Justia U.S. 1st Circuit Court of Appeals Opinion Summaries

A psychiatrist in Massachusetts operated his own private practice and, between 2015 and 2018, submitted fraudulent bills to a range of private and public health insurers, including Medicare and several major insurance companies. The fraudulent conduct included billing for over a thousand sessions at times when either he or the purported patient was out of the country. When insurers began to scrutinize his claims and requested additional billing records, he delayed responses and provided falsified records to support his claims. Eventually, at least one insurer halted payments pending his compliance, and another made payments contingent on preauthorization. Following federal investigation, the psychiatrist was indicted and, in October 2023, convicted by a jury on fourteen out of fifteen counts related to the fraud.In the United States District Court for the District of Massachusetts, the sentencing judge calculated his guidelines range based on a loss amount equating to the total billed—about $19 million—which resulted in a twenty-level sentencing enhancement. He was sentenced to ninety-nine months on the main counts, with additional concurrent sentences, and was ordered to pay approximately $6.5 million in restitution and a similar amount in criminal forfeiture. The defendant challenged both the intended loss calculation used for sentencing and the restitution amount.The United States Court of Appeals for the First Circuit reviewed the appeal. The court applied a burden-shifting framework, allowing the billed amount as prima facie evidence of intended loss, and found that the defendant did not provide sufficient evidence to show he intended to obtain less than he billed, even considering his status as an in-network provider. The appellate court also rejected his argument that restitution should be offset by claims for legitimate, unpaid services, holding that such offsets are not appropriate in the context of criminal restitution. The First Circuit affirmed the district court’s decisions in all respects. View "US v. Kinrys" on Justia Law

The case concerns the estate administrators of a former employee, Juliana Rodriguez Morel, who alleged she was discriminated and retaliated against by her employer, Mammoth Tech, Inc., during her pregnancy. After initially filing an administrative complaint with the New Hampshire Commission for Human Rights and the EEOC in 2019, Rodriguez Morel obtained a right-to-sue letter from the EEOC. She then filed a lawsuit in the United States District Court for the District of New Hampshire. That court entered a default judgment against Mammoth in 2023, awarding damages and fees.Subsequently, in 2025, the estate administrators initiated a separate action in the same district court against Travelers Casualty and Surety Company of America, Mammoth’s insurer. They sought a declaratory judgment that Travelers was required to pay the losses Mammoth incurred as a result of the default judgment, arguing that the insurer’s policy provided coverage for the claims in question. Travelers moved for judgment on the pleadings, contending that the policy did not provide coverage because Mammoth had received notice of the claims prior to the policy period, thus excluding coverage under the policy’s terms. The District Court agreed with Travelers and granted judgment on the pleadings.The United States Court of Appeals for the First Circuit reviewed the case de novo. The court held that the insurance policy’s “Related Claims” provision applied, which meant that all related claims were considered made at the time the first such claim was made. Because the first notice of the employment discrimination claims was before the policy period, the policy did not cover the judgment. The First Circuit affirmed the District Court’s decision, holding that the administrators failed to show any conflict or ambiguity in the policy that would override the Related Claims provision. View "Urena v. Travelers Casualty and Surety Co. of America" on Justia Law

