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Ninth Circuit Partially Revise Class Action Claims Against State Farm

by | Aug 22, 2024 | Events, Featured, Insurance Law, Misc., News & Updates, Professional Liability & Significant Injury Claims

On Monday, August 19, 2024, the Ninth Circuit Court of Appeals issued a published opinion in Jama, et al. v. State Farm Mutual Auto. Ins. Co., et al, No. 22-35499, 2024 U.S. App. LEXIS 20881, __ F.4th___ (9th Cir. 2024) reversing in part a Western District of Washington summary judgment ruling decertifying class action claims against two State Farm entities.

At the trial court level, the insureds asserted class action claims against State Farm based on how State Farm compensated vehicle owners for actual cash value (ACV) after accidents that involved the total loss of the insured vehicle. The insureds initially sought class certification for two classes: 1) the negotiation class; and 2) the condition class.

To determine ACV, State Farm would use an Autosource report from a third-party vendor which reported information regarding advertised price of comparable vehicles and then would make adjustments including adjustments for the condition of a vehicle and adjustments for “negotiation.”  The condition adjustment was based on the assumption that vehicles were in different conditions than those on the market and would adjust the value of the car accordingly. The negotiation adjustment was based on an assumption that a customer would negotiate with a dealer and buy a car for less than advertised price.

The District Court decertified the classes and dismissed claims against State Farm on summary judgment based on the court’s reading of Lara v. First National Ins. Co. of Amer., 25 F.4th 1134 (9th Cir. 2022) finding that just because the insureds could establish an illegal adjustment was not sufficient to establish injury on a class-wide basis “by relying class members’ car value as calculated in the Autosource reports less the amount of the challenged negotiation or condition adjustments.” 

The Ninth Circuit affirmed with respect to the condition class because it was undisputed that an insurer could take condition into account and adjust ACV accordingly and because any injury would be individualized based upon the condition of each individual’s vehicle.  However, it reversed with respect to the negotiation class.

With respect to the negotiation class, the insureds argued that Washington law did not allow an insurer to reduce ACV payments by a “typical negotiation discount”. The Court of Appeals agreed with the trial court’s  finding that applicable Administrative Code (WAC) provision (WAC 284-30-391) did not allow for such discounts and only provided for discounts specifically set forth in the WAC. See WAC 284-30-391(4)(b).  Accordingly, any reduction in ACV payment for a negotiation discount was unlawful.

The insureds asserted that class certification for the negotiation class was appropriate because it could be determined on a class wide scale for those who were paid according to the Autosource report and had their payment reduced by a uniformly applied negotiation discount. State Farm argued that measuring injury that way would effectively allow the class to establish injury just based upon the illegality of the act, which was prohibited by the Lara decision.

The trial court effectively agreed with this argument when it decertified the class and entered summary judgment for State Farm. The Ninth Circuit, however, reversed. In doing so, it clarified that its holding in Lara was distinguishable because in Lara the proposed class was broader than the proposed class in Jama.  In Lara, the proposed class included those who received a report containing an unlawful adjustment but nevertheless received ACV for other reasons. The class Jama was not as broad.

Instead, the proposed negotiation class was limited only to:

…those class members who (1) were paid based on the Autosource report, excluding those who negotiated or pursued an appraisal; and (2) were paid a negotiation adjustment that, according to the Plaintiffs, can never measure a lawful deduction.

The Ninth Circuit concluded that narrowing the class avoided the issues raised in Lara. It further summarized that the Plaintiff’s arguments were that the ACV was originally calculated based on permissible factors, but then reduced by a factor that was not allowed under Washington law. The Court went on to state that “[n]othing in Lara precludes common proof of injury as the amount of State Farm’s estimates less the impermissible deduction as to the class of owners who were paid the Autosource valuation.” Accordingly, the Court reversed the trial court’s decertification and dismissal. This included reversing summary judgment against the individual class representatives and remanding the case for consideration in light of the Court’s holding. 

Lether Law Group has represented and advised auto insurers on all aspects of coverage including valuation disputes for over 30 years. If you would like to discuss the implications of the Jama decision or coverage issues involving these types of claims, please feel free to contact our offices.

