Justia Insurance Law Opinion Summaries

This appeal arose out of Ryan Dorman's petition for an extension of his worker's compensation temporary total disability (TTD) benefits and for reimbursement of travel expenses incurred in travelling from Idaho to Cheyenne to obtain medical care. In May 2006, Dorman sought treatment from an Idaho physician for treatment of his alleged work-related injury. Due to the nature of Dorman's injury, he consulted multiple physicians, first in Idaho, then in Wyoming. With each consultation, the doctors indicated that the injury was outside of their scope of expertise, and referred Doman to another specialist. During the period that Dorman was changing physicians, the Division and Dorman negotiated a stipulation concerning his TTD benefits and other benefits. This followed OAH and district court decisions that largely reversed the Division's earlier determinations concerning TTD benefits and Dorman's need for continued medical treatment. The Stipulated Order also provided that medical benefits would be paid as directed by the district court's order. After the Division paid the stipulated TTD benefits, Dorman submitted a letter to the Division requesting extended benefits The Division thereafter issued a final determination denying them, and further denied several applications for travel expense reimbursement for Dorman's trips to Idaho and Cheyenne. The matters were referred to the OAH where a combined hearing was held on the denial of TTD benefits, denial of travel reimbursement, and denial of diagnostic testing related to Dorman's injury. The OAH upheld the denial of TTD benefits on the ground that Dorman had failed to make the required showing that the Idaho and Cheyenne doctors were the closest available medical providers. Dorman appealed the portion of the OAH order denying extended TTD benefits and travel reimbursement to the district court. Upon review, the Supreme Court affirmed the OAH denial of the travel reimbursement: Dorman could not prove that reimbursement of travel expenses was not supported by substantial evidence and in accordance with law. View "Dorman v. Wyoming" on Justia Law

Based on unethical actions during the 2004-2005 hurricane season, the Legislature enacted Section 626.854(6), Florida Statutes: A public adjuster may not directly or indirectly through any other person or entity initiate contact or engage in face-to-face or telephonic solicitation or enter into a contract with any insured or claimant under an insurance policy until at least 48 hours after the occurrence of an event that may be the subject of a claim under the insurance policy unless contact is initiated by the insured or claimant. An adjuster sued. The trial court upheld the law, accepting an interpretation that it prohibited only in-person or telephonic communication, that it primarily regulates conduct, not speech, and furthers an important governmental interest. The appeals court reversed, finding that the section regulates commercial speech and that the Department failed to demonstrate that prohibiting property owners from receiving information from public adjusters for 48 hours is justified by the possibility that some public adjuster may unduly pressure traumatized victims or otherwise engage in unethical behavior. The Florida Supreme Court affirmed, holding that the statute unconstitutionally restricts commercial speech and was not narrowly tailored to serve interests in ensuring ethical conduct by public adjusters and protecting homeowners. View "Atwater v. Kortum" on Justia Law

Claimant Henry Marange filed a disputed claim for compensation against his employer, Custom Metal Fabricators, Inc. asserting he injured his back in a work-related accident. Custom Metal answered the petition, and denied Claimant's allegation. The issue before the Supreme Court was whether the court of appeal erred in reversing of the Office of Workers' Compensation (OWC), which held that Claimant failed to establish by a preponderance of the evidence that a workplace accident occurred. Upon review of the facts in record, the Court concluded that the court of appeal erred in reversing the OWC's judgment. View "Marange v. Custom Metal Fabricators, Inc." on Justia Law

The Supreme Court granted certiorari to the Court of Appeals in "Glass v. Gates" to answer whether the definition of "any motor vehicle" in OCGA 33-24-51(a) continued to be the broader definition of the term provided for in prior case law, notwithstanding the 2002 passage of OCGA 36-92-1. As inmates at the Troup County Correctional facility, Jonathan Glass and Tony Smith were operating tractors when Smith's tractor got stuck in a ditch. Donrell Gates, Glass' detail supervisor, instructed the men to attach a chain to the tractors so Glass could use his tractor to pull Smith's from the ditch. As Glass did so, Smith engaged his tractor's bush hog, causing a rock to take flight and pierce Glass' throat. Glass bled profusely and died later that day. Plaintiffs, Glass' minor son and the executor of his estate, brought a wrongful death and survivor action against Troup County and Gates. The county sought summary judgment, claiming plaintiffs' claims were barred by sovereign immunity. The County asserted that by revising OCGA 33-24-51 (b) in 2002 (effective 2005), the legislature demonstrated its intent to apply the more narrow definition of "motor vehicle" found in OCGA 36-92-1 (6) in determining whether a local government waived sovereign immunity by purchasing liability insurance on a motor vehicle. The trial court agreed and granted summary judgment in favor of the County, concluding that the county did not waive sovereign immunity because neither a tractor nor a bush hog could be deemed a "motor vehicle" under OCGA 36-92-1. The Court of Appeals reversed, holding that the broader definition of "motor vehicle" should have been applied under 33-24-51, and that therefore, the County waived its sovereign immunity as long as it purchased insurance for the tractor and bush hog used by Smith. The Supreme Court agreed with the Court of Appeals' reasoning, and affirmed by answering the appellate court's original question in the affirmative. View "Gates v. Glass" on Justia Law