The defendant, who immigrated to the United States from Vietnam, operated a staffing agency that provided temporary laborers to various clients in Massachusetts. She managed most of the agency’s operations, including payroll, and worked closely with her daughter, who had accounting training. Between 2015 and 2019, the defendant withdrew over $3.7 million in cash from business accounts, frequently in increments just below the $10,000 federal reporting threshold, and used this cash to pay workers. Evidence at trial showed that the agency paid employees additional cash wages not reported to tax authorities, resulting in unpaid employment taxes and underreported payroll to the company’s workers’ compensation insurer, which led to lower insurance premiums.A federal grand jury in the District of Massachusetts indicted the defendant on four counts of failing to collect or pay employment taxes and one count of mail fraud. After a jury trial, she was convicted on all counts and sentenced to eighteen months’ imprisonment and two years of supervised release. She appealed, challenging the admission of evidence regarding the structuring of cash withdrawals, the district court’s refusal to give a jury instruction on implicit bias, the instructions related to tax obligations and good faith, and the sufficiency of the evidence supporting the mail fraud conviction.The United States Court of Appeals for the First Circuit reviewed the case and affirmed the convictions. The court held that evidence about the structuring of cash withdrawals was properly admitted as intrinsic to the charged offenses and relevant to intent. The refusal to instruct on implicit bias was not an error because the district court’s voir dire and instructions substantially covered the issue. The court found no reversible error in the jury instructions regarding tax law and good faith, and concluded that any error was harmless. Finally, the evidence of mail fraud was found sufficient, as it was reasonably foreseeable that the mail would be used in the insurance audit process. View "US v. Giang" on Justia Law

The plaintiff brought a suit under Puerto Rico law after her mother died while residing in an assisted living facility. The plaintiff alleged that the facility's staff, including a licensed practical nurse, incorrectly informed treating physicians that her mother was a Jehovah's Witness. As a result, necessary blood transfusions were not administered, and the mother died from heart failure. The facility’s insurer had denied coverage for the incident under its general liability policy, claiming that the alleged wrongful acts were excluded as “professional services.”The United States District Court for the District of Puerto Rico first granted partial summary judgment for the insurer, finding that certain actions—such as failing to call 911—were excluded as “professional services,” but allowed the case to proceed on claims related to record-keeping and miscommunication, concluding those were not “professional services” under existing precedent. After the case was reassigned, the new district judge reaffirmed that ruling, and a damages trial resulted in a verdict against the facility. Subsequent to a decision by the Puerto Rico Supreme Court in Rivera-Matos v. Commonwealth, which clarified the scope of “professional services” exclusions, the district judge permitted the insurer to relitigate the coverage issue, ultimately finding that the exclusion did apply to the acts in question and entering judgment for the insurer.On appeal, the United States Court of Appeals for the First Circuit held that the plaintiff had forfeited her argument that the Puerto Rico Supreme Court’s decision should not be applied retroactively, as she had not raised it below. The court further found no plain error in the application of the new precedent. The judgment of the district court in favor of the insurer was affirmed. View "Garcia-Navarro v. Universal Insurance Company" on Justia Law

Chang Goo Yoon, a licensed physical therapist operating clinics in Massachusetts, engaged in a scheme over four years to submit more than one million dollars in fraudulent claims to private health insurers, including Blue Cross Blue Shield and Aetna, for services he did not actually provide. He fabricated treatment notes, sometimes under another provider's name, and submitted false personal injury claims to his own car insurer, MAPFRE. Yoon manipulated patient addresses to ensure reimbursement checks were sent directly to him, avoiding detection by patients. His fraudulent conduct was eventually uncovered, and a jury convicted him on two counts of health care fraud, with Count One involving Blue Cross and Aetna, and Count Two concerning MAPFRE.The United States District Court for the District of Massachusetts presided over the trial. Before trial, Yoon moved to exclude evidence related to insurance company investigations into his billing, including a 2015 Blue Cross investigation and a 2007 Colorado licensing investigation. The district court limited the evidence to Yoon’s knowledge of the investigations, excluding their outcomes. The court also redacted key documents and provided limiting instructions to the jury. At trial, witnesses testified about insurance procedures and Yoon’s billing practices. Yoon challenged the admissibility of this evidence, as well as testimony from insurance investigators, arguing it was unduly prejudicial and improperly admitted.The United States Court of Appeals for the First Circuit reviewed Yoon’s appeal. The court affirmed the district court’s evidentiary rulings, holding that evidence of Yoon’s knowledge of prior investigations was highly probative of his specific intent and not unduly prejudicial given the safeguards imposed. The court also affirmed the application of two sentencing enhancements: one for intended loss based on the total amount billed, and another for abuse of a position of trust, finding both were supported by the record and correctly applied. Yoon’s conviction and sentence were affirmed. View "United States v. Yoon" on Justia Law

