insurance fraud case, ruling that the trial court judge erred in allowing prosecutors to ask a series of questions during cross-examination of the defendant about out-of-court statements she made without having corroborating evidence from another witness (Commonwealth v. Melissa Peck, No. 12-P-132, Mass. App.; 2014 Mass. App. LEXIS 82).
ST. PAUL, Minn. - Because neither an employer nor its former employee reported a sexual harassment retaliation claim to the employer's insurer within the period mandated under an insurance policy, the policy unambiguously requires no employment practices coverage, a Minnesota appeals panel affirmed July 14 (Samantha LeCuyer v. West Bend Mutual Insurance Co., No. A13-1685, Minn. App.; 2014 Minn. App. Unpub. LEXIS 714).
CINCINNATI - The Sixth Circuit U.S. Court of Appeals on July 15 found that an excess commercial general liability insurer has a duty to defend its insured against underlying claims arising from a failed real estate project in Orlando, Fla., after the primary insurer wrongfully denied coverage, reversing and remanding a lower federal court's ruling in part (IMG Worldwide Inc., et al. v. Westchester Fire Insurance Co., Nos. 13-3832/13-3837, 6th Cir.).
SACRAMENTO, Calif. - A federal judge in California on July 11 granted an insurer's motion to dismiss an insured's breach of contract and insurance bad faith lawsuit against the insurer for failure to pay on a hospital stay claim, ruling that the insured failed to show that his hospitalization was for an injury sustained in an accident, as required under the terms of the insurance policy (Steven Marks v. United States Life Insurance Co. in the City of New York, No. 14-0665, E.D. Calif.; 2014 U.S. Dist. LEXIS 94800).
PITTSBURGH - A Pennsylvania federal judge on July 15 denied the government's request to postpone a hearing on whether to issue a permanent injunction in a case challenging the Patient Protection and Affordable Care Act (ACA) contraceptive mandate (Most Reverend Lawrence E. Brandt, et al. v. Sylvia Burwell, et al., No. 14-681, W.D. Pa.).
LOS ANGELES - In an unpublished opinion, a California federal judge on July 11 remanded a hospital's health care payment breach of contract case against a self-funded insurance plan to state court, saying the Employee Retirement Income Security Act did not preempt the claims (Cedars-Sinai Medical Center v. American Apparel Inc., et al., No. 13-6564, C.D. Calif.; 2014 U.S. Dist. LEXIS 94857).
MACON, Ga. - A federal judge in Georgia on July 10 granted an insurance company's motion for default judgment against the owners and operators of a restaurant that was damaged by a fire in July 2012, ruling that the coverage for the fire was excluded because the defendants made material misrepresentations about the cause of the fire (Argonaut Great Central Insurance Company v. Bedsole Enterprises Inc., et al., No. 14-CV-146, M.D. Ga.; 2014 U.S. Dist. LEXIS 93617).
MIAMI - Four former patient recruiters who worked for a now-defunct home health care company on July 10 pleaded guilty to their roles in a $20 million health care fraud scheme, according to filings in Florida federal court (United States of America v. Abigail Aguila, et al., No. 14-cr-20300-DPG, S.D. Fla.).
PHILADELPHIA - The one-year statute of limitations in a homeowners insurance policy precludes insureds' breach of contract claim against their insurer regarding denied coverage for losses sustained from water damage, a Pennsylvania federal judge ruled July 11, also dismissing a bad faith claim (Paul Leitner and Domenica Leitner v. Allstate Insurance Co., No. 11-7377, E.D. Pa.; 2014 U.S. Dist. LEXIS 95071).
TEXARKANA, Texas - The Sixth District Texas Court of Appeals on July 10 reversed a trial court's ruling entered against the insureds after determining that the monetary sanctions against the insureds were excessive and the conduct by the insureds was not so egregious as to warrant the "death penalty" sanctions (William R. and Susan M. Knoderer v. State Farm Lloyds et al., No. 06-13-00027, Texas App., 6th Dist.; 2014 Tex. App. LEXIS 7412).
ATLANTA - A commercial general liability insurer had a duty to defend an insured in an underlying construction defect lawsuit litigation and, thus, the insurer breached that duty by failing to provide any semblance of a defense, the 11th Circuit U.S. Court of Appeals ruled July 11; however, the panel found that the insurer did not have a duty to indemnify the insured for the value of a settlement (J.B.D. Construction Inc. v. Mid-Continent Casualty Co., No. 13-10138, 11th Cir.; 2014 U.S. App. LEXIS 13358).
