Justia U.S. 7th Circuit Court of Appeals Opinion Summaries

Vee’s is a Subchapter S corporation wholly owned by Vee, who reports its income on his own tax returns. Vee sought a refund of $40,000 in penalties that the IRS had assessed because he took deductions for contributions to a benefit plan from 2004-2007 but did not file a Form 8886. In a separate Tax Court suit, the government is arguing that the deductions were improper. Contributions to multi-employer benefit plan, like the Vee's, are deductible unless the plan “maintains experience-rating arrangements with respect to individual employers,” 26 U.S.C. 419A(f)(6). Experience rating means that rather than pooling the risks and contributions of all the employees of the different employer-members to determine benefits, benefits are determined separately for each employer according to that employer’s contributions. If contributions go to purchase life insurance policies that accumulate cash value, the contributions are not tax deductible; such a plan is mainly an investment vehicle rather than insurance. Vee’s plan included no medical benefits. Vee’s contribution in ithe first year was $165,000, but the cost of the term life insurance purchased was only $5,400. The difference was invested to earn interest for and is the property of Vee. The district judge denied a refund. The Seventh Circuit affirmed. Vee’s plan was enough like the plan described in the IRS notice to require lForm 8886. View "Vee's Mktg., Inc. v. United States" on Justia Law

Essex issued a professional liability insurance policy to Galilee Medical Center, covering claims against Galilee physicians, including Angarita. Galilee’s application asked, “Do[] the Applicant’s employees or independent contractors use drugs for weight reduction for patients?” Galilee answered no. The question continued: “If yes, attach a list of drugs used and percentage of practice devoted to weight reduction.” Galilee did not identify any drugs. Galilee also answered “no” to whether its employees performed any experimental procedures and to “With the exception of surgery for obesity, does your practice include weight reduction or control by other [sic] than diet or exercise? 5.(b) Do you dispense any drugs? 5.(c) Do you use injections for weight control? 9.(a) Do you use experimental procedures, devices, drugs, or therapy in treatment or surgery?” In 2011, Ravelo, Angarita’s former patient, sued Angarita and Galilee for medical negligence based on mesotherapy treatments administered by Angarita. Mesotherapy is a non-surgical treatment involving injections into subcutaneous layers of fat, to dissolve deposits of fat and provide a more desirable body shape. Mesotherapy is not FDA-approved. Angarita admitted to providing mesotherapy treatment to more than 5,000 patients, including Ravelo. Essex denied coverage and sought a declaratory judgment rescinding the Policy. The Seventh Circuit affirmed summary judgment in favor of Essex, based on the misrepresentations in the applications. View "Essex Ins. Co. v. Angarita" on Justia Law

Cincinnati Insurance issued a liability policy to Painters, which allowed the insured to add an “additional insured” by oral agreement, if that agreement preceded the occurrence and “a certificate of insurance ... has been issued.” No permission from Cincinnati is required, if the insureds have a relationship consistent with the policy. Painters was hired to paint Vita’s premises and orally agreed to add Vita as an additional insurer. Painters’ worker fell, before there was any written confirmation of the oral agreement, and remains in a coma. In a suit by the insurer, seeking a declaration that Vita was not covered based on a certificate issued to Vita the day after the accident, the court granted summary judgment in favor of Cincinnati. The Seventh Circuit reversed. Summary judgment was premature. The policy is ambiguous. A certificate could be regarded a prerequisite to coverage of the additional insured, but also could be intended merely to memorialize the oral agreement. The policy could also mean that the oral agreement must be memorialized in writing before the insured can file a claim. Oral agreements are valid contracts and the policy is explicit that an oral agreement is sufficient to add an insured. The certificate is not a contract, but “a matter of information only” that “confers no rights upon the certificate holder.” View "Cincinnati Ins. Co. v. Vita Food Prods, Inc." on Justia Law

Morady sold life insurance policies. Davis, a former lawyer, approached elderly African-Americans and paid them small amounts to become the nominal applicant-buyers of the policies, with Morady as the insurance agent, and to put the policies into an irrevocable trust, with Davis as trustee. The beneficial interest in the trust would be sold to an investor who would pay the remaining premiums and wait for the death of the insured. The insurer would not have sold the policies had it known that the premiums would be paid by an unrelated third party in the expectation that the policy would be transferred to him; its contracts with agents, including Morady, required them to conform to an “absolute prohibition against participation in any type of premium financing scheme involving an unrelated third party,” but the law allows an investor to purchase the beneficial interest in an existing life insurance policy. The net loss to Ohio National (beyond $120,000 commissions paid to Morady) was $605,000 in litigation expenses to void the policies. The total death benefits specified in the illegal policies amounted to $2.8 million. The Seventh Circuit agreed that Morady’s conduct constituted fraud and a breach of her contract and affirmed summary judgment, with damages of $726,000. View "Ohio Nat'l Life Assurance Corp. v. Davis" on Justia Law

