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

Golden purchased automobile insurance from State Farm. The mandatory liability portion of her policy provided that State Farm would defend the insured against a third-party lawsuit using attorneys chosen by State Farm. Following a collision, Golden was represented by in-house counsel. She later filed a purported class action, claiming that “historically and traditionally” State Farm and other insurers defended third-party claims against insureds by hiring private, independent attorneys. State Farm now routinely uses in-house staff attorneys to represent insureds against such claims. Golden filed a purported class action, alleging that State Farm owes its insureds a duty to explain in its policies that house counsel may be used. The district court dismissed, holding that Indiana law creates no obligation to provide advance notification to an insured that an insurer uses house counsel to defend insureds. The court denied Golden’s request to certify the question to the Indiana Supreme Court. The Seventh Circuit affirmed, noting that Golden did not allege that she received deficient representation or that she ever objected to the use of house counsel in her suit. All of her claims depended on the existence of a duty to disclose; State Farm had no duty to disclose.View "Golden v. State Farm Mut. Auto. Ins. Co." on Justia Law

The Affordable Care Act, 42 U.S.C. 300gg-13(a)(4), requires health insurance providers (including third party administrators) to cover certain preventive services without cost to the insured, including, “with respect to women … preventive care and screenings,” including all FDA-approved contraceptive methods, sterilization, and patient education for women with reproductive capacity. The University of Notre Dame self‐insures employees’ medical expenses; Meritain administers the employee health plan. For students’ medical needs, Notre Dame has a contract with Aetna. Because Catholic doctrine forbids the use of contraceptives, Notre Dame has never paid for contraceptives for employees or permitted Aetna to insure the expense of contraceptives. Because of those religious objections and the Religious Freedom Restoration Act, 42 U.S.C. 2000bb‐1(a), the government created a religious exemption, 45 C.F.R. 147.130(a)(1)(iv)). New regulations enlarged the exemption, so that Notre Dame came within its scope. To exercise its right to opt out of paying for coverage for contraceptives, the university completed a form that alerts insurers that Notre Dame is not going to pay, so they will have to pay. The government will reimburse at least 110 percent of the third‐party administrator’s costs and Aetna can expect to recoup its costs from savings on pregnancy medical care. Several months after the regulations were promulgated, the University unsuccessfully sought a preliminary injunction. The Seventh Circuit affirmed, noting that the University had not indicated exactly what it wanted enjoined at this stage. The insurance companies were not parties, and, therefore, could not be enjoined from providing the required coverage. A religious institution has no right to prevent other institutions from engaging in acts that merely offend the institution and the University has complied by completing the required form. View "Univ. of Notre Dame v. Sebelius" on Justia Law

Richard worked for GPI for 25 years until his 2009 death. He had a basic life insurance policy through GPI’s health and welfare plan and paid for an optional supplemental life insurance policy through GPI for several years. His wife, Maureen, was the beneficiary of both policies. At the end of 2008, Richard’s supplemental life insurance policy was cancelled. Richard’s pay stubs reflected the change, beginning in January 2009. When Richard died a few months later, GPI’s insurer, ABC, paid benefits on the basic life insurance policy. Richard had been diagnosed with stage 4 cancer in September 2008. Soon after Richard’s death, Maureen’s attorney requested information regarding Richard’s supplemental life insurance policy. The company refused the request, citing its confidentiality policy, indicating that the information would only be produced in response to a subpoena. Almost two years later, Maureen filed suit, claiming that either GPI or ABC breached the policy by terminating it without Richard’s consent, in violation of the Employee Retirement Income Security Act, 29 U.S.C. 1001. The district court awarded the defendants summary judgment. The Seventh Circuit affirmed. There was no material issue of fact as to whether Richard cancelled his supplemental policy. Although Maureen speculated that someone other than Richard terminated the policy, she presented no evidence to support her assertion. View "Herzog v. Graphic Packaging Int'l, Inc." on Justia Law

