Articles Posted in Insurance Law

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The plaintiffs' complaint alleged that two groups of defendants, (1) Premera, Premera Blue Cross, and Life Wise Health Plan of Washington (collectively Premera) and (2) the Washington Alliance for Healthcare Insurance Trust and its trustee, F. Bentley Lovejoy (collectively WAHIT), colluded and made false and misleading representations to the plaintiffs that induced the plaintiffs to purchase health insurance policies under false pretenses. Plaintiff-policyholders claimed that Premera and WAHIT violated the Washington Consumer Protection Act (CPA). The plaintiffs requested only two specific forms of damages: (1) for the "unfair business practices and excessive overcharges for premiums," the plaintiffs requested "the sum of the excess premiums paid to the defendants;" and (2) "[i]f the surplus is excessive and unreasonable," the plaintiffs asserted that "the amount of the excess surplus should be refunded to the subscribers who have paid the high premiums causing the excess." On Premera and WAHIT's motion, the trial court dismissed the Policyholders' suit in its entirety based on the filed rate, primary jurisdiction, and exhaustion of remedies doctrines. Specifically, the trial court dismissed all claims of class B (small group) and class C (individuals) pursuant to CR 12(b )( 6) and dismissed all claims of class A (large group) on summary judgment under CR 56. The Court of Appeals reversed the trial court in relation to certain of the Policyholders' CPA claims. Because awarding the specific damages requested by the plaintiffs would require a court to inappropriately substitute its judgment for that of the Office of the Insurance Commissioner (OIC), the Supreme Court affirmed the trial court's dismissal of the plaintiffs' claims. View "McCarthy Fin., Inc. v. Premera" on Justia Law

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In 1989, the Washington Legislature mandated coverage for neurodevelopmental therapies (neurodevelopmental therapies or NOT) (speech, occupational, and physical therapy) in employer-sponsored group plans for children under age seven (RCW 48.44.450). In 2005, the legislature enacted the mental health parity act, which mandated coverage for "mental health services" (RCW 48.44.341). The two named plaintiffs in this case, O.S.T. and L.H. were young children diagnosed with some form of neurodevelopmental issues. Both plaintiffs at some point were insured under health policies issued by Regence BlueShield that contained blanket exclusions for neurodevelopmental therapies. Regence BlueShield did not cover O.S.T.'s therapies, so O.S.T.'s parents paid for the services. It was unclear whether Regence BlueShield denied any of L.H.'s claims. Plaintiffs filed a class-action complaint, alleging breach of contract; declaratory relief; violation of the Washington Consumer Protection Act, chapter 19.86 RCW; and seeking injunctive relief. The trial court granted partial summary judgment to the plaintiffs in late 2012, holding that "any provisions contained in Regence BlueShield policies issued and delivered to Plaintiffs O.S.T. and L.H. on or after January 1, 2008 that exclude coverage of neurodevelopmental therapies regardless of medical necessity are declared invalid, void and unenforceable by Defendant and its agents." The Court of Appeals granted discretionary review, and the Supreme Court accepted transfer. Upon review, the Supreme Court held that the statutes did not conflict, and that neurodevelopmental therapies could constitute "mental health services" if the therapies are medically necessary to treat a mental disorder identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th rev. ed. 2000) (DSM-IV-TR). Therefore, the blanket exclusions of neurodevelopmental therapies in the plaintiffs' health contracts were void and unenforceable. View "O.S.T. v. Regence BlueShield" on Justia Law

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In this case, Gary Walston was exposed to asbestos while working at The Boeing Company and was later diagnosed with mesothelioma. The Court of Appeals held that pursuant to the Industrial Insurance Act (IIA), Boeing was immune from suit because Walston had not raised a material question of fact as to whether Boeing had actual knowledge that injury was certain to occur. The Supreme Court agreed after its review of the matter: Walston has not made such a showing, and therefore, he was limited to the recovery provided by the IIA' s workers' compensation system. View "Walston v. Boeing Co." on Justia Law

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In this class action lawsuit, the trial court found that the State wrongfully denied health benefits to a number of its part-time employees. The issue this case presented for the Supreme Court's review was how to value the damages suffered by that group of employees when they were denied health benefits. The State argued that the only damages to the employees were immediate medical expenses paid by employees during the time they were denied health benefits. But evidence showed that people denied health care benefits suffer additional damage. They often avoid going to the doctor for preventive care, and they defer care for medical problems. This results in increased long-term medical costs and a lower quality of life. Based on this evidence, the trial court correctly rejected the State's limited definition of damages because it would significantly understate the damages suffered by the employees. The Supreme Court affirmed. View "Moore v. Health Care Auth." on Justia Law

