Justia Contracts Opinion Summaries

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

Defendant purchased an "own occupation" disability insurance policy from an affiliate of Plaintiff, Metropolitan Life Insurance Company (MetLife). After Defendant was diagnosed with cancer, Defendant's employment was terminated. Defendant filed a clam for disability benefits and began receiving disability payments. Defendant later began working at a lower stress job. MetLife concluded that Defendant was no longer eligible to receive disability benefits. Metlife reached this conclusion by interpreting a clause in Defendant's policy requiring Defendant to receive care by a physician that "is appropriate for the condition causing the disability" to mean that Defendant was required to pursue treatment aimed at returning him to his prior occupation. MetLife filed an action seeking a judgment declaring it had no continuing obligation to pay benefits to Defendant and reimbursement of benefits it had paid. The superior court declared MetLife was not required to continue paying Defendant benefits but that MetLife was not entitled to restitution of any benefits paid. The Supreme Court affirmed, holding (1) Defendant was not entitled to benefits under the policy since he was not receiving care designed to enable him to return to him prior occupation; and (2) MetLife was not entitled to reimbursement for benefits paid to Defendant. View "Metro. Life Ins. Co. v. Cotter" on Justia Law

Plaintiff was an additional insured on a commercial general liability insurance policy, which was issued to Plaintiff's tenant (Tenant) by Defendant, Travelers Property Casualty Company (Travelers). Plaintiff sought to invoke Travelers' duty to defend under the policy after Sarah Middeleer was injured in a fall on Plaintiff's property and brought the underlying action against Plaintiff. Plaintiff's insurer, the Netherlands Insurance Company (Netherlands), provided a defense to Plaintiff after Travelers denied any duty to defend Plaintiff in the underlying action. Plaintiff then brought the present action claiming Travelers had a duty to defend Plaintiff in the underlying action and Travelers was obligated to reimburse Netherlands for the defense costs it had expended. The trial court granted Plaintiff's motion for summary judgment. The appellate court reversed, concluding that Middeleer's injuries did not arise out of the use of the leased premises under the terms of the policy. The Supreme Court affirmed, holding that the appellate court correctly construed the governing policy language and properly concluded that Travelers did not have a duty to defend Plaintiff. View "Misiti, LLC v. Travelers Prop. Cas. Co. of Am." on Justia Law

Tiara Condominium Association (Tiara) retained Marsh & McLennan (Marsh) as its insurance broker. Marsh secured windstorm coverage through Citizens Property Insurance Corporation (Citizens), which issued a policy that contained a loss limit in an amount close to $50 million. Tiara's condominium subsequently sustained damages caused by two hurricanes. After being assured by Marsh that the loss limits coverage was per occurrence, Tiara spent more than $100 million in remediation efforts. However, when Tiara sought payment from Citizens, Citizens claimed that the loss limit was $50 million in the aggregate, not per occurrence. Tiara filed suit against Marsh, alleging, inter alia, breach of contract, breach of fiduciary duty, and negligence. The trial court granted summary judgment for Marsh on all claims. The appeals affirmed with the exception of the negligence and breach of fiduciary claims, as to which it certified a question to the Supreme Court to determine whether the economic loss rule prohibits recovery, or whether an insurance broker falls within the professional services exception that would allow Tiara to proceed with the claims. The Court answered by holding that the application of the economic loss rule is limited to products liability cases. View "Tiara Condo. Ass'n, Inc. v. Marsh & McLennan Cos. " on Justia Law

Plaintiffs brought this action in Maryland state court seeking a declaration as to Allstate's duty under a renters insurance policy to defend and indemnify plaintiffs in a tort suit brought against them, and others. On appeal, defendant challenged the district court's grant of summary judgment to Allstate, concluding that Allstate did not have a duty to defend. The court held that Maryland law applied to the issue of whether Allstate had a duty to defend plaintiffs if Maryland law would apply without the choice-of-law provision in the policy; according to Maryland's lex loci contractus rule for choice-of-law decisions, California law governed the analysis of whether Allstate had a duty to defend plaintiffs in the underlying action; and the court rejected plaintiffs' argument that Allstate nonetheless owed them a duty to defend under the policy. Accordingly, the court affirmed the judgment. View "Francis v. Allstate Ins. Co." on Justia Law

