Justia U.S. 6th Circuit Court of Appeals Opinion Summaries

Rose’s Bidwell, Ohio home was insured by State Farm. Rose also had a Personal Articles Policy that covered two Rolex watches. In 2009, a fire destroyed the house. Later that day, Rose made a claim of $696,373.30 for the dwelling, $512,765.57 for damage to personal property, $30,000 for living expenses, and $29,850 for one Rolex watch. State Farm’s investigator took a recorded statement from Rose and his wife and spoke with Rose’s ex-wife; gathered information by searching public records; and retained a fire investigator, who issued a report, finding that the fire originated in the kitchen, that electrical items did not appear to be the source of the fire, and that neither smoking nor cooking was suspected as a cause. The report indicated that non-reported human action could not be eliminated as a cause, but did not specify that the fire was deliberately ignited. State Farm denied Rose’s claims, alleging that Rose violated “Intentional Acts” and “Concealment or Fraud” conditions of his policies. Rose sued, alleging breach of contract and bad faith. The district court declined to grant summary judgment on the “Intentional Acts” clause, but found that some answers Rose gave, failing to identify multiple tax liens and judgments, in statements to State Farm were misleading and material, and granted summary judgment on the other claim. The Sixth Circuit reversed, finding material questions of fact concerning whether Rose misled investigators. View "Rose v. State Farm Fire & Cas. Co." on Justia Law

Warner, insured by State Farm, was involved in an automobile accident. Following the accident, Michigan Spine provided Warner with about $26,000 of neurological treatment. State Farm denied coverage, stating that Warner’s condition was the result of a preexisting condition. Michigan Spine submitted the claim to Medicare, which approved a conditional payment of $5,000 under the Medicare Secondary Payer Act, 42 U.S.C. 1395y. Michigan Spine sued State Farm under Michigan’s No-Fault Act and the Medicare Secondary Payer Act, which permits private causes of action against primary plans that fail to pay medical expenses for which they are responsible. The district court dismissed, holding that a private party can recover under the Secondary Payer Act only if a “primary plan” has failed to provide appropriate reimbursement only because the planholder is entitled to Medicare benefits, and State Farm did not deny coverage on that basis. The Sixth Circuit reversed and remanded. Although the text of the Secondary Payer Act is unclear as to whether a private cause of action is available against a non-group health plan that denies coverage on a basis other than Medicare eligibility, accompanying regulations and congressional intent indicate that the requirement applies only to group health plans and not to non-group health plans. Michigan Spine may pursue its claim under the Secondary Payer Act. View "MI Spine & Brain Surgeons, PLLC v. State Farm Mut. Auto Ins Co" on Justia Law

America’s largest law school, Thomas M. Cooley, has four Michigan campuses and one in Florida and about 3,500 students. . Anziska was “of counsel” at a New York law firm. On June 8, 2011, under the title “Investigating the Thomas Cooley School of Law,” Anziska posted on the website “JD Underground,” that the firm was investigating law schools for preying on the ignorance of “naive, clueless 22-year-olds. Perhaps one of the worst offenders is the Thomas Cooley School of Law, which grossly inflates its post-graduate employment data and salary information…. students are defaulting on loans at an astounding 41 percent… most likely … will continue to defraud unwitting students unless held civilly accountable. If you have any relevant information or know of anyone who has attended Thomas Cooley … correspondences will be kept strictly confidential.” On June 13, the firm received a cease-and-desist letter from Cooley, claiming that the post was defamatory. On June 15, under the title “Retraction re: Investigating the Thomas Cooley School of Law,” a partner posted on JD Underground that the earlier post “contained certain allegations which may have been couched as fact regarding employment and default data. These statements are hereby retracted.” Meanwhile, Anziska disseminated a draft proposed class action complaint involving 18 former or current Cooley students, containing the same allegations. The complaint became publicly available on the internet. Cooley sued, alleging defamation, tortious interference with business relations, breach of contract, and false light. The district court granted summary judgment in favor of defendants. The Sixth Circuit affirmed. Cooley was a limited-purpose public figure and the record would not allow a reasonable jury to conclude that the defendants published the challenged statements with actual malice.View "Thomas M. Cooley Law Sch. v. Kurzon Strauss, LLP" on Justia Law

