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There Must be a Claim for Coverage Under a Claims Made Policy\\n\\nHomeland Insurance Company of New York (Homeland) issued Plaintiff a \\nclaims made\\xa0 liability insurance policy covering errors and omissions, \\neffective January 16, 2019 to January 16, 2020. \\xa0Plaintiff eQHealth \\nAdviseWell, Inc., f/k/a eQHealth Solutions, Inc., a Louisiana \\ncorporation that provides health care management services to Medicaid \\nagencies, commercial healthcare payers, third-party administrators, and \\nself-insured employer groups.\\n\\nIn Eqhealth Advisewell, Inc. v. Homeland Ins. Co. Of N.Y., Civil Action \\nNo. 22-00050-BAJ-EWD, United States District Court, M.D. Louisiana (July\\n 15, 2023) the USDC resolved the dispute over coverage.\\n\\nBACKGROUND\\n\\nHomeland issued a Managed Care Organizations Errors and Omissions \\nLiability Policy (\\u201cthe Policy\\u201d) to Plaintiff. The Policy covered \\n\\u201cDamages and Claim Expenses in excess of the Retention that [Plaintiff \\nis] legally obligated to pay as a result of a Claim ...\\u201d A \\u201cClaim,\\u201d as \\ndefined by the Policy, \\u201cmeans any written demand from any person or \\nentity seeking money or services or civil, injunctive, or administrative\\n relief from [Plaintiff].\\u201d\\n\\nPlaintiff Authorizes Treatment For B.N., A Florida Resident, In Oklahoma\\n\\nOne of Plaintiff\'s contracts was to provide Medicaid management services\\n to the State of Florida. Under this contract, Plaintiff\'s primary \\noperational contact was Florida\'s Agency for Health Care Administration \\n(\\u201cAHCA\\u201d), which is the state agency responsible for administering \\nFlorida\'s Medicaid program. \\n\\nPlaintiff\'s Communications To Defendant Regarding B.N.\'S Treatment At \\nBrookhaven\\n\\nThe lawyer stated that \\u201c[n]o lawsuit has been filed, at least as yet.\\u201d\\xa0 \\n\\nPlaintiff and Florida AHCA\'s Settlement with Brookhaven\\n\\nAt the point of a settlement eQHealth had virtually no choice but to \\nsettle on the terms agreed by AHCA and Brookhaven. The settlement \\nagreement was signed by the last parties on September 20, 2019, and \\npursuant to it, eQHealth paid Brookhaven $262,500.\\n\\nDefendant denied coverage on February 3, 2020, stating that: \\u201c[n]o Claim\\n against eQHealth was reported to Homeland, eQHealth did not ask for \\nconsent to settle any Claim, and Homeland did not provide prior written \\nconsent for the settlement, or for any expense, payment, liability, or \\nobligation eQHealth may have had in relation to this matter. Therefore, \\nno coverage is available for the settlement payment eQHealth made to \\nBrookhaven.\\u201d\\n\\nDISCUSSION\\n\\nHomeland expressly conditioned coverage of all claims under the Policy \\non the filing of notice of a \\u201cClaim\\u201d against Plaintiff. When considering\\n what constitutes a \\u201cclaim\\u201d to trigger coverage under a \\u201cclaims-made\\u201d \\ninsurance policy, the court relied on the Fifth Circuit that instructs \\ntrial courts to differentiate the \\u201cmere threat of a claim\\u201d from an \\n\\u201cactual claim.\\u201d\\n\\nThe USDC concluded that despite the numerous communications between the parties and relevant third parties, no communication rose to the \\ndefinitional level of a \\u201cClaim\\u201d such that coverage under the Policy was \\ntriggered.\\n\\nZALMA OPINION\\n\\nHomeland included in its policy wording a definition of the word \\n"claim." For the insured to obtain defense or indemnity it must \\nestablish that a claims, as defined, happened. Without question threats \\nwere made. A settlement was reached and the insured paid money to fund \\nthe settlement. Yet, no one made a "claim" as defined, the insurer was \\nnot advised of the settlement nor was it advised of the insured\'s intent\\n to pay until after it paid although the decision to pay was a \\n"business" decision since no one made a demand in writing that they pay \\nfor a cause of loss insured against, there could not be coverage for a \\nclaim or loss triggered under the policy\'s clear and unambiguous \\ndefinition of the word "claim."\\n\\n(c) 2023 Barry Zalma & ClaimSchool, Inc.\\n\\nPlease tell your friends and colleagues about this blog and the videos \\nand let them subscribe to the blog and the videos.\\n\\n