An employee benefits plan sued a medical college that provides patient care in clinics and hospitals and an affiliated children’s hospital, with which it had provider agreements, alleging ERISA violations and breach of contract under Wisconsin law. The suit was based on the plan’s determination that an employee’s child was not covered by the plan and the hospital’s denial of its subsequent request that the hospital refund about $1.7 million the plan had already paid on behalf of the child. The plan makes no mention of refunds. The district court dismissed and awarded attorneys’ fees to the hospital as a sanction for having filed frivolous claims. The Seventh Circuit affirmed dismissal of the ERISA claims but reversed dismissal of the breach of contract claim, rejecting the district court’s finding of preemption, and imposition of sanctions. On remand of the contract claim, the district court granted summary judgment in favor of the hospital. The Seventh Circuit affirmed, noting that the hospital, having been paid in full by the plan, has no possible claim against Medicaid, that the plan took 11 months to determine that the child was not a beneficiary, and that the hospital has not been unjustly enriched. View "Kolbe & Kolbe Health & Welfare Benefit Plan v. Med. Coll. of WI" on Justia Law

In 1971 Milwaukee County provided its employees with health insurance under an ordinance that stated that the “county shall participate in the payment of monthly premiums” and extended coverage to retirees. In 1993, the ordinance was amended to provide that “[t]he County shall pay the full monthly cost of providing such [health insurance] coverage to retired members” as “part of an employee’s vested benefit contract.” Upon her 1991 retirement, Hussey had paid no co‐payments or deductibles for her health care. Her benefit plan booklet explained that with 15 years of service: “the retiree may participate in the health plan in which he/she is currently enrolled on the same basis as … the active employee group. The County will make the full premium contribution.” Until 2012, the plan coordinated benefits so that expenditures not covered by Medicare were paid in full by the County. In 2012 the County increased deductibles, co‐payments, and co‐insurance charges and modified coordination of benefits so that retirees over age 65 would pay the same deductibles, co‐payments, and co‐insurance charges as active employees. Hussey filed a purported class action, alleging that the failure to provide cost‐free health insurance to retirees constituted an unconstitutional taking of property. The Seventh Circuit agreed with the district court that the County only promised retirees the ability to participate in the same health insurance plan as active employees on a “premium‐free” basis.View "Hussey v. Milwaukee County" on Justia Law

Phusion manufactures and distributes an alcoholic beverage called “Four Loko.” Its original formula contained energy stimulants, such as caffeine, guarana, taurine, and wormwood. Phusion purchased a commercial general liability insurance policy and a umbrella policy from members of the Liberty Mutual Group. The policies include identical provisions, excluding coverage for bodily injury or property damage when the insured may be held liable by reason of causing or contributing to intoxication. Plaintiffs sued Phusion in separate state court actions, alleging injuries caused by consumption of Four Loko. Two cases involved traffic accidents, one involved a shooting, another involved paranoid behavior resulting in accidental death, and a fifth claim involved a death from heart trouble. Phusion notified Liberty, which sought a declaratory judgment regarding the scope of coverage. The district court examined the underlying cases in the context of comparable automobile exclusions and ruled that four of the five cases fell within the Liquor Liability Exclusion. The Seventh Circuit affirmed. The Liquor Liability Exclusions in the policies are unambiguous and apply to Phusion. The allegations of simple negligence raised by the plaintiffs in the underlying complaints are not sufficiently independent from the allegations that Phusion caused or contributed to the intoxication of any person. View "Netherlands Ins.. Co. v. Phusion Projects, Inc." on Justia Law