Understanding the Impact of OFAC Advisory Notices on Insurance Policies

by | Jun 26, 2024 | Decisions, Events, Featured, Insurance Law, Misc., News & Updates, Professional Liability & Significant Injury Claims

One of the most unusual notices that exists in many policies is the OFAC Advisory Notice. This notice, which can function to freeze or block an insurance contract, is rarely considered by claims professionals or insureds. So, what is OFAC?

OFAC stands for the Office of Foreign Assets Control, which is a financial intelligence and enforcement agency operating under the U.S. Treasury Department. The Division of Foreign Assets Control (DFAC), the precursor to OFAC, was created in the 1950s, when China entered the Korean War. DFAC blocked Chinese and North Korean assets that were subject to US jurisdiction. Thereafter, following a 1962 Treasury Department Order, DFAC officially became OFAC. Yet, despite OFACs presence as a governmental entity for over 70 years, little is known about it. Even less is known about OFAC’s relationship to the insurance industry.

In 2018, OFAC mandated an advisory notice restricting claims activities and payments when any person or entity benefiting from the subject insurance policy has violated US sanctions law or is a Specially Designated National and Blocked Person under OFAC. Included in the Specially Designated National and Blocked Persons list are various foreign agents, front organizations, terrorists, terrorist organizations, and narcotics traffickers.

In essence, the advisory mandates that insurers are restricted from issuing payments on claims where a designated entity is involved. Per the terms of the advisory this could include entities that are subject to foreign trade embargoes or sanctions.

Based upon our research, the OFAC advisory has been construed only a few times in the insurance industry. However, there has been increased discussions regarding this notice due to heightened worldwide tensions and international sanctions placed on certain countries, such as Russia, as a result of military activity. Further, the advisory notice would apply to any business or entity that is in violation of human rights, is subject to trade embargoes or sanctions, or is engaged in narcotics trafficking.

Although the advisory notice provides that the insured’s policy can be frozen or blocked if they are found to be in violation of OFAC regulations, neither OFAC nor case law provides clear direction as to what those exact ramifications are. This issue, however, should be considered in regard to any claim where such a designated entity may be involved, either as an insured or as the beneficiary of insurance payment.

Insurers who issue cyber coverage likely face the largest impact from the OFAC advisory notice. In fact, in 2020 the OFAC issued an Advisory on Potential Sanctions Risks for Facilitating Ransomware Payments and issued an updated Advisory regarding same on September 21, 2021. That advisory, a copy of which is also linked to this newsletter, provides that facilitating ransomware payments demanded as a result of malicious cyber attacks may violate the OFAC advisory with respect to payments to those who have violated U.S. sanctions law or are Specially Dedicated national and Blocked Persons. The 2021 Advisory further provides as follows:

OFAC may impose civil penalties for sanctions violations based on strict liability, meaning that a person subject to U.S. jurisdiction may be held civilly liable even if such person did not know or have reason to know that it was engaging in a transaction that was prohibited under sanctions laws and regulations administered by OFAC.

In other words, an insurer who issues cyber coverage runs the very real risk of running afoul of OFAC regulations by issuing payment for any cyber ransom attack without first getting permission from the OFAC. As a result of these risks, insurers offering this type of coverage would benefit significantly by putting into place policies and protocols to ensure compliance with OFAC regulations and to ensure that proper reporting and communication with OFAC take place prior to issuing payment for any cyber ransom attack.

The attorneys at Lether Law Group have been providing insurers with coverage advice and recommendations for more than 30 years. Our experience includes addressing cyber claims and coverage issues under cyber policies.  If you’d like to discuss this particular coverage issue or other insurance related issues arising in the ever-changing world of insurance, please feel free to contact our office.

