Dallas Fort Worth Insurance Lawyer Blog

Family Member Exclusions – Where The Family Member Lives

June 1, 2017 | Mark S. Humphreys

Mineral Wells attorneys who handle underinsured motorist claims need to read this Austin Court of Appeals opinion. It is styled, Johnson v. State Farm Automobile Insurance Company.

This suit arises from a suit brought by Jerry Johnson seeking declarations construing the terms of two insurance policies following an automobile accident in which Jerry’s son, Jacob, was injured while Jerry was driving.

In 2008, Jerry and Jacob were traveling in Colorado in a rented car driven by Jerry when Jerry caused an accident which severely injured his 11 year old son. Jacob. Jacob lived with his parents at the time of the accident and remained in the home until May 29, 2015, when he permanently moved out of the residence. Jerry had an auto policy and an umbrella policy with State Farm. The auto policy contains a provision, the “family member exclusion,” that excludes from liability coverage bodily injury to “any family member, except to the extent of the minimum limits of Liability Coverage required” by the Texas Motor Vehicle Safety-Responsibility Act, which was $25,000 at the time. “Family member” is defined as “a person who is a resident of your household and related to you by blood, marriage, or adoption.” The umbrella policy has a similar provision. Jerry sought coverage under both policies. State Farm refused coverage beyond the $25,000.00 minimum.

Life Insurance And Divorce

May 30, 2017 | Mark S. Humphreys

Life Insurance Lawyers in the Dallas and Fort Worth area will see situations on a regular basis where the person who died had a life insurance policy naming the other spouse as the beneficiary – but there was a divorce later and the policy naming the ex-spouse was never changed. What to do? This is discuss in a National Review article titled, Divorces Can Be Messy … For Life Insurers.

Divorces are often characterized as “messy” for good reason. While divorce proceedings can prove particularly challenging for the individual participants, they can also pose challenges for those adjudicating competing life insurance claims when the decedent insured’s ex-spouse, who has been designated as a policy beneficiary, claims a right to the death benefit instead of the surviving spouse, the insured’s estate or a secondary beneficiary.

Divorce-related life insurance disputes can end up before courts in litigation over the decedent insured’s estate, in litigation brought by a purported beneficiary against the insurance company, or in inter-pleader actions filed by the insurer. In an inter-pleader action, the insurance company files a petition with the court seeking an order determining, for instance, which spouse – surviving or ex – is entitled to the decedent insured’s policy proceeds following a divorce.

What If The Insurance Company Says The Claim Will Be Paid – ERISA

May 28, 2017 | Mark S. Humphreys

Insurance lawyers needs to know about this ERISA case. It is from the U.S. District Court, Southern District of Texas, Houston Division, and is styled, Houston Metro And Spine Surgery Center, LLC v. BlueCross BlueShield of Illinois, et al.

Houston Metro alleges BCBS failed to pay for medical services it provided under its patients’ health benefit plans. Hoston Metro sued under a promissory estoppel claim under Texas law, based on the allegation that Houston Metro provided the medical services only after BCBC represented that the patient and procedure were covered by a health benefit plan and that Houston Metro would be paid in accordance with that plan. BCBS moved to dismiss the claim based on it being preempted by ERISA.

Section 1132(a) allows an ERISA plan’s participants and beneficiaries to sue “to recover benefits due to him under the terms of the plan, to enforce his rights under the terms or the plan, or to clarify his right to future benefits under the terms of the plan.” The United States Supreme Court has read 1132 to preempt any state law cause of action that duplicates, supplements, or supplants the ERISA civil enforcement scheme.

Homeowners Policies And Hail Claims

May 27, 2017 | Mark S. Humphreys

Parker county insurance lawyers will see lots of homeowners claims resulting from hail damage claims. When this occurs and the insurance company does not want to pay the claim and a lawsuit is filed, the likely result is the insurance company trying to have the case heard in Federal Court. An Eastern District, Sherman Division opinion deals with this situation. The opinion is styled, Lopez v. Allstate Vehicle and Property Insurance Company.

When a hail storm hit the Lopez home, a claim was filed with Allstate. The adjuster, Gary Harbison was assigned to investigate the claim and he concluded there was no damage and any potential damage had occurred prior to the storm. A lawsuit was filed and Harbison was sued with the allegations against him being that he conducted a substandard and improper investigation, that he was scared of losing his job, and he was fraudulent in his report because the Lopez’s public adjuster had found much more damage. Lopez claims damages totaling $30,646.73.

The lawsuit was filed in Denton County Court alleging breach of contract, violations of the Texas DTPA, and violations of the Texas Insurance Code, fraud, negligence, and gross negligence.

ERISA And Administrative Review

May 25, 2017 | Mark S. Humphreys

ERISA lawyers can tell you how important the administrative record is when fighting adverse determinations in ERISA cases. This is illustrated in a 2017 case from the U.S. District Court, Southern District of Texas, Houston Division. The opinion is styled, Elaine Wilson v. Blue Cross and Blue Shield of Texas.

