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

Four plaintiffs each established an employee benefit plan under the Employee Retirement Income Security Act funded by a combination of employer contributions and covered employee payroll deductions; each entered into a Benefit Management Service Agreement with PBA, which specified that PBA would provide services, such as paying medical providers for claims incurred under the Plans. Each Agreement required PBA to establish a segregated bank account for each Plan into which it would deposit the funds that it received from the corresponding plaintiff for paying the medical claims and authorized PBA to pay medical claims by writing checks from this account. PBA not only failed to use funds supplied by plaintiffs to pay the claims incurred under the corresponding Plan, but commingled and misappropriated Plan funds. PBA did not pay all claims, despite receiving money for payment of those claims from the respective plaintiffs. The amounts unpaid for the plaintiffs are: $501,380.75, $409,943.88, $384,574.17, and $44,290.12. The district court found that PBA was a fiduciary under ERISA (29 U.S.C. 1002(21)(A)), had breached its fiduciary duties, and that ERISA preempted Permco’s breach-of-contract claims. The Sixth Circuit affirmed. View "Guyan Int'l, Inc. v. Prof'l Benefits Adm'rs, Inc." on Justia Law

Ronske’s widow sued Heil after a dump truck body it manufactured caused Ronske’s death. Heil held a commercial general liability policy. Evanston insured the first $1 million loss in excess of $500,000 self-insured retention. Heil was required to defend, investigate, and accept any reasonable settlement offer within the SIR; Evanston could choose to assume charge of defense and settlement. Heil retained attorney Pelini. After more than two years, Evanston wanted to assume defense and appointed Sutter, with Pelini to remain involved. Pelini’s fees would count toward exhaustion of the SIR, and Evanston would pay Pelini’s fees in excess of the SIR. The parties settled for $5,711,000. Evanston paid $1 million, leaving Heil responsible for $4,711,000 and $63,533.79 in fees and costs in excess of its SIR. Evanston declined to pay fees and costs. A jury found that Evanston breached the contract and refused in bad faith to pay amounts owed under the policy, but did not fail to settle the wrongful death action in bad faith, awarded Heil compensatory damages plus prejudgment interest for breach of contract, $15,883.44 in statutory damages for bad faith refusal to pay, and $2 million punitive damages. The Sixth Circuit vacated the $2 million punitive damages award, but affirmed the finding of liability under state law. View "Heil Co. v. Evanston Ins. Co." on Justia Law

This insurance coverage dispute arose from a policy designed to protect financial institutions from losses caused by dishonest employees. Trying to recover nearly one million dollars stolen by an employee from client brokerage accounts, three financial institutions sued the insurance company that issued the policy. The district court held that the policy covered the losses and granted summary judgment to the financial institutions. The Sixth Circuit Court of Appeals affirmed the court's liability judgment and all but one of its damages calculations, holding (1) the stolen money was covered property; (2) the employee's theft caused a direct loss to the bank; (3) the employee committed his dishonest acts with the manifest intent to cause the loss; and (4) the district court's decision to subtract another insurance company's $50,000 pay-out to the banks based on another employee-dishonesty policy from the damages award was error. Remanded. View "First Defiance Fin. Corp. v. Progressive Cas. Ins." on Justia Law

This insurance coverage dispute arose from a policy designed to protect financial institutions from losses caused by dishonest employees. Trying to recover nearly one million dollars stolen by an employee from client brokerage accounts, three financial institutions sued the insurance company that issued the policy. The district court held that the policy covered the losses and granted summary judgment to the financial institutions. The Sixth Circuit Court of Appeals affirmed the court's liability judgment and all but one of its damages calculations, holding (1) the stolen money was covered property; (2) the employee's theft caused a direct loss to the bank; (3) the employee committed his dishonest acts with the manifest intent to cause the loss; and (4) the district court's decision to subtract another insurance company's $50,000 pay-out to the banks based on another employee-dishonesty policy from the damages award was error. Remanded. View "First Defiance Fin. Corp. v. Progressive Cas. Ins." on Justia Law

Plaintiffs sought to recover on behalf of themselves and similarly-situated employees and retirees of the City of Cincinnati the current value of the 870,021 shares of Anthem stock that the City received from Anthem’s demutualization. Plaintiffs asserted eight claims for breach of contract and four tort claims against Anthem and three breach of contract claims and four tort claims against the City. The district court certified the class: 2,536 people named as insureds, or former members of a group of insured persons, covered under a health care group policy from June 18 through November 2, 2001. The class included “Class A” members, who had an insurance policy with Anthem prior to its merger with Community in 1995 and “Class B” members who received a health insurance group policy after the merger. The court later dismissed. The Sixth Circuit, exercising jurisdiction under the Class Action Fairness Act of 2005, 28 U.S.C. 1332(d), affirmed. Plaintiffs cannot recover any demutualization compensation; the City was the policyholder before the merger and maintained its policyholder rights post-merger through a grandfather clause, including any rights to demutualization proceeds. The 2001 demutualization process did not disrupt the City’s membership interests or confer any equity rights to Plaintiffs. View "Mell v. Anthem, Inc." on Justia Law

