Justia California Court of Appeals Opinion SummariesArticles Posted in Insurance Law
Dones v. Life Insurance Co. of North America
While employed by Alameda County and on a medical leave of absence, Johnson enrolled online in supplemental life insurance coverage under a LINA group insurance policy. She remained on leave on the policy’s effective date and died six months later, without returning to work. When her beneficiary claimed benefits, LINA denied coverage based on a policy provision stating the insurance would not become effective if the employee was not in “active service” on the effective date. Johnson’s beneficiary sued for breach of contract, arguing that LINA and the county waived or were estopped from asserting the active service precondition.The court of appeal affirmed the dismissal of Alameda County but reversed the dismissal of LINA. In determining the effect of preconditions to effective coverage, waiver and estoppel are questions of fact. There are factual questions as to what Johnson knew or should have known about the active service requirement and whether the conduct of LINA and the county supported a reasonable expectation that the supplemental insurance was in place and effective. It is not apparent that “active service” has a single unambiguous meaning such that Johnson necessarily must have known she was not in “active service” because she was on medical leave. If Johnson’s policy went into effect, LINA, not the county, is liable for improper denial of benefits. View "Dones v. Life Insurance Co. of North America" on Justia Law
Murray v. UPS Capital Ins. Agency, Inc.
David Murray purchased used computer equipment worth nearly $40,000, which was damaged by the United Postal Service (UPS) while it was being transported from California to Texas. Murray believed he purchased appropriate insurance to cover this loss, but the insurance company denied his claim. Murray sued his insurance broker, UPS Capital Insurance Agency (UPS Capital), for breach of contract and negligence, claiming UPS Capital owed him a special duty to make the insurance policy language understandable to an ordinary person and to explain the scope of coverage. The court granted UPS Capital’s motion for summary judgment after concluding there was no heightened duty of care and dismissed Murray’s lawsuit. On appeal, Murray asked the Court of Appeal to create a new rule that brokers/agents, specializing in a specific field of insurance, hold themselves out as experts, and are subject to a heightened duty of care towards clients seeking that particular kind of insurance. While the Court declined the invitation to create a per se rule, it concluded Murray raised triable issues of fact as to whether UPS Capital undertook a special duty by holding itself out as having expertise in inland marine insurance, and Murray reasonably relied on its expertise. Therefore, the Court reversed the judgment of dismissal and remanded the matter for further proceedings. View "Murray v. UPS Capital Ins. Agency, Inc." on Justia Law
Ghazarian v. Magellan Health
Plaintiffs Rafi Ghazarian and Edna Betgovargez had a son, A.G., with autism. A.G. received applied behavior analysis (ABA) therapy for his autism under a health insurance policy (the policy) plaintiffs had with defendant California Physicians’ Service dba Blue Shield of California (Blue Shield). Mental health benefits under this policy are administered by defendants Magellan Health, Inc. and Human Affairs International of California (collectively Magellan). By law, the policy had to provide A.G. with all medically necessary ABA therapy. Before A.G. turned seven years old, defendants Blue Shield and Magellan approved him for 157 hours of medically necessary ABA therapy per month. But shortly after he turned seven, defendants denied plaintiffs’ request for 157 hours of therapy on grounds only 81 hours per month were medically necessary. Plaintiffs requested the Department of Managed Health Care conduct an independent review of the denial. Two of the three independent physician reviewers disagreed with the denial, while the other agreed. As a result, the Department ordered Blue Shield to reverse the denial and authorize the requested care. Plaintiffs then filed this lawsuit against defendants, asserting breach of the implied covenant of good faith and fair dealing against Blue Shield, and claims for intentional interference with contract and violations of Business and Professions Code section 17200 (the UCL) against defendants. Defendants each successfully moved for summary judgment. As to the bad faith claim, the trial court found that since one of the independent physicians agreed with the denial, Blue Shield acted reasonably as a matter of law. As to the intentional interference with contract claim, the court found no contract existed between plaintiffs and A.G.’s treatment provider with which defendants could interfere. Finally, the court found the UCL claim was based on the same allegations as the other claims and thus also failed. After its review, the Court of Appeal concluded summary judgment was improperly granted as to the bad faith and UCL claims. "[I]t is well established that an insurer may be liable for bad faith if it unfairly evaluates a claim. Here, there are factual disputes as to the fairness of defendants’ evaluation. . . .There are questions of fact as to the reasonability of these standards. If defendants used unfair criteria to evaluate plaintiffs’ claim, they did not fairly evaluate it and may be liable for bad faith." Conversely, the Court found summary judgment proper as to the intentional interference with contract claim because plaintiffs failed to show any contract with which defendants interfered. View "Ghazarian v. Magellan Health" on Justia Law
Storm v. The Standard Fire Insurance Co.