Washington State Supreme Court Clarifies Law on “Reasonable Investigation” and Determination of “Reasonable” Charges for Personal Injury Protection Claims

by | Feb 16, 2024 | Decisions, Events, Featured, Insurance Law, Misc., News & Updates, Professional Liability & Significant Injury Claims

On February 15, 2024, the Washington State Supreme Court issued its decision in Schiff v. Liberty Mutual Fire Insurance Company, et al., Case No. 101576-3, which examined “… what an insurer must do to meet the ‘reasonable investigation’ requirement and the requirement to pay ‘all reasonable and necessary’ medical expenses” under Washington’s Personal Injury Protection (“PIP”) statutes and Washington law.

The decision arose out of a suit filed by Dr. Stann Schiff alleging that the insurers’ practice of reducing provider bills based on computer-generated calculations violated Washington law.  It was undisputed that Liberty Mutual Fire Insurance Company and Liberty Mutual Insurance Company (collectively “Liberty”), used a third-party database called FAIR Health to determine reasonableness of a medical provides charges when Liberty received medical bills from an insured under either a PIP or a MedPay (supplemental medical payment coverage) claim. [1]

The trial court denied both parties’ attempts at summary judgment and the Court of Appeals accepted discretionary review. The Court of Appeal, relying on its prior holding in Folweiler Chiropractic, P.S. v. American Family Insurance Co, 5 Wn. App. 2d 829, 429 P.3d 813 (2018) reversed the trial court’s denial of Dr. Schiff’s motion. The Court of Appeals reasoned, based on the Folweiler decision, that: 1) it was an unfair practice under the Washington Consumer Protection Act (“CPA”) to not conduct an individualized assessment of a medical bill; and that 2) RCW 48.22.095(1)(a) and RCW 4.22.005(7) required an individualized assessment.

The database provided information for an insurer to compare charges for specific medical treatments in a geographical area and to determine the percentiles of those charges.  Liberty apparently had an established practice of paying 100% of a medical provider’s bill if it was below the 80th percentile for the procedure/treatment in the geographical area. However, if the bill exceeded the 80th percentile, Liberty would reduce the charges to the 80th percentile charge and pay that amount. It was undisputed that Liberty did not conduct individualized investigations with respect to the bills at issue, but instead relied upon 80th percentile information from the database.

The trial court denied both parties’ attempts at summary judgment and the Court of Appeals accepted discretionary review. The Court of Appeal, relying on its prior holding in Folweiler Chiropractic, P.S. v. American Family Insurance Co, 5 Wn. App. 2d 829, 429 P.3d 813 (2018) reversed the trial court’s denial of Dr. Schiff’s motion. The Court of Appeals reasoned, based on the Folweiler decision, that: 1) it was an unfair practice under the Washington Consumer Protection Act (“CPA”) to not conduct an individualized assessment of a medical bill; and that 2) RCW 48.22.095(1)(a) and RCW 4.22.005(7) required an individualized assessment.

The Supreme Court rejected the Court of Appeals’ analysis and overturned the Court of Appeals. In doing so, the Supreme Court effectively also overturned the Folweiler decision’s individualized assessment requirement. In discussing the Folweiler decision, the Supreme Court stated and held as follows:

Though the Court of Appeals cited to the relevant statutes and regulations, it failed to explain how they mandate an inquiry into the qualifications of the medical provider and did not cite any case to bolster its interpretation. The PIP statutes and the insurance code do not have any express requirement that the insurers look specifically at the qualifications of a medical provider to determine the reasonableness of the charge.

Schiff Opinion at 12 (emphasis added).

Instead, the Supreme Court held that the insurance code: 1) places the responsibility on an insurer to determine whether to deny, limit, or terminate medical benefits if the insurer determines the claim is not reasonable or necessary; 2) that the code tasks insurers to conduct their own reasonable investigation; 2) that the code requires insurers to create their own reasonable standards for promptly investigating a claim.

After reviewing the Washington Administrative Code (“WAC”) and the properties of the FAIR Health database, the Supreme Court held that “Comparing charges for the same treatment in the same geographic area is relevant to the determination of reasonableness.” Schiff Opinion at 14.

As a result of this conclusion, and in light of out-of-state authority addressing the same issues, the Supreme Court ultimately held in favor of Liberty as follows:

We hold that the 80th percentile practice and the use of the FAIR Health database is not unfair or unreasonable and does not violate the CPA or the PIP requirements to establish standards under which reasonable charges for medical procedures are determined.

