Justia Government & Administrative Law Opinion Summaries

In 1993, the County and the Orange County Employee Retirement System (OCERS) entered into a Memorandum of Understanding (MOU), allowing the County to access surplus investment earnings controlled by OCERS and depositing a portion of the surplus into an account to pay for county retirees' health insurance. The county adopted the Retiree Medical Plan, funded by those investment earnings and mandatory employee deductions. The Plan explicitly provided that it did not create any vested rights. The labor unions then entered into MOUs, requiring the county to administer the Plan and that retirees receive a Medical Insurance Grant. In 1993-2007, retired employees received a monthly grant benefit to defray the cost of health insurance. In 2004, the county negotiated with its unions to restructure the underfunded program, reducing benefits for retirees.Plaintiffs filed suit. The Ninth Circuit affirmed summary judgment in favor of the county. The 1993 Plan explicitly provided that it did not create any vested right to benefits. The Plan was adopted by resolution and became law with respect to Grant Benefits, part of the MOUs. The MOUs expired on their own terms by a specific date. Absent express language providing that the Grant Benefits vested, the right to the benefits expired when the MOUs expired. The Plan was not unilaterally imposed on the unions and their employees without collective bargaining; the unions executed MOUs adopting the Plan. The court rejected an assertion that the Grant Benefit was deferred compensation and vested upon retirement, similar to pension benefits. View "Harris v. County of Orange" on Justia Law

Petitioner AmGUARD Insurance Group (Carrier), insurer of Pelmac Industries, Inc. (Pelmac), appealed a New Hampshire Compensation Appeals Board (CAB) decision awarding workers’ compensation death benefits to the respondent, the decedent-employee’s estate. The Carrier argued that the decedent’s original June 5, 2018 injury was not a work-related injury, and, in the alternative, that his subsequent death by suicide did not result from the original injury. The Carrier also argued that the CAB violated its due process rights. Finding no reversible error, the New Hampshire Supreme Court affirmed. View "Appeal of Pelmac Industries, Inc." on Justia Law

UnitedHealthcare Medicare Advantage insurers challenged the Overpayment Rule, promulgated by the Centers for Medicare and Medicaid Services (CMS) under 42 U.S.C. 1301-1320d-8, 1395-1395hhh, in an effort to trim costs. The Rule requires that, if an insurer learns that a diagnosis submitted to CMS for payment lacks support in the beneficiary’s medical record, the insurer must refund that payment within 60 days. UnitedHealth claims that the Overpayment Rule is subject to a principle of “actuarial equivalence,” and fails to comply. Two health plans that pay the same percentage of medical expenses are said to have benefits that are actuarially equivalent.The D.C. Circuit rejected the challenge. Actuarial equivalence does not apply to the Overpayment Rule or the statutory overpayment-refund obligation under which it was promulgated. Reference to actuarial equivalence appears in a different statutory subchapter from the requirement to refund overpayments; neither provision cross-references the other. The actuarial-equivalence requirement and the overpayment-refund obligation serve different ends. The actuarial-equivalence provision requires CMS to model a demographically and medically analogous beneficiary population in traditional Medicare to determine the prospective lump-sum payments to Medicare Advantage insurers. The Overpayment Rule, in contrast, applies after the fact to require Medicare Advantage insurers to refund any payment increment they obtained based on a diagnosis they know lacks support in their beneficiaries’ medical records. View "UnitedHealthcare Insurance Co v. Becerra" on Justia Law

Plaintiffs, domestic entities, entered into an insurance contract providing coverage for a Texas townhome complex that they own and operate. The Policy was underwritten by Lloyd’s, members of a foreign organization, and contains a mandatory arbitration provision, providing that the seat of the Arbitration shall be in New York and the Arbitration Tribunal shall apply the law of New York. In 2017, Hurricane Harvey caused an estimated $5,660,000 in damages to the townhome complex. A third-party claims administrator for Lloyd’s concluded that the Policy’s deductible was $3,600,000.Plaintiffs filed a complaint in the Western District of Washington asserting breach of contract, failure to communicate policy changes, and unfair claims handling practices in violation of Washington law, asserting that the deductible should be $600,000. Lloyd’s moved to compel arbitration and stay proceedings, arguing that the Policy’s arbitration provision falls within the scope of the Convention on the Recognition and Enforcement of Foreign Arbitral Awards. Plaintiffs did not contest that the arbitration provision falls within the Convention’s scope but argued the provision is unenforceable because Washington law specifically prohibits the enforcement of arbitration clauses in insurance contracts. Plaintiffs cited the McCarran-Ferguson Act, 15 U.S.C. 1011–15, which provides that state insurance law preempts conflicting federal law. On interlocutory review, the Ninth Circuit upheld an order granting Lloyd’s motion. Article II, Section 3 of the Convention is self-executing, and therefore is not an “Act of Congress” subject to reverse-preemption under the McCarran-Ferguson Act. View "CLMS Management Services Limited Partnership v, Amwins Brokerage of Georgia" on Justia Law

Nationwide Mutual Insurance Company issued two public-official bonds as surety for Eddie Carthan, a member of the Holmes County, Mississippi Board of Supervisors. On appeal, the State Auditor claimed Nationwide was liable under both bonds. The undisputed facts showed the Board never paid the premium for the first bond, which was only for a year. Instead, the Board asked if the first bond could be “converted” to a four-year bond that would cover Carthan’s entire term. Nationwide complied with the Board’s request. It cancelled the first bond and issued a second bond covering Carthan’s entire term for which the Board paid the premium. After review, the Mississippi Supreme Court found no evidence that Carthan was actually secured simultaneously by two separate bonds. Rather, the Court found the undisputed facts showed the Board intended to procure and did in fact obtain one public-official bond in the amount of $100,000 as surety for Carthan. Because Nationwide paid $100,000 under the second, paid-for bond, the chancellor did not err by granting Nationwide summary judgment on all claims based on the first bond. View "White v. Nationwide Mutual Insurance Company" on Justia Law