In Washington, a liability insurer unclear of its obligation to defend an insured may invoke a "reservation of rights" defense while it seeks a declaration regarding coverage. The issue before the Supreme Court in this case centered on whether the insurer may unilaterally condition its reservation on making the insured absorb defense costs if a court ultimately determines there is no coverage. The Supreme Court responded in the negative: "we recognize…that an insurer may avoid or minimize its responsibility for defense costs when an insured belatedly tenders a claim and the insurer demonstrates actual and substantial prejudice as a result." View "Nat'l Sur. Corp. v. Immunex Corp." on Justia Law

K&D Enterprises, through its manager, Mid-America, contracted to purchase an apartment complex. Prior to the closing, K&D Enterprises created a new company, Euclid-Richmond Gardens, and assigned its rights under the purchase agreement to that new company. Euclid-Richmond Gardens hired K&D Group, Inc., a property-management company, to manage the apartment. K&D Group hired former employees of Mid-America and assumed the operations of the complex. The Bureau of Workers' Compensation later conducted an audit and determined K&D Group was the successor in interest to the business operations of Mid-America, a determination that authorized the Bureau to base K&D Group's experience rating, in part, on Mid-America's past experience, which included a large workers' compensation claim. After K&D Group's administrative appeal was denied, K&D Group unsuccessfully filed a mandamus action in the court of appeals. The Supreme Court reversed the judgment of the court of appeals and issued the writ of mandamus, holding that K&D Group was not a successor in interest for purposes of workers' compensation law, and thus, the Bureau abused its discretion when it transferred part of Mid-America's experience rating to K&D Group. View "State ex rel. K&D Group, Inc. v. Buehrer" on Justia Law

Motel was insured under a policy issued by Insurer. The policy provided coverage for, as well as a duty to defend against, claims for bodily injury and personal and advertising injury liability. The policy expressly disclaimed coverage for both bodily injury and personal and advertising injury when the injury arose out of intentional conduct. Specifically, the policy excluded coverage for harm resulting from acts of sexual molestation by motel employees. After an off-duty motel employee molested a young motel guest, Insurer sought a declaratory judgment to enforce its reading of the contract disclaiming coverage for, and its duty to defend against, a civil complaint brought by the motel guest. The trial court granted summary judgment in favor of Insurer. The Supreme Court affirmed, holding that the abuse/molestation exclusion excluded from coverage the act of the employee, as the victim was in the "care" of the motel at the time of the molestation per the language of the exclusion. View "Holiday Hospitality Franchising, Inc. v. Amco Ins. Co." on Justia Law

Plaintiffs, Katherine and Michael, were living together in a home that was destroyed by a fire in 1998. Seeking to rebuild their home, Michael and Katherine completed an application for property insurance with American Family Mutual Insurance Company. American Family issued the policy. In 2003, Plaintiffs' garage was destroyed in a fire, and Plaintiffs filed a claim with American Family. During follow-up investigations, Michael disclosed the 1998 fire to American Family. American Family, treating the prior fire loss nondisclosure as a misrepresentation, voided the insurance policy ab initio and denied Plaintiffs' claim. Plaintiffs filed suit against American Family claiming breach of contract and intentional infliction of emotional distress. The trial court granted summary judgment for American Family. Plaintiffs appealed, challenging the grant of summary judgment on grounds that American Family failed to return the premiums paid by Plaintiffs. The Supreme Court affirmed, holding that Plaintiffs' assignment of error was not properly before the Court on appeal. View "Dodd v. Am. Family Mut. Ins. Co." on Justia Law

This case stemmed from the explosion and sinking of Transocean's Deepwater Horizon in April 2010. At issue were the obligations of Transocean's primary and excess-liability insurers to cover BP's pollution-related liabilities deriving from the ensuing oil spill in the Gulf of Mexico. Because the court, applying Texas law, found that the umbrella policies between the Insurers and Transocean did not impose any relevant limitation upon the extent to which BP was an additional insured, and because the additional insured provision in the Drilling Contract was separate from and additional to the indemnity provisions therein, the court found BP was entitled to coverage under each of Transocean's policies as an additional insured as a matter of law. The court reversed the judgment of the district court and remanded the case. View "In Re: Deepwater Horizon" on Justia Law