The insurer operates a preferred-provider system that offers patients better benefits, or lower co-payments, for patronizing medical providers who have agreed with the insurer to accept lower reimbursements (per procedure) in exchange for a better flow of business. The chiropractor plaintiffs signed such “participating provider” or “network” agreements. Providers bill the insurer directly regardless of whether a patient obtained coverage as part of an Employee Retirement Income Security Act (ERISA) welfare-benefit plan or through some other means, such as an affinity-group policy or an insurance exchange under the Affordable Care Act. Chiropractors sued, contending that, when determining how much to pay for services rendered to patients, the insurer failed to use the procedures required by ERISA, 29 U.S.C. 1133. The district court concluded that plaintiffs are beneficiaries under ERISA and awarded damages and injunctions requiring the insurer to follow section 1133 and Department of Labor regulations. The Seventh Circuit reversed, noting that plaintiffs concede that they are not participants under the ERISA definition and that a network contract between a medical provider and an insurer does not make that provider a “beneficiary” under ERISA. View "Pa. Chiropractic Ass'n v. Independence Hosp. Indem., Inc." on Justia Law

Brown filed a class action complaint, alleging that she contacted Defender by telephone in response to its advertisement for a home security system; that, during several calls, she provided Defender with personal information; and that Defender recorded those calls without her permission and without notifying her of the recording. Brown claimed violations of California Penal Code 632, which prohibits the recording of confidential telephone communications without the consent of all parties. Defender owned a commercial general liability insurance policy issued by First Mercury, covering “personal injury” and “advertising injury.” In a separate definitions section, the policy defined both “advertising injuries” and “personal injuries” as those “arising out of … [o]ral or written publication of material that violates a person’s right of privacy.” The parties eventually reached a settlement. Defender provided First Mercury with timely notice of the Brown suit. First Mercury denied coverage and refused to defend. The Seventh Circuit affirmed dismissal of Defender’s suit against First Mercury. Defender’s Policy requires “publication,” which was neither alleged nor proven. View "Defender Sec. Co. v. First Mercury Ins. Co." on Justia Law

In 1989, the Supreme Court held that courts should apply de novo review in suits challenging denials of employee benefits governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132(a)(1), but if the benefit plan provided expressly for a different, more deferential standard of review, that specific provision would control over the default rule of de novo review. Insurance companies and plan sponsors began including such provisions in most benefit plans, typically saying the insurer or plan administrator would exercise discretionary judgment in interpreting a plan or deciding whether to pay benefits. Courts would then apply a deferential standard of review under which a denial would stand unless it was “arbitrary and capricious.” Later, state laws were adopted to protect employees and plan beneficiaries from abuse of such discretion. An Illinois insurance law, prohibited provisions “purporting to reserve discretion” to insurers to interpret health and disability insurance policies. The Seventh Circuit rejected a preemption challenge and applied the state law in a case involving a challenge to an insurance provider’s definition of “disability,” The court did not address whether the denial of benefits was arbitrary and capricious. View "Fontaine v. Metropolitan Life Ins. Co" on Justia Law

Religious, not-for-profit organizations challenged the “contraceptive mandate” of the Patient Protection and Affordable Care Act of 2010 (ACA), 42 U.S.C. 300gg-13(a)(4), arguing that the ACA’s accommodations for religious organizations impose a substantial burden on their free exercise of religion, and that the ACA and accompanying regulations are not the least restrictive means of furthering a compelling government interest, in violation of the plaintiffs’ rights under the Religious Freedom Restoration Act of 1993 (RFRA), 42 U.S.C. 2000bb. The district court entered a preliminary injunction. The Seventh Circuit reversed, stating: It is the operation of federal law, not any actions that the plaintiffs must take, that causes the provisions of services that the plaintiffs find morally objectionable. The accommodation has the legal effect of removing from objectors any connection to the provision of contraceptive services. View "Grace Schools v. Burwell" on Justia Law

Castro-Cortes was working for Astro, a subcontractor of JRJ, when he fell through a hole on the jRJ property. He sued JRJ for personal injury in Illinois state court. After being served in that suit, JRJ’s two members, Panfil and Michelon, filed a report with Nautilus under a general commercial liability policy. Nautilus refused to defend, citing three grounds: that the underlying lawsuit was against JRJ, but the named insureds were Panfil and Michelon; the “Contractor-Subcontracted Work Endorsement;” and the “Employee Exclusion.” The JRJ parties filed a federal suit for breach of contract. On summary judgment, the district court determined that Nautilus breached its duty to defend because there was at least the potential for coverage of the underlying lawsuit. The Seventh Circuit affirmed, stating that it is a close case and that the bar to finding a duty to defend is low. The court construed the language of the exclusions in favor of JRJ, noting that the burden of proving that a claim falls within an exclusion rests on the insurer. View "Panfil v. Nautilus Ins. Co." on Justia Law

Vandenberg, attending a cruise on a chartered yacht, was injured when he fell from the upper deck because the bench on which he was sitting tipped over, while the boat was anchored in Lake Michigan. The bench was not secured to the deck, nor did the upper deck have a railing. The fall left Vandenberg paralyzed from the chest down. The yacht was owned by a closely held corporation. Vandenberg alleged that Rose Paving, a company run by Rose, one of three owners of the corporation, was a booking agent that maintained a marketing relationship for the chartering of the yacht. He filed suit, alleging negligence, and settled with the defendants. The defendants agreed to pay $25 million through the assignment of their claims against their insurers. Westfield was the insurance provider for defendant Rose Paving. Westfield disputed that its insurance policies with Rose Paving covered the yacht accident and sought a declaratory judgment. The district court granted Westfield’s motion for judgment on the pleadings. The Seventh Circuit affirmed, finding that injuries came under the policies’ watercraft exclusion. View "Westfield Ins. Co. v. Vandenberg" on Justia Law