Allstate Insurance Company et al. (Allstate) filed a complaint on behalf of itself and the People of California (qui tam) against Dr. Sonny Rubin and related medical providers (Rubin). Allstate generally alleged Rubin prepared fraudulent patient medical reports and billing statements in support of insurance claims. Rubin filed an anti-SLAPP motion, arguing the preparation and submission of its medical reports and bills were protected litigation activities. The trial court denied Rubin’s motion. "Litigation is not 'under [serious] consideration' - and thereby protected activity under the anti-SLAPP statute - if the ligation is merely a 'possibility.'" The Court of Appeal found that Rubin failed to show its medical reports and bills were prepared outside of its usual course of business in anticipation of litigation that was “under [serious] consideration.” Thus, the Court affirmed the trial court’s order denying Rubin’s anti-SLAPP motion. View "California ex rel. Allstate Ins. Co. v. Rubin" on Justia Law

In 1989, the Hamel Fire Protection District and Alhambra Fire Protection District formed a joint venture, “the Service” to provide ambulance service to residents of both districts. In 2012, a Service-operated ambulance collided with a semi-truck. The semi-truck drivers and ambulance passengers were seriously injured. The accident produced three lawsuits that eventually settled. Continental paid all attorney’s fees assessed for Hamel Fire’s defenses. Country Mutual had issued a multiperil commercial lines insurance policy to the Service.. Hamel Fire was the named insured on the Continental policy. Continental defended Hamel Fire in each lawsuit after first tendering them to Country Mutual, which ignored each tender. The ambulance was a covered auto under policies issued by both, which provided primary coverage for owned autos and excess coverage for non-owned autos.Continental sued Country Mutual. The district court granted Continental’s motion for summary judgment finding that the Service, and not Hamel Fire, owned the ambulance. Based on that finding, and both policies’ “Other Insurance” clauses, the court determined that Country Mutual owed primary coverage for the costs to defend Hamel Fire in the underlying lawsuits, while Continental only owed excess coverage. The Seventh Circuit affirmed, reasoning that the evidence strongly reflects the parties’ intent that Country Mutual’s insured owned the ambulance. The resulting award of attorney’s fees under Illinois law was reasonable. View "Continental Western Insurance Co. v. Country Mutual Insurance Co." on Justia Law

A Town of Cottageville police officer shot and killed the former town Mayor Bert Reeves. A federal jury awarded Reeves' estate $97,500,000 in damages. The South Carolina Municipal Insurance and Risk Financing Fund, which insured the town, paid $10,000,000 to settle the federal lawsuit and two other lawsuits. The Settlement Agreement provided for two questions to be submitted to the state courts: (1) whether the amount of indemnity coverage available under the policy was more than $1,000,000; and (2) whether the South Carolina Tort Claims Act applied to a bad faith action against the Fund. The South Carolina Supreme Court answered the first question "yes"; it declined to answer the second. View "Reeves v. South Carolina Municipal Insurance" on Justia Law

Keith Bronner sued the City of Detroit seeking no-fault benefits. Bronner was a passenger on a city-operated bus when the bus was involved in an accident with a garbage truck operated by GFL Environmental USA Inc. The city self-insured its buses under the no-fault act, MCL 500.3101 et seq. Under the city’s contract with GFL, GFL agreed to indemnify the city against any liabilities or other expenses incurred by or asserted against the city because of a negligent or tortious act or omission attributable to GFL. The city paid Bronner about $58,000 in benefits before the relationship broke down and Bronner sued the city. Shortly after Bronner sued the city, the city filed a third-party complaint against GFL pursuant to the indemnification agreement in their contract. GFL moved for summary judgment, arguing that the city was attempting to improperly shift its burden under the no-fault act to GFL contrary to public policy. The circuit court denied GFL’s motion and granted summary judgment for the city. GFL appealed as of right, arguing that the indemnification agreement was void because it circumvented the no- fault act. The Court of Appeals agreed with GFL and reversed in an unpublished opinion, citing the comprehensive nature of the no-fault act and concluding that the act outlined the only mechanisms by which a no-fault insurer could recover the cost of benefits paid to beneficiaries. The Michigan Supreme Court reversed, finding that regardless of the differing opportunities for an insurer to reach an indemnification agreement with a vendor, such agreements were enforceable. View "Bronner v. City of Detroit" on Justia Law

When a Colorado court ordered Colorado Health Insurance Cooperative into liquidation, the government owed Colorado Health $24,489,799 for reinsurance debts under the Patient Protection and Affordable Care Act (ACA), 42 U.S.C. 18061. The reinsurance program, which only lasted three years, collected yearly payments from all insurers and made payments to insurers of particularly costly individuals that year. Colorado Health owed the Department of Health and Human Services $42,000,000 for debts under ACA’s risk adjustment program, which charges insurers of individuals who had below-average actuarial risk and pays insurers of individuals who had above-average actuarial risk. The government attempted to leapfrog other insolvency creditors through offset, rather than paying its debt and making a claim against Colorado Health’s estate as an insolvency creditor.The Federal Circuit affirmed the Claims Court in ordering the government to pay. Neither state nor federal law affords the government a right to offset. Colorado law concerning the liquidation of insurance companies is limited to offsetting debts and credits in contractual obligations. ACA does not preempt Colorado insolvency law; a “Netting Regulation” is directed to an ancillary issue, payment convenience. The government has not shown a “significant conflict between an identifiable federal policy or interest and the operation of state law.” View "Conway v. United States" on Justia Law