Central States, an employee benefit plan governed by the Employee Retirement Income Security Act, provides health insurance for Teamsters and their families. Guarantee Trust provides sports injury insurance for student athletes. Each of 13 high school and college athletes, all children of Teamsters, holds general health insurance from Central and sports injury insurance from Guarantee. Each suffered an injury while playing sports (most often football) between 2006 and 2009, and sought coverage from both companies. Each time Guarantee refused to pay the athlete’s medical expenses, and each time Central paid the bill under protest. The district court entered a declaratory judgment under ERISA, 29 U.S.C. 1132(a)(3)(B), that, when coverage of student athletes overlap, Guarantee must pay, and ordered Guarantee to reimburse Central for the payouts to the 13 students. The Sixth Circuit, affirmed in part characterizing the case as a “you first” paradox, or ‘gastonette.” An ERISA plan may coordinate benefits with another policy, but may not redefine the coverage of another policy. Absent the Central plan, the Guarantee policy would cover the sports injuries at issue without question. An ERISA plan must keep doing what it would do in another plan’s absence. That amounts to coordinating benefits, not redefining coverage. View "Cent St, SE & SW Areas Health & Welfare Fund v. First Agency, Inc." on Justia Law

In 1957, the FDA approved propoxyphene for the treatment of mild to moderate pain, under the trade name Darvon. In 1972, the manufacturer obtained FDA approval to market another product combining propoxyphene with acetaminophen, under the name Darvocet. Because the new drug application (NDA) process is onerous, Congress passed the Drug Price Competition and Patent Term Restoration Act of 1984, (Hatch-Waxman Act) to make available more low cost generic drugs. Generic drugs require an abbreviated new drug application (ANDA) showing that the drug is equivalent to and that labeling proposed is the same approved for the brand-name drug. Several companies obtained approval to market generic versions of Darvon and Darvocet. Complaints about perceived risks associated with propoxyphene began in 1978; eventually the United Kingdom withdrew it from the market. Two FDA advisory committees recommended withdrawal from the market, but the FDA ordered the NDA holder to change the label to include “Black Box” warnings and to undertake a clinical trial to assess the risks of a particular cardiac complication. In 2010, the FDA determined that the risks of propoxyphene outweighed its benefits and ordered its removal from the market. Plaintiffs in 68 consolidated cases alleged that they ingested propoxyphene products prior to its withdrawal and that manufacturers continued marketing propoxyphene after they knew or should have known that risks exceeded benefits. The district court dismissed. The Sixth Circuit affirmed, except with respect to one plaintiff.View "Germain v. Teva Pharm, USA, Inc" on Justia Law

The Dirty World website enables users to anonymously upload comments, photographs, and video, which Richie selects and publishes along with his own editorial comments. Jones is a Kentucky high school teacher and a member of the cheerleading squad for the Cincinnati Bengals football team. She was the subject of several submissions posted by anonymous users and of editorial remarks posted by Richie, including photographs of Jones and a statement that she “slept with every other Bengal Football player.” Jones requested that the post be removed. Richie declined. A subsequent post alleged that her former boyfriend “tested positive for Chlamydia Infection and Gonorrhea ... sure Sarah also has both ... he brags about doing sarah in … her class room at the school she teaches at DIXIE Heights." Richie's responded to the post: “Why are all high school teachers freaks in the sack?” Jones brought claims of defamation, libel per se, false light, and intentional inflection of emotional distress. The district court rejected arguments that the claims were barred by the Communications Decency Act of 1996 (CDA), 47 U.S.C. 230. A second trial resulted in a verdict for $38,000 in compensatory damages and $300,000 in punitive damages. The Sixth Circuit reversed. Under the CDA, Richie and Dirty World were neither creators nor developers of the challenged content. Jones’s tort claims are grounded on the statements of another content provider, but sought to impose liability on Dirty World and Richie as if they were the publishers or speakers of those statements. Section 230(c)(1) bars those claims. View "Jones v. Dirty World Entm't" on Justia Law

Brown claimed that he injured his shoulder while paving a road for his employer Ajax Paving, and sought workers’ compensation. Ajax introduced medical testimony suggesting that the injury occurred outside of work. While the case remained pending before the Michigan administrative agency, Brown and Ajax settled. Brown, however, thought that Ajax had introduced false medical testimony and that it had done the same to other employees, and sued Ajax and its insurers, claims administrators and the doctor, under the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. 1964(c). The district court dismissed. The Sixth Circuit affirmed. Under the Act, Brown must show that illegal racketeering activities have “injured [him] in his business or property.” The Sixth Circuit has held that “loss or diminution of benefits the plaintiff expects to receive under a workers’ compensation scheme does not constitute an injury to ‘business or property’ under RICO.” View "Brown v. Ajax Paving Indus., Inc." on Justia Law

