Justia U.S. 9th Circuit Court of Appeals Opinion Summaries

Plaintiffs, who have hearing loss severe enough to qualify them as disabled, filed suit claiming that Kaiser's health insurance plan's categorical exclusion of most hearing loss treatment discriminates against hearing disabled people in violation of Section 1557 of the Patient Protection and Affordable Care Act (ACA). The district court ruled that Kaiser's plans do not exclude benefits based on disability because the plans treat individuals with hearing loss alike, regardless of whether their hearing loss is disabling.The Ninth Circuit agreed with the district court that plaintiffs have failed to state a plausible discrimination claim. The panel explained that the ACA specifically prohibits discrimination in plan benefit design, and a categorical exclusion of treatment for hearing loss would raise an inference of discrimination against hearing disabled people notwithstanding that it would also adversely affect individuals with non-disabling hearing loss. However, the exclusion in this case is not categorical. The panel stated that, while Kaiser's coverage of cochlear implants is inadequate to serve plaintiffs' health needs, it may adequately serve the needs of hearing disabled people as a group. Therefore, the panel affirmed the district court's dismissal of the second amended complaint. The panel reversed the district court's dismissal without leave to amend and remanded. View "Schmitt v. Kaiser Foundation Health Plan of Washington" on Justia Law

The Ninth Circuit certified to the Nevada Supreme Court the following questions: Whether, under Nevada law, the burden of proving the applicability of an exception to an exclusion of coverage in an insurance policy falls on the insurer or the insured? Whichever party bears such a burden, may it rely on evidence extrinsic to the complaint to carry its burden, and if so, is it limited to extrinsic evidence available at the time the insured tendered the defense of the lawsuit to the insurer? View "Zurich American Insurance Co. v. Ironshore Specialty Insurance Co." on Justia Law

After plaintiffs were awarded more than $45 million in a products liability suit brought against EcoSmart, EcoSmart declared bankruptcy and plaintiffs brought a direct action against EcoSmart's insurer, LMIC, for payment on the judgment. LMIC argued that its policy with EcoSmart had a forum-selection clause designating Australian courts as the exclusive forum. The district court granted LMIC's motion to dismiss on grounds of forum non conveniens.The Ninth Circuit held that, because plaintiffs stand in the shoes of EcoSmart, their third-party creditors' rights are derivative of the rights and limitations held by the bankrupt insured, and thus the forum-selection clause applies. The panel also held that plaintiffs have not shown that the clause violates California public policy or that Australia is an inadequate forum for suit. Accordingly, the panel affirmed the district court's judgment. View "Lewis v. Liberty Mutual Insurance Co." on Justia Law

The Ninth Circuit reversed the district court's judgment in favor of Medicare in an action brought by CIGA, seeking declaratory relief after Medicare paid for and demanded reimbursement from CIGA for medical expenses of certain individuals whose workers' compensation benefits CIGA was administering.The panel held that Medicare, as a secondary payer, was entitled to seek reimbursement from a beneficiary's primary payer, typically private insurance. However, CIGA was not a primary plan, and specifically was not a workmen's compensation law or plan. Rather, the panel held that CIGA was an insolvency insurer of last resort. The panel explained that insurance regulation was a field traditionally occupied by the states, and it must presume that the Medicare secondary payer provisions do not preempt state insurance laws unless Congress clearly manifested its intent to do so. Furthermore, nothing in the Medicare statute or its implementing regulations suggested that Congress meant to interfere with state schemes to protect against insurer insolvencies. View "California Insurance Guarantee Assoc. v. Azar" on Justia Law

The Ninth Circuit certified the following question of state law to the Supreme Court of Arizona: What is the standard for determining whether National Union unreasonably withheld consent to Apollo's settlement with shareholders in breach of contract under a policy where the insurer has no duty to defend? View "Apollo Education Group, Inc. v. National Union Fire Insurance Co." on Justia Law

The Ninth Circuit certified the following question of state law to the Supreme Court of Hawai'i: Under Hawai'i law, is a permissive user of an insured vehicle, whose connection to the insured vehicle is permission to use the vehicle to run errands and drive to work, entitled to uninsured motorist (UM) benefits under the chain-of-events test because he was injured by an uninsured motorist? View "State Farm Mutual Automobile Insurance, Co. v. Mizuno" on Justia Law

After Hamas fired rockets from Gaza into Israel, Universal moved the production of their televisions series out of Jerusalem at significant expense. Universal filed an insurance claim for coverage of those costs under a television production insurance policy and the insurer, Atlantic, denied coverage based on the policy's war exclusions.The Ninth Circuit reversed the district court's grant of summary judgment for Atlantic in part and held that Atlantic breached its contract when it denied coverage by defining Hamas' conduct as "war" or "warlike action by a military force." Because the district court did not address the third war exclusion regarding whether Hamas' actions constituted "insurrection, rebellion, or revolution," the panel remanded for the district court to address that question in the first instance. Consequently, the panel vacated the district court's grant of summary judgment on Universal's bad faith claim because it turned on the district court's erroneous analysis of the first two war exclusions. The panel remanded for further proceedings. View "Universal Cable Productions, LLC v. Atlantic Specialty Insurance Co." on Justia Law

The Ninth Circuit certified the following question of state insurance law to the Nevada Supreme Court: Is an insurer entitled to reimbursement of costs already expended in defense of its insureds where a determination has been made that the insurer owed no duty to defend and the insurer expressly reserved its right to seek reimbursement in writing after defense has been tendered but where the insurance policy contains no reservation of rights? View "Nautilus Insurance Co. v. Access Medical, LLC" on Justia Law

Plaintiffs, operators of a gas purification plant, filed suit against its insurer, Ace, after the insurer denied coverage for damage caused by broken metal brackets that secured crucial components. The Ninth Circuit affirmed the district court's application of Washington law and its discovery sanctions against plaintiffs.However, the panel reversed the district court's grant of summary judgment in favor of the insurer and held that there was a triable issue of fact as to whether the insurer was prejudiced by plaintiffs' remedial actions, whether plaintiffs' loss was fortuitous, whether the policy's Boiler and Machinery endorsement applied to independently confer coverage for plaintiffs' losses, whether the Endorsement's "accident" coverage applied, and whether a 16 month shutdown was consistent with the exercise of due diligence and dispatch. View "Ingenco Holdings, LLC v. ACE American Insurance Co." on Justia Law

The Ninth Circuit affirmed the district court's dismissal of plaintiffs' claim that their insurer, Blue Shield, violated the Medical Loss Ratio (MLR) provision of the Patient Protection and Affordable Care Act (ACA). The MLR is the ratio between what an insurer pays out in claims for medical services and the revenue it takes in.The panel held that there was no basis in the language, history, intent or spirit of the ACA to narrow the MLR by excluding payments for services rendered by out-of-network physicians. In this case, the MLR was properly calculated under federal law by including the settlement reimbursements for medical services by nonnetwork providers. Therefore, the district court correctly recognized the services were covered by the plan and the payments were made. View "Morris v. California Physicians' Service" on Justia Law