A 2018 data breach at Barracuda Networks exposed protected health information of patients of Zoll Services LLC, a subsidiary of Zoll Medical Corporation. Zoll had contracted with Fusion LLC for data security services, and Fusion in turn relied on Barracuda’s technology. The agreements between these companies included certain liability and indemnification provisions, as well as a right for Barracuda to audit Fusion’s customer contracts. After the breach, Zoll settled a class action brought by its customers whose data was compromised.Following these events, Zoll initiated arbitration against Fusion and filed suit against Barracuda in the U.S. District Court for the District of Massachusetts. Fusion intervened and asserted additional claims against Barracuda. The district court dismissed most claims but allowed Zoll’s equitable indemnification claim and Fusion’s breach of contract and breach of the covenant of good faith and fair dealing claims to proceed. After arbitration and settlements, Axis Insurance Company, as assignee and subrogee of Zoll and Fusion, was substituted as plaintiff. Barracuda moved for summary judgment on the remaining claims, which the district court granted.On appeal, the United States Court of Appeals for the First Circuit reviewed the district court’s summary judgment rulings de novo. The appellate court held that Axis failed to present evidence of a relationship between Zoll and Barracuda that would support derivative or vicarious liability necessary for equitable indemnification under Massachusetts law. The court found that Fusion did not meet a condition precedent in its contract with Barracuda, and Barracuda had not waived or was estopped from asserting that condition. Further, Axis could not show that Barracuda breached the covenant of good faith and fair dealing, as no relevant contractual right existed. The First Circuit affirmed the district court’s grant of summary judgment in favor of Barracuda on all claims. View "Axis Insurance Company v. Barracuda Networks, Inc." on Justia Law

Peterson’s Oil Service, Inc. supplied heating fuel to customers in Massachusetts between 2012 and 2019. The fuel contained higher-than-standard levels of biodiesel, averaging 35% between 2015 and 2018, exceeding the 5% industry standard for ordinary heating oil. Customers alleged that this biodiesel-blended fuel was incompatible with conventional heating systems, caused repeated heat loss, and resulted in permanent damage to their equipment. They brought a class action in Massachusetts state court against Peterson’s and its officers, asserting claims for breach of contract, fraud, and negligence, including allegations that Peterson’s continued supplying the fuel despite customer complaints and only later disclosed the high biodiesel content.United States Fire Insurance Company and The North River Insurance Company had issued Peterson’s a series of commercial general liability and umbrella policies. The insurers initially defended Peterson’s in the class action under a reservation of rights, then filed suit in the United States District Court for the District of Massachusetts seeking a declaration that they owed no duty to defend or indemnify Peterson’s. The insurers moved for summary judgment, arguing that the claims did not arise from a covered “occurrence” and that policy provisions limiting or excluding coverage for failure to supply applied. The district court denied summary judgment, finding a genuine dispute as to whether Peterson’s actions were accidental and holding that the failure-to-supply provisions were ambiguous and did not apply.On appeal, the United States Court of Appeals for the First Circuit affirmed. The court held that the underlying complaint alleged a potentially covered “occurrence” because it was possible Peterson’s did not intend or expect the property damage alleged. The court also held that the failure-to-supply provisions were ambiguous and, under Massachusetts law, must be construed in favor of coverage. The district court’s summary judgment rulings were affirmed. View "United States Fire Insurance Company v. Peterson's Oil Service, Inc." on Justia Law