Schiff Opinion at 16.

The Schiff decision effectively overturns the Folweiler decision and provides insurers with further clarity on their investigatory obligations and reasonableness determinations in PIP matters.  Insurers remain responsible for determining whether to deny, limit or terminate medical benefits where the insurer determines treatment was not reasonable or necessary. Insurers are also still required to conduct a reasonable investigation and develop reasonable standards to promptly investigate claims.

As the Schiff decision makes clear, insurers can safely continue to rely on databases such as the FAIR Health database to determine whether a provider’s charges are reasonable and are not required to individually investigate and vet each provider when making that determination as part of that process.

The attorneys at Lether Law Group have in excess of thirty-one years’ experience in defending and advising insurers on the handling of PIP claims. This experience includes handling claims and litigating insurance disputes in the state of Washington. Please do not hesitate to contact our office if you have any questions regarding the Schiff decision or any other insurance matter.

[1] The FAIR Health database was identified as an “independent, nonprofit, medical claim database.”

Oregon Supreme Court Unilaterally Creates “Negligence” Cause of Action Against Insurers

by | Jan 5, 2024 | Decisions, Dispute Resolution, Events, Featured, Insurance Law, Misc., News & Updates, Professional Liability & Significant Injury Claims

On December 29, 2023, the Oregon Supreme Court effectively created new bad faith liability exposure for insurers doing business in Oregon when it issued its opinion in Moody v. Or. Cmty. Credit Union, 371 Ore. 772, 2023 Ore. LEXIS 692 (2023). In Moody, an insured sued a life insurance company for breach of contract and negligence based on a denial of a claim for life insurance proceeds.

The Plaintiff’s husband was the named insured under a life insurance policy and was accidently shot and killed. At the time of his death, the decedent had marijuana in his system. The Plaintiff filed a claim, and the defendant insurer initially denied the claim because the decedent’s death purportedly fell within an exclusion for deaths caused by or resulting from being under the influence of a narcotic or other drug.

The Plaintiff brought suit alleging that the death was not caused by or resulting from the use of any drug. She alleged claims for breach of contract, breach of the implied covenant of good faith and fair dealing, and negligence. Plaintiff sought both economic and non-economic damages including emotional distress damages. The extra-contractual claims were dismissed by the trial court and proceeded to an appeal. The Court of Appeals reversed the trial court’s dismissal of the negligence claim and the Supreme Court accepted direct review.

On review, the Supreme Court framed the primary question as whether the Plaintiff could pursue a negligence per se claim. The Court clarified that, in Oregon, a negligence per se claim is shorthand for a negligence claim that otherwise exists where the standard of care is set forth in a statute or rule and violation of the statute or rules raises a presumption of negligence.

Under that framework, the Court first examined whether the Plaintiff had a legally protected interest sufficient to subject the Defendant to liability for emotional distress damages. In determining that she did, the Court examined ORS 746.230 (Oregon’s Unfair Claim Settlement Practices statute). While acknowledging that the statute did not create an independent cause of action, the Supreme Court nevertheless found as follows:

We find that the statue provides explicit notice to insurers of the conduct that is required and, in requiring insurers to conduct reasonable investigations and to settle claims when liability becomes reasonably clear, does so in terms that are consistent with the standard of care applicable in common claw negligence cases.

Moody, 2023 Ore. LEXIS 692 at *41.

The Court went on to hold that permitting a common law negligence claim could further the statute’s purpose by deterring insurers from engaging in prohibited conduct. The Court went on to find that allowing emotional distress damages would not place an undue burden on the Defendant because insurers are in a relationship of mutual expectations with insureds and that the insurer could reasonably foresee that failing to exercise reasonable care in the handling of the relationship could result in emotional harm. Finally, the Court held that the claimed harm was of sufficient importance under public policy to justify allowing the claim to proceed. The Court’s ultimate conclusion was stated as follows:

Considering all of those factors, and not relying on any one of them alone, we conclude that the insurance claim practices that ORS 476.230 requires and the emotional harm that may foreseeably occur if that statute is violated are sufficiently weighty to merit imposition of common-law negligence and recovery of emotional distress damages.