In an action arising from an underinsured motorist arbitration, the Court of Appeal reversed the trial court's order striking plaintiff's memorandum of costs and remanded the matter with directions for the trial court to consider whether the costs as claimed by plaintiff are recoverable within the meaning of Code of Civil Procedure section 998 and 1293.2.The court held that the relevant policy language, which stated that "[e]ach party will . . . [p]ay the expenses it incurs [in arbitration]" and "[b]ear the expenses of the arbitrator equally," does not preclude the recovery under section 998 of arbitration costs, or the recovery under section 1293.2 of post-arbitration costs. The court explained that specifying how the costs are to be paid in the first instance says nothing about whether such costs may be recouped later under the cost-shifting provisions of sections 998 or 1293.2.The court also held that the insurance policy strictly limited the decisional authority of the arbitrator to two issues—plaintiff's entitlement to damages, and the amount thereof. However, the court explained that it did not give the arbitrator the power to award costs. Therefore, the court found Heimlich v. Shivji (2019) 7 Cal.5th 350 (Heimlich) distinguishable. View "Storm v. The Standard Fire Insurance Co." on Justia Law
Posted in: Insurance Law
Carter v. Pulte Home Corp.
Pulte, a residential developer, was sued for construction defects by the owners of 38 homes. Many subcontractors worked on the projects, under contracts requiring each subcontractor to indemnify Pulte and to name it as an additional insured on the subcontractor’s commercial general liability insurance. Pulte cross-complained against subcontractors who worked on the homes. Travelers, the insurer for four subcontractors, provided a defense. The “Blanket Additional Insured Endorsements” to Travelers’s named insureds’ policies stated that the “person or organization is only an additional insured with respect to liability caused by ‘your work’ for that additional insured.Travelers filed a complaint in intervention against the insurers for seven subcontractors (respondents), who declined to provide a defense, seeking equitable subrogation. Pulte settled the homeowners’ claims and its claims against all the subcontractors. The court concluded that it “would not be just” to find respondents jointly and severally liable for the costs Travelers sought to recover. There was considerable variation in the number of homes each respondent worked on. The homeowners’ complaints did not indicate which subcontractor worked on which home, and no evidence was presented as to whether the work of any subcontractor was defective.The court of appeal affirmed. Pulte was entitled to indemnity and defense from each respondent only with respect to its own scope of work. Travelers was "not seeking to stand in Pulte’s shoes. It is seeking to stand in a different, more advantageous" shoes. View "Carter v. Pulte Home Corp." on Justia Law
Santa Fe Braun, Inc. v. Insurance Co. of North America
Braun sought coverage for numerous asbestos-related claims under various excess insurance policies. In phased proceedings lasting over 10 years, the trial court entered judgment in favor of the excess insurers based on Braun’s failure to establish that the primary and, in some cases, underlying layers of excess insurance had been exhausted.Braun challenged the interpretation of the policies as requiring exhaustion of all underlying layers of insurance (horizontal exhaustion) rather than exhaustion of only policies specified in each policy (vertical exhaustion). Braun also argued the court abused its discretion in refusing to consider additional evidence of exhaustion presented four years after the trial's evidentiary phase was completed. The California Supreme Court subsequently decided “Montrose,” addressing the sequence in which the insured could access its excess insurance policies for coverage of claims for continuous environmental damage caused in 1947-1982. Interpreting the language of those excess policies, the Montrose court held the insured “is entitled to access otherwise available coverage under any excess policy once it has exhausted directly underlying excess policies for the same policy period.”After considering Montrose, the court of appeal reversed. The trial court erred in interpreting the Braun policies to require horizontal exhaustion of all primary and underlying excess insurance coverage before accessing coverage under the excess policies at issue. The trial court abused its discretion in refusing to consider Braun’s new evidence of exhaustion. View "Santa Fe Braun, Inc. v. Insurance Co. of North America" on Justia Law
Posted in: Insurance Law
Ben-E-Lect v. Anthem Blue Cross Life and Health Insurance Co.
Ben-E-Lect, a third-party insurance claim administrator, developed a medical expense reimbursement plan; employers could buy a group policy of medical insurance with a high deductible and self-fund to pay for the healthcare expenses employees incurred within the annual deductible or any copay requirement. The practice of employers’ using such plans in conjunction with a high-deductible health plan is called “wrapping.” Ben-E-Lect was the state’s largest third-party administrator for small group employers who wrapped their employee medical policies. Anthem provides fully insured health plans to the California small group employer market. Beginning in 2006, Anthem announced a series of policies that limited wrapping. In 2014, Anthem prohibited wrapping all Anthem plans. Employer groups who used Anthem plans certified they would not wrap Anthem policies, and agents certified they would not advise employers to enter into any employer-sponsored wrapping plan. Ben-E-Lect sued Anthem.The court of appeal affirmed that Anthem’s policy to prohibit wrapping its health insurance products violated the Cartwright Act (Bus. & Prof. Code, 16700); interfered with Ben-E-Lect’s prospective business relationships; and was an illegal, coercive, vertical group boycott under the antitrust rule of reason (Bus. & Prof. Code, 17200), because Anthem told its insurance agents that if they wrapped any Anthem policies they would be subject to termination loss of sales commissions. The court affirmed an award of $7.38 million and an injunction. The trial court considered sufficient evidence of market power and market injury. View "Ben-E-Lect v. Anthem Blue Cross Life and Health Insurance Co." on Justia Law
Eghtesad v. State Farm General Insurance Co.