Customers of a heating oil company in Massachusetts brought a state court class action alleging that, starting in 2012, the company sold home heating oil with excessive biodiesel content, which damaged their heating equipment. The company received a demand letter and complaint in March 2019, before it was insured by the plaintiff insurance company. The insurance company began providing coverage in July 2019 under a commercial general liability policy and an umbrella policy. The policy included provisions excluding coverage for property damage known to the insured before the policy period began.After being asked to defend the company in the state class action, the insurer refused, arguing that the company’s prior knowledge of the alleged damage—based on the demand letter, complaint, and media coverage—triggered the policy’s known loss and loss-in-progress exclusions. The insurer then filed a declaratory judgment action in the United States District Court for the District of Massachusetts, seeking a ruling that it had no duty to defend or indemnify. The state court class had two subclasses: customers who received oil before July 5, 2019, and those who first received oil after that date.The district court found that the insurer had no duty to defend claims by customers who received oil before the policy period, but did have a duty to defend claims by customers who first received oil after coverage began, since the company could not have known of damage that had not yet occurred. Applying the “in for one, in for all” rule, the court held the insurer must defend the entire suit. The court denied summary judgment for the insurer on the duty to defend and granted partial summary judgment to the insured.The United States Court of Appeals for the First Circuit affirmed, holding that the policy’s known loss and loss-in-progress provisions did not bar coverage for claims by customers whose property damage began after the policy period commenced, and thus the insurer has a duty to defend the entire class action. View "Federated Mutual Insurance Co. v. Peterson's Oil Service, Inc." on Justia Law

A dispute arose when an insurance company denied coverage to an entity listed as an "Additional Insured" under a claims-made insurance policy. The insurer had issued the policy to a company operating an elder care facility. The plaintiff, a commercial real estate lender, had provided a loan secured by a mortgage on the property and later sought the appointment of a receiver after the operator defaulted. In January 2022, several residents were removed from the facility, leading to lawsuits alleging wrongful eviction and other claims against entities involved in financing and controlling the facility, including the plaintiff.The United States District Court for the District of Massachusetts reviewed the plaintiff’s suit seeking a declaration that the insurer had a duty to defend it in two underlying lawsuits. The district court granted summary judgment in part to each party, holding that the insurer had a duty to defend the plaintiff in one action (the Frost action) based on a claim related to the collection of an administrative fee, but not in the other (the Salie action), due to the plaintiff’s failure to provide timely notice as required by the policy. The court also granted summary judgment to the insurer on the plaintiff’s state-law claims for unfair and deceptive practices, finding insufficient evidence of bad faith.On appeal, the United States Court of Appeals for the First Circuit reversed the district court’s decision regarding the Frost action, holding that the insurer did not have a duty to defend because the claims did not allege liability solely attributable to the original insured, as required by the policy’s endorsement. The court affirmed the district court’s decision as to the Salie action and the state-law claims, concluding that the plaintiff’s failure to comply with the policy’s notice requirements and the insurer’s reasonable denial of coverage precluded recovery. The case was remanded for further proceedings. View "BI 40 LLC v. Ironshore Specialty Insurance Company" on Justia Law

In January 2015, Paula Appleton was severely injured in a car accident when a pickup truck struck her vehicle from behind. Appleton filed an insurance claim against the driver, whose policy was administered by AIG Claims, Inc. Over four years, Appleton and AIG exchanged settlement offers and attended three mediations but failed to reach a settlement. In March 2019, a Massachusetts state court jury awarded Appleton $7.5 million in damages. Appleton then sued AIG and National Union Fire Insurance Company in federal court, alleging they failed to conduct a reasonable investigation and did not extend a prompt and fair settlement offer as required by Massachusetts law.The United States District Court for the District of Massachusetts granted summary judgment in favor of the defendants. The court concluded that the defendants conducted a reasonable investigation and that their duty to extend a prompt and fair settlement offer was not triggered because the value of Appleton's damages never became clear.The United States Court of Appeals for the First Circuit reviewed the case. The court determined that a reasonable jury could find that Appleton's damages became clear in early 2018 and that the defendants failed to extend a prompt and fair settlement offer afterward. Consequently, the court vacated the district court's summary judgment ruling in part and remanded for trial on Appleton's settlement claim. However, the court affirmed the district court's grant of summary judgment on Appleton's claim that the defendants failed to conduct a reasonable investigation. View "Appleton v. National Union Fire Insurance Co." on Justia Law