This case is before the Court on a Motion for Summary Judgment filed by BCBS. The Court ruled in favor of BCBS. BCBS insured Wilson under a group health plan which is organized under the Employee Retirement Income Security Act of 1974, and provides for impatient hospital expenses, medical and surgical expenses, and preventative care. The Plan specifies that coverage does not extend to, in relevant part, the following:

1. Any services or supplies which are not Medically Necessary and essential to the diagnosis or direct care and treatment of a sickness, injury, condition, disease, or bodily malfunction.

Exhausting Administrative Remedies – ERISA

May 23, 2017 | Mark S. Humphreys

Exhausting administrative remedies is the law when it comes to ERISA claims. This is again illustrated in a 2017 opinion from the U.S. 5th Circuit. The opinion is styled, Memorial Hermann Health System v. Southwest LTC, Limited Employee Benefits Plan; Southwest LTC, Limited.

Memorial sued Southwest seeking payment of medical bills incurred by a patient covered by a Southwest health benefits plan. The district court granted summary judgment in favor of Southwest, concluding that Memorial failed to exhaust administrative remedies. This appeal followed.

The patient, C.W., was covered by an ERISA governed plan managed by Southwest. Maritain was the third party administrator. C.W. incurred over $400,000 in medical bills as a patient at Memorial. C.W. assigned her insurance benefits to Memorial, who sought collection from Maritain.

Denial Due To Exclusion In Policy

May 21, 2017 | Mark S. Humphreys

There are several reasons an insurance company will deny coverage under an insurance policy. Probably the most common reason is due to a misrepresentation in the policy application. The second most common reason is based on exclusions or limitations in the policy. This makes reading the policy and comparing that policy language against the facts in the case to see whether or not the coverage denial can withstand scrutiny.

The U.S. District Court Southern District, Galveston Division, issued a good opinion discussing this issue in 2017. The opinion is styled, Robert Garner; dba Kustom Kolors Boatworks, Ex Rel, et al v. Nautilus Insurance Company.

Nautilus issued a CGL policy to Garner and during the policy period, Garner was sued by a customer, Andrew Dykes, who alleged Garner did poor repair on his boat and caused further damage to his boat by the work that Garner performed. He sued Garner under the Texas Deceptive Trade Practices Act.

Life Insurance For Government Employees

May 20, 2017 | Mark S. Humphreys

It’s bad enough when private insurance companies mistreat life insurance beneficiaries but an April 2017, story from the Chicago Tribune shows that the U.S. Government does the same thing. The story is titled, USPS Agrees To $49 Million Settlement For ‘Dawdling” In Paying Life Insurance Beneficiaries.

It’s bad enough for family members when a loved one dies.

Getting cheated by Uncle Sam afterward makes it worse.

Texas Slayer Statute

May 18, 2017 | Mark S. Humphreys

Life insurance lawyers know about Texas Insurance Code, Section 1103.151. Also known as the Texas Slayer Statute, it states:

A beneficiary of a life insurance policy or contract forfeits the beneficiary’s interest in the policy or contract if the beneficiary is a principle or an accomplice in wilfully bringing about the death of the insured.

Section 1103.152, goes on to say the proceeds of the policy go to the contingent beneficiary if there is one or goes goes to the estate if there is not.

Remember – There Is An Obligation To Cooperate With Your Own Insurance Company When Making A Claim

May 16, 2017 | Mark S. Humphreys

Experienced insurance law lawyers in Hamilton, Texas, know the above is true. This obligation is illustrated in a 2017, hail damage claim opinion out of the Southern District, Houston Division. The opinion is styled, Metro Hospitality Partners, Ltd., d/b/a Crowne Plaza Hotel v. Lexington Insurance Company.

When a business sues its property insurer and the type of damage is clearly covered, the usual pattern is that the insurance company has failed to pay anything, has failed to pay anything close to what the insured claimed, or has taken too long to pay. This case is different. Here, the property insurer promptly adjusted the claim the insured presented and paid a large sum within the month after the hailstorm that damaged the insured’s hotel. The insurer identified and paid what it concluded were the remaining amounts owed about two months after that. The insured claimed that more money was owed. The insurer asked for documents and information substantiating the demand for additional payment. The insured refused. The policy required the insured to “cooperate” with the insurer. What we have here, says the insurer, is a failure to cooperate. What we have here, says the insured, is a breach of the insurance contract and of the duty of good faith and fair dealing.

After a hail storm, the insured, Metro, promptly notified its Lexington. Lexington quickly responded, inspected, and identified the amount of covered damage and the amount it owed. The parties disputed whether the hailstorm damage justified an insurer-paid new roof, or whether normal wear and tear made a new roof Metro’s responsibility.