Justia Insurance Law Opinion Summaries

Palmetto Hardwood, Inc., employed Petitioner Clifton Sparks as a saw operator. Petitioner suffered three work-related injuries during this employment, the first two of which injured Petitioner's lower back. In the third incident, Petitioner was required to remove a piece of metal from under a gang saw. In the process, the metal exploded and a three- to four-inch cubic piece struck him in the head. Petitioner subsequently sought workers' compensation for his injuries. At the hearing, Petitioner testified to substantial head pain, loss of cognitive ability, and other brain-function-related symptoms, including inability to read without severe headache, loss of his mathematical abilities, inability to balance while standing or to walk without a cane, hand tremors, anxiety, and more. Petitioner argued on appeal to the Supreme Court that the Court of Appeals erred when it applied an improper definition of "physical brain damage" within the meaning of section 42-9-10(C). The Supreme Court disagreed. Because "physical brain damage" as contemplated in S.C. Code Ann. 42-9-10 required "severe and permanent physical brain damage as a result of a compensable injury" and the Workers' Compensation Commission's finding that Petitioner did not suffer such brain damage was supported by substantial evidence in the record, the Court affirmed the Court of Appeals. View "Sparks v. Palmetto Hardwood" on Justia Law

Maria Marusa was driving her car when it was struck by a police cruiser driven by a police officer (Officer). Marusa and her daughter (collectively, Appellants) were injured in the accident. Appellants filed suit against Marusa's insurer (Insurer), seeking damages to compensate for medical expenses and pain and suffering. Insurer answered that it was not obligated to pay damages because even though the policy included uninsured-motorist coverage and the officer was an uninsured motorist, Appellants were not "legally entitled to recover" because Officer was immune under the Ohio Political Subdivision Tort Liability Law (OPSTLL). The trial court granted summary judgment for Insurer, and the court of appeals affirmed. The Supreme Court reversed, holding that the language of the policy unambiguously provides uninsured/underinsured motorist coverage when the insured is injured by an owner or operator who is immune under the OPSTLL. View "Marusa v. Erie Ins. Co." on Justia Law

Michael Jassek appealed a district court judgment that affirmed the binding dispute resolution decision of Workforce Safety and Insurance ("WSI") that denied payment for a myoelectric prosthesis. Upon review of the matter, the Supreme Court concluded the district court did not have subject matter jurisdiction, and therefore vacated the judgment. Jassek contended that because WSI failed to explain its reasons for disregarding the medical evidence favorable to Jassek, its binding dispute resolution decision was arbitrary, and that WSI's binding dispute resolution procedure violated his right to due process because it failed to provide a formal hearing. The language of N.D.C.C. 65-02-20 unambiguously provides that "[a] dispute resolution decision under this section requested by a medical provider concerning . . . a request for . . . treatment is not reviewable by any court." The statute based appealability on the identity of the party who requests binding dispute resolution, not on who appeals the binding dispute resolution decision. Jassek’s orthotist was a "medical provider," and this dispute concernd "a request for diagnostic tests or treatment," specifically the determination of an appropriate prosthetic device. Accordingly, WSI's decision on the medical provider’s request for binding dispute resolution was not reviewable by the district court, the district court was without subject matter jurisdiction, and the judgment affirming WSI's decision was void. View "Jassek v. Workforce Safety and Insurance" on Justia Law

Defendant-Appellant Lloyds of London Syndicate 2003 ("Lloyds") appealed the district court's denial of its summary judgment motion and subsequent grant of summary judgment in favor of Plaintiff-Appellee Brecek & Young Advisors, Inc. ("BYA") in an action arising out of a professional liability insurance contract. The district court concluded Lloyds failed to pay sufficient indemnity to BYA for claims brought against BYA in an arbitration before the National Association of Securities Dealers. The underlying suit alleged BYA agents mismanaged and unlawfully "churned" the investment accounts of its clients. The court concluded the claims brought in the arbitration did not relate back to earlier claims brought outside the policy period and, therefore, rejected Lloyds' argument coverage was precluded altogether. Additionally, the court rejected BYA's argument that Lloyds was equitably estopped from denying coverage due to its course of conduct in receiving and defending the claims. Upon review, the Tenth Circuit concluded that the district court erred in its interpretation of the law of the case, and therefore abused its discretion in making its judgments in this case. Accordingly, the district court's decisions were reversed and the case remanded for further proceedings. View "Brecek & Young Advisors, Inc. v. Lloyds of London Syndicate 2003" on Justia Law