Plaintiffs sued behalf of themselves and all other purchasers of title insurance in Ohio from March 2004 through the present. They alleged that 22 title-insurance companies and the Ohio Title Insurance Rating Bureau violated antitrust laws (Sherman Act, 15 U.S.C. 1; Ohio Rev. Code 1331.01) by conspiring to set unreasonably high title-insurance rates. The title-insurance companies filed rates with the Ohio Department of Insurance through OTIRB, a properly licensed rating bureau. Plaintiffs claimed that it was impossible for the Department to review the reasonableness of the rates collectively set by defendants because those rates are based principally on undisclosed costs, which allegedly included “kickbacks, referral fees and other expenses designed to solicit business referrals.” The district court dismissed, holding that the filed-rate doctrine applied to title insurance, and foreclosed claims for monetary damages and that Ohio statutes (Title XXXIX) completely foreclosed federal and state antitrust claims. The Sixth Circuit affirmed, noting that there are at least 45 similar cases, nationwide. The filed-rate doctrine, which limits antitrust remedies available to private parties, is irrelevant because the actions are barred by state law. View "Katz v. Fidelity Nat'l Title Ins." on Justia Law

In 1990, Pedicini purchased a LICOA supplemental cancer-insurance policy that provided for unlimited cash benefits, payable directly to Pedicini, equal to “usual and customary charges” for radiation or chemotherapy received as treatment. In 2001, Pedicini obtained assistance from an insurance agent, who negotiated a policy with LICOA that capped benefits for treatments at $25,000 per year, lowering the premium. The policy, effective October 2001, tied benefits to “actual charges” made by a person or entity furnishing services treatment or material. Unbeknownst to Pedicini, in February 2001, LICOA changed its practices. It had paid benefits tied to the amount billed by medical providers regardless of the amount accepted in payment, but began paying benefits equal to the amount accepted as full payment by providers. LICOA did not notify policyholders, but did notify its agents. In 2007, Pedicini was diagnosed with cancer. His benefits were only equal to the discounted amount accepted by his provider due to his status as a Medicare recipient. Pedicini won summary judgment on a breach of contract claim, but the court ruled in favor of LICOA on bad faith claims. The Sixth Circuit affirmed on the contract claim, but reversed with respect to bad faith claims. View "Pedicini v. Life Ins. Co. of AL" on Justia Law

Cogswell purchased the vacant paper mill in a tax foreclosure sale for $70,000. The site has more than 20 buildings, covering 440,700 square feet. Evanston issued first-party property insurance with a building coverage limit of $1,000,000, subject to coinsurance at 80%. On the first day of coverage, 15,700 square feet (less than 4%) were damaged by fire. Evanston determined that actual cash value of the buildings at the time of loss was $10,223,384.80; under the coinsurance provision, Cogswell was required to carry insurance of $8,178,707.84. Cogswell carried only $1 million. Evanston determined that it was liable for 12.23% ($1 million/ $8,178,707.84); calculated cash value of loss at $342,836.46; and determined that it was liable for $36,918.27 ($342,836.46 times 12.23% less $5,000 deductible). An umpire, appointed under the contract determined actual cash value of $1,540,000.00 and damage at $736,384.89. Cogswell demanded $554,553.49, the net amount under the appraisal after application of the coinsurance provision and deductible. The district court vacated the appraisal and granted Evanston judgment on a second appraisal. The Sixth Circuit affirmed. The provision calling for appointment of an umpire is not governed by the Federal Arbitration Act, 9 U.S.C. 1, which would require deference; the parties agreed to the process under Michigan law.View "Evanston Ins. Co. v. Cogswell Props., LLC" on Justia Law

Stryker, a manufacturer of medical devices, sued its umbrella insurer XL, seeking coverage for claims stemming from the implantation of expired artificial knees. The dispute concerned the precise "defect" that triggers batch coverage under the Medical Products Endorsement. The district court held that XL was liable under the policy for the entirety of Stryker’s losses on both direct claims brought against Stryker, as well as claims brought against Pfizer that Stryker was obligated to reimburse under an asset purchase agreement. The court found that the items were defective if they were available in Stryker’s inventory for implantation by physicians beyond their shelf-life of five years. The Sixth Circuit affirmed XL’s liability for the full amount of Stryker’s losses and pre-judgment interest. XL’s payment to Pfizer applies to exhaust the policy with respect to the direct claims. The court reversed the holding that the aggregate limit of liability of the XL policy does not apply to the judgments on the direct claims and remanded for determination of what portion, if any, of the total liability for those judgments beyond $15 million represents consequential damages as defined under Michigan contract law. View "Howmedica Osteonics, Corp. v. Nat'l Union Fire Ins. Co." on Justia Law

TIG issued a $25 million excess policy to Stryker, a manufacturer of medical devices. Coverage attached above the underlying (XL) umbrella policy, with a limit of $15 million. Stryker sued XL, seeking defense and indemnification for claims related to replacement knees (first suit). Pfizer then sued Stryker, seeking indemnification with respect to claims based on Uni-Knees; the companies had an asset purchase agreement. The court ruled in favor of Pfizer. When XL denied coverage, Stryker sued both insurers. In 2008, the district court held that XL was liable for all of Stryker's liabilities with respect to both suits and also granted declaratory judgment against TIG. XL settled directly with Pfizer, and obtained a ruling that this satisfied its obligations. TIG moved to remove the declaratory judgment ruling, arguing that the ruling that XL was responsible with respect to both suits made it impossible to subject TIG to liability. The district court denied this motion. The Sixth Circuit affirmed that the case is not moot, noting that the claims may exhaust the XL policy; reversed a ruling that TIG is precluded from raising coverage defenses on remand, noting that TIG was not a party to the first suit; and remanded. View "Stryker Corp. v. Nat'l Union Fire Ins. Co." on Justia Law