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Expedia (and several other hotel booking websites, collectively, "Petitioners") has been subject to approximately 80 underlying lawsuits by states, counties, and municipalities (collectively, taxing authorities) for purportedly failing to collect the right amount of local occupancy taxes from its hotel customers. Expedia tendered most of the suits to its insurer, Zurich, although some were tendered late. Zurich refused to defend Expedia on a number of grounds, including late tender and that the underlying suits may be excluded from the policies' coverage. The trial court declined to make a determination of Zurich's duty to defend Expedia, instead ordering discovery that Expedia claimed was prejudicial to the underlying actions. Petitioners sought adjudication of their summary judgment motion concerning their respective insurers' duty to defend them in cases brought by local taxing authorities. They further requested a stay of discovery in the coverage action that could prejudice them in the underlying litigation. Upon review of the matter, the Washington Supreme Court held that the trial court erred by delaying adjudication of Zurich's duty to defend Expedia. Accordingly, the Court vacated the trial court's order. The case was remanded to the trial court to determine Zurich's duty to defend Expedia in each of the 54 underlying cases subject to Expedia's motion. The trial court was furthermore ordered to stay discovery in the coverage action until it could make a factual determination as to which parts of discovery are potentially prejudicial to Expedia in the underlying actions. View "Expedia, Inc. v. Steadfast Ins. Co." on Justia Law

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Petitioner Albert Boogaard argued that the comprehensive marine liability insurance policy he purchased from International Marine Underwriters (IMU) for his general partnership, ABCD Marine, covered bodily injuries he suffered while working as an independent contractor for Northland Services Inc. (NSI). Specifically, petitioner claimed that even as a general partner he qualified and was covered as a third party under the "insured contract" provision of the policy. IMU contended that as a general partner and insured, Boogaard was not a third party under the insured contract provision. The Supreme Court affirmed summary judgment in favor of IMU. As a general partner, Boogaard did not qualify as a third party under the "insured contract" provision in accordance with Washington partnership law. View "Int'l Marine Underwriters v. ABCD Marine, LLC" on Justia Law

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Petitioner Jennifer Mau was convicted of making false insurance claims. She challenged the sufficiency of the evidence presented against her at trial. Upon review, the Supreme Court found that the State failed to prove the existence of any "contract of insurance" underlying Petitioner's claim. Therefore the Court reversed her conviction. View "Washington v. Mau" on Justia Law

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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

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Petitioner Bruce Cedell lost his home in a fire. After hearing nothing from his insurer for several months, the company threatened to deny coverage and issued an ultimatum to Petitioner to accept one quarter of what the trial court eventually found Petitioner's claims to be worth. Petitioner brought suit alleging bad faith. The company resisted disclosing its claims file, among other things, and Petitioner moved to compel production. After a hearing and a review of the claims file in camera, the trial court granted Petitioner's motion. On interlocutory review, the Court of Appeals held that the attorney-client privilege applied to a bad faith claim by a first party insured, that the fraud exception to the attorney-client privilege required a showing of actual fraud, and that the trial court erred in reviewing Petitioner's claims file in camera because Petitioner had not made a sufficient prima facie showing of fraud. Upon review, the Supreme Court affirmed in part, reversed in part, and remanded to the trial for further proceedings. "In first party insurance claims by insured's claiming bad faith in the handling and processing of claims, other than UIM claims, there is a presumption of no attorney-client privilege. However, the insurer may assert an attorney-client privilege upon a showing in camera that the attorney was providing counsel to the insurer and not engaged in a quasi-fiduciary function. Upon such a showing, the insured may be entitled to pierce the attorney-client privilege. If the civil fraud exception is asserted, the court must engage in a two-step process. First, upon a showing that a reasonable person would have a reasonable belief that an act of bad faith has occurred, the trial court will perform an in camera review of the claimed privileged materials. Second, after in camera review and upon a finding there is a foundation to permit a claim of bad faith to proceed, the attorney-client privilege shall be deemed to be waived. . . . Cedell is entitled to broad discovery, including, presumptively the entire claims file. The insurer may overcome this presumption by showing in camera its attorney was not engaged in the quasi-fiduciary tasks of investigating and evaluating the claim." View "Cedell v. Farmers Ins. Co. of Wash." on Justia Law

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The issue before the Supreme Court in this case centered on an insured's duty to cooperate with an insurer's claim investigation. Petitioner John Staples' claim was denied for failing to cooperate, namely failing to submit to an examination under oath (EUO). Petitioner sued the insurer for bad faith and related causes of action; the trial court dismissed the case on summary judgment. Upon review of the record, the Supreme Court concluded that genuine issues of fact still existed and made summary judgment inappropriate in this case. Accordingly, the Court reversed and remanded the case for further proceedings. View "Staples v. Allstate Ins. Co." on Justia Law