NEWARK, N.J. - In an unpublished opinion, a New Jersey federal judge on July 9 granted final approval of a class action settlement over wrongful reimbursements for out-of-network health care services (Cathleen McDonough v. Horizon Blue Cross Blue Shield of New Jersey, No. 09-571, D. N.J.; 2014 U.S. Dist. LEXIS 93559).
CARSON CITY, Nev. - A divided Nevada Supreme Court on July 10 held that the Medicare Act preempts a plaintiff's state common-law negligence claims regarding the retention and investigation of contracted Medicare providers (Louis Morrison v. Health Plan of Nevada, et al., No. 61082, Nev. Sup.; 2014 Nev. LEXIS 67).
ST. LOUIS - The Eighth Circuit U.S. Court of Appeals found on July 11 that because an insured failed to submit a one-page proof-of-loss form, an insurer is entitled to judgment in a White River, Ark., flood coverage dispute, reversing and remanding a lower federal court's $92,845.19 ruling against the insurer (Jennie Lee Stoner v. Southern Farm Bureau Casualty Insurance Co., No. 13-2488, 8th Cir.; 2014 U.S. App. LEXIS 13171).
ST. LOUIS - A lower federal court committed reversible legal error by excusing an insured from complying with the proof of loss requirement in a standard flood insurance policy (SFIP), the Eighth Circuit U.S. Court of Appeals ruled July 11, reversing and remanding a $47,059.32 damages award in favor of the insured on his breach of contract claim against the insurer (Mike McCarty v. Southern Farm Bureau Casualty Insurance Co., No. 13-2490, 8th Cir.; 2014 U.S. App. LEXIS 13173).
CHICAGO - A foreign reinsurer told the Seventh Circuit U.S. Court of Appeals on July 10 that new U.S. Supreme Court decisions regarding the Foreign Sovereign Immunities Act (FSIA) do not help the arguments of an alleged assignee to certain rights under a number of reinsurance agreements regarding the appeals court's jurisdiction over an arbitration dispute (Pine Top Receivables of Illinois, LLC v. Banco De Seguros Del Estado, No. 13-1364, 7th Cir.).
PHILADELPHIA - A commercial general liability insurance policy precludes coverage to an insured for damage to installed glass because one of the insured's subcontractors caused the property damage to the glass through improper performance of its work, the Third Circuit U.S. Court of Appeals affirmed July 11 (Allegheny Design Management Inc. v. Travelers Indemnity Company of America, No. 13-4263, 3rd Cir.; 2014 U.S. App. LEXIS 13190).
ST. LOUIS - Because a supervisory level employee was not a member of an insured's board of directors, he is not an insured under a commercial general liability insurance policy, the Eighth Circuit U.S. Court of Appeals ruled July 11, affirming a lower federal court's ruling that there is no coverage for an $850,000 default judgment entered against the supervisor (United Fire & Casualty Insurance Co. v. Dennis Thompson, et al., No. 13-2352, 8th Cir.; 2014 U.S. App. LEXIS 13174).
SCRANTON, Pa. - A federal judge in Pennsylvania on July 7 dismissed two insureds' insurance bad faith claim, ruling that the insureds failed to provide factual allegations to support their claim as required under state law (Robert Flynn, et al. v. Nationwide Insurance Co. of America, No. 13-2993, M.D. Pa.; 2014 U.S. Dist. LEXIS 91431).
WEST PALM BEACH, Fla. - A Florida appeals panel ruled July 9 that a lower court erred in applying a Florida statute retroactively in finding that an insured failed to timely file her breach of contract lawsuit, further holding that the lower court also erred in dismissing the lawsuit on the basis that the insured failed to comply with the policy's notice of loss provision (Arlene Donovan v. Florida Peninsula Insurance Co., No. 4D11-4648, Fla. App., 4th Dist.).
SAN JUAN, Puerto Rico - Gross negligence claims against former bank officials concerning specific loans are covered by the 2006-07 directors and officers insurance policies, and the rest of the claims involving other borrowers are covered by the 2009-10 policies, a Puerto Rico federal judge ruled July 9, further finding that an insured vs. insured policy exclusion does not bar coverage (W Holding Co., Inc., et al. v. AIG Ins. Co., et al., No. 11-2271 (GAG), D. P.R.; 2014 U.S. Dist. LEXIS 94005).
ALLENTOWN, Pa. - Dismissal of an insured's breach of contract and insurance bad faith lawsuit against her automobile insurance carrier is not warranted, a federal judge in Pennsylvania ruled July 8, because the insured has shown that the insurer failed to properly and timely pay her for covered injuries under an underinsured motorist policy (Esther R. Padilla v. State Farm Mutual Automobile Insurance Co., No. 14-2102, E.D. Pa.; 2014 U.S. Dist. LEXIS 92230).