NEWARK, N.J. - A health insurance plan's provision barring insureds from assigning rights leaves a provider pursuing its individual right to payment under state law and precludes removal and preemption under the Employee Retirement Income Security Act of 1974, a federal judge in New Jersey held Sept. 11 (Progressive Spine & Orthopaedics LLC v. Anthem Blue Cross Blue Shield, No. 17-536, D. N.J., 2017 U.S. Dist. LEXIS 147466).
ANAPOLIS, Md. - A Maryland appeals court panel on Sept. 11 ruled that a trial court did not err when admitting evidence related to a woman's fraudulent insurance claim for jewelry that was allegedly stolen, finding that she waived her right to appellate review because her attorney did not renew the objection after evidence outside of the claim was admitted (Phanta U. Daramy v. Maryland, No. 1373, September Term 2016, Md. Spec. App., 2017 Md. App. LEXIS 926).
SAN FRANCISCO - A district court correctly concluded that a disability claimant is not entitled to long-term disability benefits because the claimant failed to prove that her disability had a physical component that would not be excluded under the plan's mental-health limitation, the Ninth Circuit U.S. Court of Appeals ruled Sept. 11 (Leah A. Bilyeu v. Morgan Stanley Long Term Disability Plan, et al., No. 16-15254 No. 16-15314, 9th Cir., 2017 U.S. App. LEXIS 17510).
LANSING, Mich. - A Michigan appeals panel on Sept. 7 held that an insurance policy's personal profit or advantage exclusion applies to bar coverage for an underlying consent judgment arising from an alleged "conduit financing scheme" between charter schools (Employers Mutual Casualty Co. v. Helicon Associates, Inc., et al., No. 322215, Mich. App., 2017 Mich. App. LEXIS 1405).
BATON ROUGE, La. - A trial court erred in granting an insurer's motion for summary judgment in a dispute over coverage for water and mold damage because the expert testimony proffered by the insureds was improperly excluded by the trial court, the First Circuit Louisiana Court of Appeal said Sept. 8 (Melvin and Anjeanette Adolph v. Lighthouse Property Insurance Corp., No. 2016 CA 1275, La. App., 1st Cir., 2017 La. App. LEXIS 1597).
LAS VEGAS - An insured contractor failed to adequately allege complete diversity between itself and the relevant names of an insurance syndicate, a Nevada federal judge ruled Sept. 11, dismissing the dispute over coverage for an underlying construction defect case (Centex Homes v. Navigators Specialty Insurance Co., No. 16-01958, D. Nev., 2017 U.S. Dist. LEXIS 146824).
CHICAGO - A federal judge in Illinois on Sept. 11 ruled that a dermatologist who was found guilty of eight counts of health care fraud and eight counts of making false statements related to health care matters is not entitled to a new trial, finding that the evidence presented by the government supported his conviction and that even if statements made by the prosecution during closing arguments were improper, they were not a reversible error (United States of America v. Omeed Memar, No. 15 CR 345, N.D. Ill., 2017 U.S. Dist. LEXIS 146306).
PASADENA, Calif. - The Patient Protection and Affordable Care Act (ACA)'s ban on lifetime benefit maximums does not apply to retiree plans governed by the Employee Retirement Income Security Act, but the plan documents are sufficiently confusing to state a cause of action, a Ninth Circuit U.S. Court of Appeals held Sept. 8 (Gary King, et al. v. Blue Cross and Blue Shield of Illinois, et al., No. 15-55880, 9th Cir., 2017 U.S. App. LEXIS 17387).
NEW ORLEANS - A federal judge in Louisiana on Sept. 7 sentenced a California man to one year in prison for his role in a $38 million health care fraud scheme that involved the sale and distribution of talking glucose meters that were not medically necessary (United States of America v. Geoffrey Ricketts, et al., No. 15cr153, E.D. La.).
SAVANNAH, Ga. - A federal judge in Georgia on Sept. 6 dismissed without prejudice a relator's claims under the qui tam provision of the False Claims Act (FCA) accusing two health care clinics and their providers of failing to submit reimbursements to Medicare, Medicaid and private insurers in 14 states for overpayments the clinics received, finding that the woman's claims are barred by public disclosure and that they did not meet the heightened pleading requirements of Federal Rules of Civil Procedure (8)(a) and 9(b) (United States of America, ex rel. Tracy Payton v. Pediatric Services of America, Inc., et al., No. 16-cv-102, S.D. Ga., 2017 U.S. Dist. LEXIS 144289).
CHICAGO - An Illinois appeals panel on Sept. 7 affirmed a lower court's ruling that a law firm's amended complaint against its clients' professional liability insurer fails to adequately plead claims for account stated and fraudulent misrepresentation (Law Offices of Arnold Landis, P.C., v. OneBeacon Midwest Insurance Company, No. 1-16-0079, Ill. App., 1st Dist., 4th Div., 2017 Ill. App. Unpub. LEXIS 1834).
MINNEAPOLIS - A federal judge in Minnesota on Sept. 7 dismissed with prejudice claims asserted by four insurance companies that two chiropractors, their firms and individuals who allegedly recruited patients for the doctors violated the Racketeer Influenced and Corrupt Organizations Act, finding that the companies' allegations failed to show the existence of an enterprise (Illinois Farmers Insurance Company, et al. v. Timothy W. Guthman, et al., No. 17-270, D. Minn., 2017 U.S. Dist. LEXIS 144866).