Brooks Insurance Agency, Sidney Brooks (its agent), and Nationwide Mutual Insurance Company and Nationwide Mutual Fire Insurance Company (collectively "Nationwide") petitioned the Supreme Court for a writ of mandamus to direct the Jefferson Circuit Court to vacate its order denying their motion to dismiss an action filed by Guster Law Firm, LLC, and Guster Properties, LLP (collectively "Guster"), against them. Guster made a claim for a fire loss under commercial property policies issued to it by Nationwide. In April 2011, Nationwide filed a declaratory-judgment action requesting that the federal court determine the rights and obligations under the insurance policies it had issued to Guster. Guster answered and asserted compulsory counterclaims against Nationwide, including bad-faith failure to pay an insurance claim and breach of contract, among others. Months later, Guster filed a lawsuit in the Jefferson Circuit Court alleging against the agency, Brooks, and Nationwide: negligent/wanton failure to provide insurance coverage; misrepresentation; suppression and concealment; and negligent/wanton failure to train. The agency, Brooks, and Nationwide moved to dismiss the state court action on the ground that the action violated the state abatement statute and the compulsory-counterclaim rule. The trial court summarily denied the motion to dismiss. The agency, Brooks, and Nationwide then petitioned the Supreme Court for mandamus relief. Upon review, the Supreme Court affirmed in part, reversed in part, and issued the writ. Although the causes of action in the federal court and the state court arose out of the same transaction or occurrence and were thus related, Guster's claims against the agency and Brooks were not compulsory counterclaims in the federal declaratory-judgment action because the agency and Brooks were not "opposing part[ies]" in the federal action. Accordingly, the Alabama abatement statute mandated that the claims against Nationwide in Guster's complaint filed in state court be dismissed. The Court concluded that the agency and Brooks did not show a clear legal right to the dismissal of Guster's claims against them in the state-court action. However, Nationwide did show a clear legal right to the dismissal of Guster's claims against it in the state-court action, therefore the trial court erred in denying the motion to dismiss as to Nationwide. View "Guster Law Firm, LLC v. Brooks Insurance Agency" on Justia Law

"At its most basic level, this case presents a policy dispute: whose policy choice concerning health insurance premiums for State employees controls—the General Assembly's or the Budget and Control Board's?" The issue before the Supreme Court centered on "maintaining and enforcing the constitutional and statutory framework through which such issues must be resolved. " Upon review of the arguments of the parties and the applicable case law, the Supreme Court found that the General Assembly had and exercised the power to determine the contribution rates of enrollees for the State's health insurance plan in 2013. The Court held that the Budget and Control Board violated the separation of powers provision by substituting its own policy for that of the General Assembly, entered judgment for the petitioners, and directed the Board to use the appropriated funds for premium increases and return the premium increases previously collected from enrollees. View "Hampton v. Haley" on Justia Law

In 2007, Employers Mutual Casualty Company (EMC) brought a declaratory judgment action against the Donnellys and Rimar Construction, Inc. (RMI) to establish that under its policy of insurance with RCI, EMC had no duty or responsibility to pay damages claimed by the Donnellys in litigation between the Donnellys and RCI. The declaratory judgment action was stayed until a verdict was reached in the underlying action. In the underlying action, the Donnellys were awarded damages, costs and attorney fees against RCI. Subsequently the district court entered summary judgment in the declaratory action, finding that there was no insurance coverage for the damages the Donnellys incurred, but that there was coverage for costs and attorney fees. On appeal, EMC argued that the district court erred in its determination that it had a duty to pay attorney fees and costs when there were no damages awarded to the plaintiff subject to the policy coverage. The Donnellys cross appealed, arguing the district court erred in its conclusion that EMC did not have a duty to cover the damages in this case, and that the Donnellys were entitled to attorney fees. Upon review, the Supreme Court affirmed the district court's decision. View "Employers Mutual Casualty Co v. Donnelly" on Justia Law

Plaintiff, on behalf of herself and the Estate, challenged the district court's grant of summary judgment to Zenith on the Estate's breach of the insurance contract claim. After review and oral argument, the court certified questions to the Florida Supreme Court: (1) Does the estate have standing to bring its breach of contract claim against Zenith under the employer liability policy? (2) If so, does the provision in the employer liability policy which excludes from coverage "any obligation imposed by workers' compensation . . . law" operate to exclude coverage of the estate's claim against Zenith for the tort judgment? (3) If the estate's claim was not barred by the workers' compensation exclusion, does the release in the workers' compensation settlement agreement otherwise prohibit the estate's collection of the tort judgment? View "Morales v. Zenith Ins. Co." on Justia Law

ANI, a risk retention group, filed suit seeking declaratory and injunctive relief against the Commissioner and the Division of Insurance under 42 U.S.C. 1983. ANI claimed that an order of the Commissioner violated the Liability Risk Retention Act (LRRA), 15 U.S.C. 3902(a)(1). The court held that the Commissioner's Order, which barred ANI from writing first dollar liability insurance policies in Nevada, was preempted by the LRRA. Therefore, the court affirmed the district court's entry of declaratory and injunctive relief in favor of ANI. However, the LRRA did not confer a right to be free from state law that could be enforced under 42 U.S.C. 1983, making fees under 42 U.S.C. 1988 unavailable. Thus, the court vacated the fee award. Finally, the court remanded so that the district court could enter a new summary judgment order consistent with this opinion. View "Alliance of Nonprofits for Ins. v. Kipper, et al" on Justia Law

Petitioner-Claimant Nancy Bertrand injured her right foot when she slipped on a wet floor while employed as a child care worker for Respondent Laura Dester Center (Employer). She sought certiorari review of the opinion of the Court of Civil Appeals (COCA) which sustained the Workers' Compensation Court's (WCC) denial of her request for travel costs to and from a vocational rehabilitation facility. Claimant contended that her allowance for travel expenses was effectively eliminated under the new Workers' Compensation Code, enacted August 26, 2011, which set a minimum for reimbursement of twenty miles round-trip. Claimant's total round-trip mileage was fourteen miles for which she was previously paid prior to the effective date of the Code. The trial court ordered the new law was procedural and could be applied retroactively. But after its review, the Supreme Court concluded that the WCC ordered vocational rehabilitation before August 26, 2011, and the treatment facility was outside the city limits of Claimant's hometown. As such, the Supreme Court reversed. View "Bertrand v. Laura Dester Center" on Justia Law