On January 13, 2009, Jackson was in a car accident with an agent of the Immigration and Customs Enforcement Agency (ICE) within the U.S. Department of Homeland Security (DHS). Jackson suffered damage to her head and spinal cord. Jackson retained the services of Shaffer, an attorney with the firm “Michigan Autolaw.” On March 5, 2009, Shaffer erroneously submitted Jackson’s administrative claim for Damage, Injury, or Death, to DHS, which forwarded Jackson’s claim to ICE. On June 17, ICE received Jackson’s claim. The cover letter listed Shaffer’s address in Southfield, Michigan. The claim form included Jackson’s mailing address. On July 7, ICE confirmed receipt of Jackson’s claim in correspondence, sent to the Southfield address, stating that ICE would process Jackson’s claim pursuant to the Federal Tort Claim Act, which allows an agency “up to six months to adjudicate a damage claim, beginning from the date the agency receives the claim.” On March 8, 2011, ICE sent to the Southfield address a “final determination” denying Jackson’s claim, stating that Jackson could file suit no later than six months after the date of mailing. On March 23, the Postal Service returned the denial as “Not Deliverable…Unable to Forward.” Autolaw had changed locations in May, 2010. Jackson contends that Autolaw had a one-year forwarding order for its mail. The parties also disagree whether the information about changing locations was conveyed to ICE. Despite receiving the undelivered mail, ICE took no further action. On January 11, 2012, Jackson filed suit. The district court dismissed, finding that the mailing of the denial letter triggered the six-month limitation and declining to apply equitable tolling. The Sixth Circuit affirmed. View "Jackson v. United States" on Justia Law

Cameron returned to Kentucky after serving as a Marine in Iraq and applied for VA Medical Benefits, but did not include verification of service (DD-214). Four months later, the VA verified his service, but its record did not reflect combat service or other eligibility; his status was “Rejected.” A week later, Cameron’s records were updated and he was retroactively enrolled. Cameron had been involved in killing a civilian family. His parents had contacted the Lexington VA mental health department and urged their son to seek help. Tiffany, his wife, told him that she and their baby would not continue to live with him unless he sought help. Days before his enrollment was corrected Cameron went to the Leestown VA. The intake clerk recognized that Cameron was in urgent need of help and talked to him for 40 minutes, despite not finding his enrollment. She concluded that Cameron was suicidal. No mental health professional was available at Leestown. She sent him to Cooper Drive VA. Cameron called his father later, stating that he had been turned away from Cooper Drive because he did not have his DD-214. Cameron drove home. He and Tiffany searched for the form. Cameron became frustrated and threatened Tiffany, who called 911. While on the phone, she heard a shot. Her husband had committed suicide. His family asserted claims under the Federal Tort Claims Act. The district court dismissed, holding that it did not have jurisdiction over a “benefits determination,” Veterans’ Judicial Review Act, 38 U.S.C. 511.The Sixth Circuit reversed. Whether the clinics had a duty to care for Cameron is an improper question for this stage. The government failed to show that the actions of the VA employees satisfied the test of the FTCA’s discretionary function exception. View "Anestis v. United States" on Justia Law

Nicole discovered Shawn’s body in their Ohio home. Shawn had gone out drinking the night before, while Nicole spent the night at a friend’s house. The Medical Examiner’s Office reported the cause of death as “[a]sphyxia by extreme and restricted position (positional asphyxia)” and the manner of death as “[a]cute ethanol intoxication ... ACCIDENT: Prolonged and extreme hypertension of neck and torso while intoxicated.” Shawn’s blood-alcohol level at the time of autopsy was .22%. Nicole filed a $212,000 claim for accidental-death benefits with the Plan, which covers “injury” as a result of an “accident,” defined as “an unintended or unforeseeable event or occurrence which happens suddenly and violently.” No benefits will be paid if the “Covered Person [is] deemed and presumed, under the law of the locale … to be under the influence of alcohol or intoxicating liquors.” Nationwide directed denial of Nicole’s claim, citing Exclusion 12, but quoting an earlier version that provided: “The Covered Person being deemed and presumed … to be driving or operating a motor vehicle while under the influence…” Later, based on amended Exclusion 12, Nationwide upheld the denial; its appeals panel affirmed. Nicole filed suit, asserting claims under the Employee Retirement Income Security Act and a common-law breach-of-fiduciary-duty claim. The district court entered judgment in favor of the defendants, but agreed with Nicole that the appeals panel had breached its statutory duty to provide her with Plan-related documents upon written request, and imposed a penalty of $55 per day ($8,910). The Sixth Circuit affirmed. View "Cultrona v. Nationwide Life Ins. Co." on Justia Law