DES MOINES, Iowa - A pair of women may continue with their class action lawsuit claiming that their insurer violated the Patient Protection and Affordable Care Act (ACA) by charging for lactation consultation services, but nothing in the Employee Retirement Income Security Act requires insurers to list such providers separately, and the sex discrimination claims fail as well, a federal judge in Iowa held Sept. 6 (Jillian York, et al. v. Wellmark Inc., et al., No. 16-627, S.D. Iowa).
NEW YORK - A New York bankruptcy judge on Sept. 6 refused to dismiss an order requiring a defunct brokerage company to arbitrate in Bermuda its dispute with a foreign specialty reinsurer over a $15 million policy, despite the brokerage company's argument that its liquidation plan supersedes an arbitration provision (In re: MF Global Holdings Ltd., et al., MF Global Holdings Ltd., et al. v. Allied World Assurance Company Ltd., et al., Chapter 11 No. 11-15059, Adv. Proc. No. 16-01251, S.D. N.Y. Bkcy., 2017 Bankr. LEXIS 2379).
WASHINGTON, D.C. - Judgment on any ruling that the government improperly withheld funds from a bankrupt Patient Protection and Affordable Care Act (ACA) insurer would need to wait until resolution of pending appeals of risk-corridor rulings, a federal claims court judge held Sept. 5 in staying the case (Doug Ommen, et al. v. United States, No. 17-957, Fed. Clms., 2017 U.S. Claims LEXIS 1081).
MONTGOMERY, Ala. - An Alabama federal judge on Sept. 7 ordered a nonprofit public insurer and a reinsurer to arbitrate a $1.3 million breach of contract lawsuit based upon an arbitration clause in a reinsurance agreement (Alabama Municipal Insurance Corp. v. Munich Reinsurance America Inc., No. 16-00948, M.D. Ala., 2017 U.S. Dist. LEXIS 144748).
CHICAGO - An insured showed that genuine issues of material fact exist as to whether all primary policies have been exhausted for an excess insurance policy to be triggered and as to whether a pollution exclusion applies, an Illinois federal judge ruled Sept. 7, denying summary judgment to a reinsurer who indemnified the excess policy (Velsicol Chemical LLC v. Westchester Fire Insurance Co., No. 15-2534, N.D. Ill., 2017 U.S. Dist. LEXIS 144698).
ST. LOUIS - The Eighth Circuit U.S. Court of Appeals on Sept. 7 found that a health plan provider bears the burden to allocate a $350 million settlement between a potentially covered lawsuit and a noncovered lawsuit, affirming a lower court's ruling in favor of four excess insurers in a coverage dispute over the underlying indemnity and defense costs (United Health Group Inc. v. Executive Risk Specialty Insurance Co., et al., No. 15-1076, 8th Cir., 2017 U.S. App. LEXIS 17324).
MOBILE, Ala. - An Alabama federal judge on Sept. 6 held that a building owner insured has failed to satisfy its burden of establishing that an exception to a deluxe property policy's rain limitation applies, concluding that neither the property policy nor a commercial general liability insurance policy covers the insured's damages arising from a roof leak caused by 2.43 inches of rain (Travelers Property Casualty Company of America v. Brookwood, LLC, No. 15-01016, N.D. Ala., 2017 U.S. Dist. LEXIS 143894).
STATESVILLE, N.C. - A North Carolina federal judge on Sept. 1 dismissed a bad faith claim alleged against an insurer in an automobile coverage suit after determining that there is no evidence that the insurer recognized that the insured's claim was a valid claim under the policy and then refused to pay (New Hickory Pizza Inc., d/b/a Domino's Pizza v. TIG Insurance Co., No. 16-164, W.D. N.C., 2017 U.S. Dist. LEXIS 142091).
COLUMBUS, Ohio - While the majority of the Ohio Supreme Court on Sept. 5 dismissed an appeal in a case over coverage under a commercial general liability insurance policy for construction defects, a dissenting justice wrote that the policy does not define "occurs" with regard to the requirement that the property damage occur during the policy period (Lightning Rod Mutual Insurance Co. v. Robert Southworth, et al., No. 2016-1116, Ohio Sup., 2017 Ohio LEXIS 1660).
UTICA, N.Y. - In a dispute over an underlying $325 million settlement of asbestos claims, an insurer argues in a Sept. 1 motion that a New York federal judge should exclude testimony from a reinsurer's former employee because he has no personal involvement in the contracts (Utica Mutual Insurance Co. v. Fireman's Fund Insurance Co., No. 09-cv-00853, N.D. N.Y.).
SAN FRANCISCO - A district court erred in finding that a disability plan administrator did not abuse its discretion in terminating a claimant's benefits because the plan failed to consider reliable evidence in support of the plan participant's claim, the Ninth Circuit U.S. Court of Appeals said Sept. 6 in reversing and remanding the lower court's ruling in favor of the plan (Sonia Cruz-Baca v. Edison International Long Term Disability Plan, No. 15-56921, 9th Cir., 2017 U.S. App. LEXIS 17214).
HARRISBURG, Pa. - A film company says to a Pennsylvania trial court on Aug. 31 that it will deliver distribution revenue in its possession to an insolvent insurer's liquidator (In re: Reliance Insurance Co. in liquidation, No. 1 REL 2001, Pa. Cmwlth.).
PHILADELPHIA - Granting commercial general liability insurers' motion for summary judgment in a breach of contract lawsuit, a Pennsylvania federal judge held Aug. 31 that underlying construction defects claims against insureds fail to amount to an "occurrence" under the policies and that the "real estate development activities-completed operations" exclusion further bars coverage (Northridge Village LP, et al. v. Travelers Indemnity Co. of Connecticut, et al., No. 15-1947, E.D. Pa., 2017 U.S. Dist. LEXIS 140541).