In 1994, Norem purchased a “Flexible Premium Variable Life Insurance Policy” from Lincoln Benefit. With variable life insurance, part of the premium is allocated to the insurer’s investment funds, called subaccounts. Policyholders may move their investments within the subaccounts and the death benefit, which is guaranteed not to fall below a certain amount. With variable universal life, the policyholder may easily invest and alter insurance coverage. The policy is comprised of the policy value, which represents the investment component, and its net amount at risk, which represents the insurance component. Norem purchased his policy because he wanted both life insurance and an investment vehicle for the proceeds from the sale of his ownership of a medical business. The policy has a “cost of insurance” (COI) charge deducted monthly from the policy. The policy explains how the COI rate is calculated. Norem filed a putative class action on behalf of himself and other similarly situated policyholders, claiming that Lincoln Benefit breached the terms of its policies in its method of calculating the COI rate.Before deciding on class certification, the district court granted summary judgment to Lincoln Benefit, concluding that its calculation of COI rates did not breach the contract. The Seventh Circuit affirmed. View "Norem v. Lincoln Benefit Life Co." on Justia Law

The NECA-IBEW Health and Welfare Fund provides health benefits to members of a local union of electrical workers. The Fund negotiated a Local Agreement with Sav-Rx, a provider of prescription-drug benefits, under which Sav-Rx reimburses pharmacies for dispensing medication and then invoices the Fund for some of its costs. The Local Agreement does not call for arbitration. A few months later, Sav-Rx negotiated a different agreement with the national organization of the IBEW, with which the local is affiliated. The National Agreement offers locals reduced charges and more services than the Local Agreement and contains a mandatory arbitration clause. Local unions and funds could opt into the National Agreement, but the Fund's trustees never voted on the matter. Over the next eight years the Fund accepted from Sav-Rx services provided by the National Agreement. The Fund sued Sav-Rx for invoicing the Fund at rates not authorized by either the Local or National Agreement. The district court dismissed, finding that Fund had accepted the benefits of the National Agreement and was bound to it; Sav-Rx established that the Fund knew it was accepting benefits under the National Agreement. The Seventh Circuit affirmed. View "NECA-IBEW Rockford Local Union 364 Health & Welfare Fund v. A&A Drug Co." on Justia Law

After discovering that she had lung cancer that had spread to her brain, Killian underwent aggressive treatment on the advice of her doctor. The treatment was unsuccessful and she died. Her husband submitted medical bills for the cost of the treatments to her health insurance company. The company denied coverage on most of the expenses because the provider was not covered by the insurance plan network. The husband filed suit, seeking benefits for incurred medical expenses, relief for breach of fiduciary duty, and statutory damages for failure to produce plan documents. The district court dismissed denial-of-benefits and breach-of-fiduciary-duty claims, but awarded minimal statutory damages against the plan administrator. In 2012, the Seventh Circuit affirmed the dismissals, rejecting an argument that the plan documents were in conflict, but remanded for recalculation of the statutory damages award. On rehearing, en banc, the Seventh Circuit affirmed the denial of benefits and statutory penalties holdings, but reversed on the breach of fiduciary duty claim. The instructions given in plan documents were deficient and a reasonable trier of fact could rule in favor of Killian, based on telephone conversations in which Killian attempt to determine whether the physicians who were about to perform surgery were within the network. View "Killian v. Concert Health Plan" on Justia Law

In a proposed class action, Schilke alleged that Wachovia, her lender and holder of a mortgage on her home, fraudulently placed insurance on her property when her homeowner’s policy lapsed. Wachovia secured the replacement coverage from ASI and charged her for it, as specifically permitted by her loan agreement. The premium was more than twice what she had paid for her own policy and included a commission to Wachovia’s insurance-agency affiliate, also as permitted under the loan agreement. Schilke calls the commission a “kickback” and asserted statutory and common-law claims, most sounding in fraud or contract. The district court dismissed based on federal preemption and the filed-rate doctrine. The Seventh Circuit affirmed. The loan agreement and related disclosures and notices conclusively show that there was no deception at work. Wachovia fully disclosed that lender-placed insurance could be significantly more expensive than her own policy and could include a fee or other compensation to the bank and its insurance-agency affiliate. Maintaining property insurance was Schilke’s contractual obligation and she failed to fulfill it. . View "Schilke v. Am. Sec. Ins. Co." on Justia Law