Eghtesad’s pro se complaint claimed that he leased property to Martinez; State Farm issued Martinez a fire and liability insurance policy; Eghtesad was named on the policy as an additional insured; Eghtesad sought coverage for property damage; and State Farm told Eghtesad he was covered only for claims of slander. Eghtesad did not file an opposition to State Farm’s demurrer but asked for 60 days to try to settle and get counsel. The court continued the hearing. On the day his opposition was due, Eghtesad sought a further continuance of 90 days, informing the court that he had been involved in an auto accident. He attached a note from his doctor. The court granted Eghtesad “one final continuance” and set the hearing out for two additional weeks. Three days before the new hearing date, without having filed a response to the demurrer, Eghtesad sought another continuance, again providing a doctor’s note. The court did not grant a further continuance and sustained the demurrer without leave to amend.The court of appeal reversed, finding that Eghtesad should have been given an opportunity to amend his complaint. For an original complaint, regardless of whether the plaintiff has requested leave to amend, a trial court’s denial of leave to amend constitutes an abuse of discretion unless the complaint “shows on its face that it is incapable of amendment.” View "Eghtesad v. State Farm General Insurance Co." on Justia Law
Trilogy Plumbing, Inc. v. Navigators Specialty Ins. Co.
Defendant Navigators Specialty Insurance Company (Navigators) appealed a trial court order denying its special motion to strike under California’s anti-SLAPP statute. Plaintiff Trilogy Plumbing, Inc. (Trilogy) alleged that Navigators, as Trilogy’s insurer, gave instructions with which Trilogy did not agree to attorneys Navigators had retained to defend Trilogy and wrongfully negotiated settlements without Trilogy’s consent. Navigators contended the alleged conduct constituted protected activity under Code of Civil Procedure section 425.17 (e)(2) and, therefore, the trial court erred by denying the anti-SLAPP motion. After review, the Court of Appeal affirmed: the allegations challenged by the anti-SLAPP motion described Navigators’ mishandling of the claims process with regard to 33 different lawsuits involving Trilogy. While the alleged acts were generally connected to litigation, they did not include any written or oral statement or writing made in connection with an issue under consideration or review by a judicial body and therefore did not constitute protected activity under section 425.16. View "Trilogy Plumbing, Inc. v. Navigators Specialty Ins. Co." on Justia Law
State Comp. Ins. Fund v. ReadyLink Healthcare, Inc.
Defendant ReadyLink Healthcare, Inc. (ReadyLink) was a nurse staffing company that placed nurses in hospitals, typically on a short-term basis. Plaintiff State Compensation Insurance Fund (SCIF) was a public enterprise fund created by statute as a workers' compensation insurer. Premiums that SCIF charged were based in part on the employer's payroll for a particular insurance year. SCIF and ReadyLink disputed the final amount of premium ReadyLink owed to SCIF for the 2005 policy year (September 1, 2005 to September 1, 2006). ReadyLink considered certain payments made to its nurses as per diem payments; SCIF felt those should have been considered as payroll under the relevant workers' compensation regulations. The Insurance Commissioner concurred with SCIF's characterization of the payments. A trial court rejected ReadyLink's petition for a writ of administrative mandamus to prohibit the Insurance Commissioner from enforcing its decision, and an appellate court affirmed the trial court's judgment. SCIF subsequently filed the action underlying this appeal, later moving for a judgment on the pleadings, claiming the issue of the premium ReadyLink owed for the 2005 policy year had been previously determined in the administrative proceedings, which was then affirmed after judicial review. The trial court granted SCIF's motion for judgment on the pleadings. On appeal, ReadyLink conceded it previously litigated and lost its challenge to SCIF's decision to include per diem amounts as payroll for the 2005 insurance year, but argued it never had the opportunity to challenge whether SCIF otherwise properly calculated the premium amount that it claims was due pursuant to the terms of the contract between the parties, or whether SCIF's past conduct, which ReadyLink alleged included SCIF's acceptance of ReadyLink's exclusions of its per diem payments from payroll in prior policy years and SCIF's exclusion of per diem amounts in paying out on workers' compensation claims filed by ReadyLink employees, might bar SCIF from being entitled to collect that premium amount under the contract. To this, the Court of Appeal concurred the trial court erred in granting SCIF's motion for judgment on the pleadings. Judgment was reversed, and the matter remanded for further proceedings. View "State Comp. Ins. Fund v. ReadyLink Healthcare, Inc." on Justia Law