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Tag Archives: Insurance

Insurance – Long-Term Disability – ERISA – ‘Full & Fair Review’ – Denial Letter – Reference to Different Claimant (access required)

Cole v. Aetna Life Insurance Co. Where the defendant-insurer’s letter denying plaintiff’s claim for long-term disability benefits consisted of one-third boilerplate, one-third references to a different claimant, and one-third direct quote from the consulting physician, it does not appear that plaintiff received the full and fair review required by ERISA. The court grants plaintiff’s motion to remand for reconsideration with supplemental evidence.

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Law gives plaintiffs right to know details of defendant’s insurance coverage   (access required)

A provision tucked inside the S.C. Fairness in Civil Justice Act of 2011 quietly became law earlier this month, and is expected to reduce the number of personal injury lawsuits filed in the state’s courts. The law took effect Jan. 1 as part of the tort reform bill and requires auto insurers that may be liable for any part of a claim to disclose coverage limits to plaintiffs prior to the filing of a lawsuit. Plaintiffs seeking the information must first file a certified written request that includes the accident report tied to their claims. Insurers have 30 days to reply. Defense litigator Jack D. Griffeth (pictured) of Collins & Lacy in Greenville said the disclosure law is not particularly bad news for the insurers he often represents, as long as they stay in compliance with the new criteria.

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Labor & Employment – Insurance – Long-Term Disability – Benefit Amount — Physician (access required)

Fortier v. Principal Life. Ins. Co. A physician who closed his practice when he became medically disabled cannot collect the maximum monthly disability payment he says he is owed under the practice’s long term disability policy, as the plan administrator was entitled to interpret plan language to allow deduction of the physician’s medical-practice start-up costs from his income to determine that the monthly disability payment could not exceed the physician’s monthly predisability earnings...

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Insurance – Auto – UIM – Attorney’s Fees & Costs – Civil Practice – Discovery Violation (access required)

National Union Fire Insurance Co. of Pittsburgh v. Bettencourt The S.C. underinsured motorist statute reflects the General Assembly’s intent to limit the remuneration available from UIM coverage to actual damages stemming from bodily injury or punitive damages arising out of the accident causing that bodily injury. Neither S.C. Code Ann. § 38-77-160 nor S.C. case law supports the proposition that attorney’s fees and costs arising from an at-fault driver’s insurer’s failure to make an admission of fact under Rules 36 and 37(c), SCRCP, are compensable under the UIM statute.

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Civil Practice – Standing – Tort/Negligence – Wrongful Death – Insurance – Declaratory Judgment Action (access required)

QBE Insurance Corp. v. Sellers In the underlying state-court wrongful death action, defendant Sellers is suing plaintiff’s insured. In this action, plaintiff seeks a declaratory judgment that its general commercial liability policy does not require plaintiff to defend or indemnify its insured in the wrongful death action. Even though, under S.C. law, Sellers might not have standing to assert a counterclaim alleging that an additional policy applies, under federal law, Sellers has standing to assert such a counterclaim.

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Insurance – Homeowners – Replacement Cost Provision – Breach of Contract Claim – Appraisal Process – Waiver (access required)

Coker v. Fireman’s Fund Insurance Co. The homeowners’ insurance policy at issue says that the insured must “agree to ... repair or rebuild the Dwelling or Other Structure with equivalent construction” in order for the policy’s full-cost replacement coverage provision to apply. There is no express language limiting payment until after reconstruction is complete. The defendant-insurer is not entitled to summary judgment based on the fact that plaintiffs have not yet incurred the replacement costs. The insurer’s motion for summary judgment or, in the alternative, to compel appraisal is denied.

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Workers’ Compensation – Insurance – Coverage Lapse – Premium Adjustment (access required)

Burris v. Propst Lumber & Logging, Inc. The respondent-carrier had the authority to make an interim adjustment to the defendant-employer’s workers’ compensation insurance premium and to cancel the policy when the employer failed to pay on time and in full. We affirm the Appellate Panel’s ruling that the policy did not provide coverage on the date the claimant sustained injuries while working for the employer.

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Insurance – Title – Real Property – Damages – Diminution in Value – Date – Question Certified (access required)

Whitlock v. Stewart Title Guaranty Co. In 2006, defendant insured the title of plaintiff’s Myrtle Beach property, and a title defect was discovered in January 2010, preventing plaintiff from building on property. The title insurance policy does not define “actual loss,” plaintiff asserts the proper valuation date is the date the policy was issued, and defendant asserts the proper valuation date is the date the title defect was discovered, by which time plaintiff’s property had depreciated.

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Insurance – Health – Administrative Appeals – Tolling (access required)

Stafford v. Wal-Mart Stores, Inc. Associates’ Health & Welfare Plan After denying plaintiff’s first appeal, the defendant-insurer notified plaintiff that, if he requested a voluntary, second level of appeal, the 180-day time limit for instituting a civil lawsuit would be tolled during the time between his request for a second-level appeal and defendant’s ruling on that appeal. Although plaintiff and his lawyer both believed a second-level appeal removed the 180-day time limit and made a three-year statute of limitations applicable, innocent mistakes are not a ground for the equitable tolling of filing deadlines.

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Insurance – Professional Liability – Accountants – Attorneys — Prior Knowledge – Innocent Insured (access required)

Continental Casualty Co. v. Jones Although the accountant who filled out the application for professional malpractice insurance didn’t know about her partner’s misappropriation of his clients’ funds, her partner’s knowledge of potential claims at the time of the application bars coverage of the misappropriation claims. Summary judgment for the insurer.

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