Moody, 2023 Ore. LEXIS 692 at *51.

While the Court cautioned that its conclusion would not make every contracting party liable for negligence that causes emotional harm, the holding is extremely concerning and problematic for insurers. In fact, the holding may effectively overturn long-standing Oregon case law holding that insurers are not liable in tort for the handling of an insurance claim. See, e.g., Farris v. U.S. Fid. and Guar. Co., 284 Ore. 453, 587 P.2d 1015 (1978) (Farris II). This issue was recognized in the Moody dissent as follows:

The majority’s analysis creates uncertainty about the remaining precedential effect of Farris II. If the majority means to distinguish Farris II on its facts, then courts may still rely on Farris II as rejecting tort liability for third-party insurers that have denied coverage in bad faith, which were the facts presented in that case. On the Other hand, if the majority is distinguishing Farris II based on the pleadings or based on the legal theory that the plaintiffs asserted in that case, then Farris II might have no precedential effect in any case styled as a negligence claim.

Moody, 2023 Ore. LEXIS 692 at *78 n.7.

The full nature and impact of the Moody decision will likely remain unknown until the Oregon Supreme Court has had the opportunity to further clarify or refine its holding in subsequent cases. As it stands, insurers in Oregon now potentially face liability for general damages (and potentially other alleged consequential damages) in tort as long as those claims are styled as negligence claims. Effectively, the Oregon Supreme Court has created bad faith liability for insurers based on a negligence standard of proof. This reflects a substantial increase in exposure for insurers doing business in Oregon especially when one considers that the majority of jurisdictions require a higher burden of proof for bad faith claims (i.e. unreasonable, frivolous, or unfounded denial of benefits).

The attorneys at Lether Law Group have in excess of thirty-one years’ experience in advising insurers on the handling of extra-contractual claims. This experience includes handling claims and litigating insurance disputes in the state of Oregon. We have several attorneys licensed in Oregon and actively litigating coverage and extra-contractual claims in that jurisdiction. Please do not hesitate to contact our office if you have any questions regarding the Moody decision or any other insurance matter.

 

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Lether Law Group Hosts the 2023 IAPL Annual General Meeting in Washington D.C.

by | Nov 15, 2023 | Events, Featured, Misc., News & Updates

The International Association of Practicing Lawyers (IAPL) is a select group of attorneys representing countries throughout the world.

For several years, Tom Lether has been the representative of the United States at the semiannual meetings. The IAPL presents an excellent networking opportunity for lawyers from multiple countries. More importantly, it provides an opportunity for lawyers with different cultural, religious, and geographic backgrounds to come together and discover that they all have common interests and goals. The ability to learn about legal systems around the world and exchange information in a collegial fashion with other lawyers provides incredible insight into international law.

In addition, the IAPL has become a true family of lawyers. Bonding over dinner, discussing history, politics, and legal systems in various parts of the world is an incredible experience.

This year’s 2023 IAPL annual general meeting was hosted by Lether Law Group in Washington, DC. It is the first time the IAPL has held their annual meeting in the United States for a number of years.

Washington, D.C. was a perfect setting for the IAPL. Members had an opportunity to bond over long walks to and from Georgetown, enjoy fantastic meals, experience an excellent guided tour throughout the major sites of Washington, D.C., and take a trip to the inner sanctum of the United States Supreme Court. Along the way, there were day visits to places like Alexandria and Arlington National Cemetery.

This year’s keynote speaker, Tom Lether, presented a seminar on the American legal and governmental systems, with a specific focus on the history of the debate between states’ rights advocates and those in favor of a centralized Federal Government. This presentation also discussed the never-ending dispute over how to interpret the Constitution.

This speech was presented in the context of American history and the American Civil War. Along the way, members were introduced to how these legal concepts have recently impacted the Supreme Court’s decisions in cases like the Dobbs v. Jackson decision that was cited in our newsletter.

