John N Wilborn's Legal Cases (3)

Insurance

Horton V. USAA Casualty Ins. Co. Case Number CV-06-02810-PHX-D

Sep 20, 2010

OUTCOME: Class Action Case Settled

Specifically, plaintiffs allege that USAA submitted healthcare bills from insureds with first party medical coverage, who were involved in covered automobile claims, to a medical/fee audit review which ... recommended payment of less than the full amount of the submitted charges. USAA paid less than the full amount of the submitted health care charges based on recommendations from the audit review which were based on a statistical analysis of the reasonableness of the submitted charge; were based on a PPO or PPN agreement determined applicable to the submitted charge; or were based on the resolution of the submitted charge by a negotiation between USAA and the provider. The plaintiffs alleged that these reductions constitute d bad faith and breach of contract. The settlement class consists of insureds under a USAA automobile policy that contained first-party medical coverage including Medical Payments , Personal Injury Protection, First Party Benefit, Medical Expense Benefits and/or Automobile Death and Disability Coverages (“Medpay”). The insureds must have made claims for Medpay benefits from June 27, 2005 through July 3, 2008; the bills must have been submitted to the medical/fee audit review; USAA must not have paid the full amount of the healthcare charges based on the review recommendations; and the insured must not have exhausted their policy limits. Health care providers with valid written assignments of these claims are also class members. The settlement provides monetary relief to insureds and health care providers as well as business practice changes regarding reimbursements and audits.

Insurance

John and Julie Vedder vs. National Union Fire Insurance Company of Pittsburgh CV2003-015960

Jan 01, 2007

OUTCOME: Case Settled Confidentially

The Plaintiff, John Vedder, was employed as a superintendent by Walters & Wolf. Walters & Wolf was insured by the Defendant for auto and for worker’s compensation as well. On August 1, 2000 the Plain ... tiff was driving a company truck insured by the Defendant under a National Union policy issued to the employer. While stopped at a stop sign the Plaintiff’s vehicle was rear-ended so severely that the Plaintiff’s seat broke and his head smashed through the back window of the club-cab sized pick up truck. The Plaintiff sustained injuries to his head, back and neck. During the period immediately after the Plaintiff filed his lawsuit, the Plaintiff made a demand for payment on his own policy. He was personally insured by American Family for UIM coverage up to the limit of $100,000.00. The Plaintiff made a claim on his own insurance policy for underinsured motorist coverage. American Family accepted the claim and investigated, finding that the Defendant’s underinsured coverage was primary up to the limits of $1,000,000.00. Meanwhile the Defendant defended the lawsuit. First Defendant refused to answer the lawsuit and sent two letters to the Plaintiff stating that there was no coverage. The Plaintiff finally compelled the Defendant to file an answer which was filed on October 22, 2004, almost ten months after the Plaintiff served the lawsuit. When the Defendant served its initial disclosure statement it stated that the Defendant, discovered that it never offered Walters & Wolf underinsured motorist coverage. Because it is a de facto requirement under its own policy and by statute, the Defendant failed to comply with the statute. This meant the Defendant had no right to offset any payments to the Plaintiff, made by workers’ compensation insurers.

Insurance

Standard Fire Insurance v Rebecca Atchely CV2002-003479

Jan 01, 2007

OUTCOME: Case Settled Confidentially

Plaintiff, Standard Fire Insurance Company denied their insureds, the Childs defense and indemnity, after Rebecca Atchley’s only son died in their home. The Childs were conducting childcare services ... in their home, which might Standard alleged was not covered under the policy. The denial forced the Childs to seek protection on their own. The Childs were forced to enter into an agreement whereby they would not be subjected to any liability in exchange for a judgment entered against them in the amount of $4.85 million dollars. Atchley then filed a counterclaim to Standard's Declaratory Action, alleging Breach of Contract and Bad Faith. Atchley argued the coverage should have been granted based on a reasonable reading of the policy and/or reasonable expectations.

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