Tom’s presentation sparked a lengthy discussion among the members about American politics and history, which underscored the importance of the IAPL organization. A link to a written version of Tom’s speech is below:

"The Gathering Storm"

For anyone interested in the IAPL, we also invite them to follow the link below to learn more about this truly fantastic organization:

IAPL Webpage

Business Interruption Claims Resulting from Wildfire Losses: What You Need to Know

by | Sep 8, 2023 | Featured, Natural Disaster Claims, News & Updates

As a result of the recent Lahaina wildfires occurring in Maui, Hawaiʻi, the question of what is covered under commercial property policies for business interruption claims has resurfaced.

Under most commercial policies, business interruption coverage is available to an insured whose business is closed as a result of a covered loss. Unfortunately, most policies require there to be direct physical loss or damage resulting in the closure of the business. For example, a fire destroying all or part of the business making it impossible for the business owner to operate.

During the Covid pandemic, hundreds of thousands of businesses around the world were closed due to governmental orders requiring businesses to shut down. As a result, billions of dollars arose from thousands of claims for business interruption coverage associated with these shutdowns.

Obviously, in the Covid context, businesses were shut down not necessarily as a result of direct physical damage, but rather by governmental order. As a result, coverage litigation ensued not only in the United States, but on a global basis in regard to these claims. Specifically, these Covid based lawsuits involved whether business interruption claims are viable as a result of a Covid governmental shutdown order. The vast majority of decisions worldwide found that there was no coverage for such shutdowns. Many insurance policies included business interruption coverage for closures resulting from governmental orders. Once again, however, most decisions from around the United States found that the governmental order had to be based upon a direct physical loss or damage to an adjoining property. Unfortunately, this resulted in there being no coverage. In addition, the final issue involved coverage for a partial suspension opposed to full suspension of the business. Specifically, certain commercial business policies provide coverage for a partial suspension. In other words, if the business is only partially suspended, there may be coverage available.

In regard to the Lahaina wildfires, a significant number of commercial buildings have been damaged or destroyed. In these situations, a business owner should have coverage for their business losses. Specifically, there is likely direct physical damage to the building. If the shutdown of the business is unrelated to a governmental order, the insurers will determine the amount of business interruption coverage owed based upon the income earned by the business and continuing expenses. Such claims are typically ascertainable through a review of a business’s financial records.

A more complicated issue involves how much time an insured may have to recover for business interruption. This is called the period of restoration. In other words, how long should it take for the business to be restored? In some policies, the period of restoration is defined as the shortest time necessary for a business owner to repair or relocate the business. However, there may also be a limitation as to the amount of time a business owner can collect on a business owner merchant claim. This is oftentimes limited to one or two years. In light of the very real possibility that restoration regarding the Lahaina wildfires will take more than two years, there is a significant potential for a number of business owners to find themselves in a situation where they will not have adequate business interruption coverage.

Even if the building has not been destroyed, an insured can still submit a claim for business interruption. For example, there are a number of businesses that have minor damage or that foreclosed as a result of governmental orders restricting access to the burn zone. To the extent there is any minor damage, there is still potential for coverage. By way of example, if there is smoke damage or exposure to hazardous materials, that type of damage may be sufficient to qualify as a direct physical loss or damage.

Moreover, if there is no damage whatsoever, the question will be whether the policy provides coverage for governmental shut down. Typically, in these instances the policy will say the insurer will provide coverage if there is damage to adjoining properties such that a local or state government has restricted access to the insured’s property. For example, if a neighboring building burns down and the insured’s business cannot reopen due to the business’s street being closed, there will be coverage. Accordingly, even though the insured’s building is arguably not damaged, there may still be coverage if the policy does provide coverage for the governmental order.

As a result of the above, here is what a business owner needs to know:

    • How long will my policy pay for business interruption?
    • What type of coverage do I have?
    • Do I have Governmental Order type coverage?

As always, if you have any questions regarding your insurance policy or any of the information provided above, please feel free to reach out to our office. Lether Law Group proudly employs attorneys who are born and raised on the islands of Maui, Oahu, and the Big Island. We are more than happy to provide you with guidance on understanding your specific policy coverages.