The Wyoming Workers' Safety and Compensation Division awarded benefits to Appellant Gary Mitcheson after he fell at work and injured his tailbone in July of 2007. Approximately two years later, the Division issued a final determination denying payment for medical care that Appellant claimed was related to his workplace injury. Appellant requested a contested case hearing, and the Office of Administrative Hearings (OAH) upheld the Division's determination. Appellant appealed to the district court, which upheld the OAH's order. On appeal, Appellant challenged the OAH order contending: (1) the order was arbitrary and unsupported by substantial evidence; (2) the OAH's denial of payment for treating Appellant's tailbone was arbitrary; and (3) the OAH order denying payment for medical care contrary to the "Rule Out" rule was contrary to law. Finding the issues Appellant raised on appeal to be without merit, the Supreme Court affirmed the OAH's decision. View "Mitcheson v. Wyoming" on Justia Law

This appeal involved the interpretation of a claims-made professional liability insurance policy that Appellant Physicians Insurance Company of Wisconsin, Inc., d.b.a. PIC Wisconsin (PIC), issued to nonparty dentist Hamid Ahmadi, D.D.S. The policy covered dental malpractice claims made against Dr. Ahmadi and reported to PIC during the policy period. On cross-motions for summary judgment, the district court determined that PIC received constructive notice of Respondent Glenn Williams’s malpractice claim against Dr. Ahmadi while the policy was in force and held that this was enough to trigger coverage. Upon review, the Supreme Court reversed, finding that a "report" of a potential demand for damages to qualify as a "claim" required sufficient specificity to alert the insurer’s claim department to the existence of a potential demand for damages arising out of an identifiable incident, involving an identified or identifiable claimant or claimants, with actual or anticipated injuries. The Court did not find an ambiguity that would permit the PIC policy to have been triggered by the report of a default judgment against the doctor filed in public records. As such, the Court remanded the case with instructions to enter summary judgment in favor of PIC. View "Physicians Insurance Co. v. Williams" on Justia Law

Claimant Crystal DeLeon sought workers' compensation benefits for a work-related injury to her back, neck and one shoulder. SAIF Corporation, her insurer, accepted the claim but awarded only temporary partial disability; the insurer did not award Claimant permanent partial disability. Claimant sought reconsideration, and the Department of Consumer and Business Services awarded her an eleven percent permanent partial disability for her shoulder. The insurer appealed the Department's award; the ALJ agreed with the insurer and reduced the permanent partial disability award to zero. Claimant appealed the ALJ's decision to the Workers' Compensation Board. The board reversed the ALJ and reinstated the eleven percent disability determination, and awarded attorney's fees. The issue on appeal concerned the authority of the Workers' Compensation Board to award attorney fees. Upon review, the Supreme Court found that the Board indeed has statutory authority to award attorneys' fees. View "SAIF Corp. v. DeLeon" on Justia Law

Plaintiff-Appellee Larry Frederick brought a putative class action suit against Hartford Underwriters Insurance Company (Hartford) in Colorado state court; Hartford removed the case to federal court. Looking to the face of Plaintiff’s complaint, the district court concluded that the amount in controversy did not exceed $5,000,000 (which was required for federal jurisdiction under the Class Action Fairness Act (CAFA)). Accordingly, the district court remanded the case to state court. In reaching its decision, the district court acknowledged that the Tenth Circuit had not defined the burden a defendant must carry to prevent a remand in a CAFA suit. Faced with this question, the Tenth Circuit held that a defendant in these circumstances is entitled to present his own estimate of the amount at stake and must show by a preponderance of the evidence that the amount in controversy exceeds the amount in 28 U.S.C. 1332(d)(2) (currently $5,000,000). The Court emphasized that the preponderance standard applies to punitive damages as well, and that such damages cannot be assumed when calculating the amount in controversy. Accordingly, the Court reversed the district court and remanded the case for further proceedings. View "Frederick v. Hartford" on Justia Law

The New York City Off-Track Betting Corporation (NYC OTB) was a public benefit corporation charged with operating an off-track pari-mutuel betting system within the City. Later, NYC OTB filed for bankruptcy and shut down. The City's Corporation Counsel then announced that NYC OTB retirees would lose coverage under the City's health insurance and welfare benefit plans because the Corporation was no longer able to reimburse the City. A union representing NYC OTB employees and retirees and others (collectively, Plaintiffs) brought suit against the State and City, seeking a judgment declaring that the failure of the State and City to fund, and the termination of retiree health insurance and supplemental benefits, violated the City Administrative Code and other express and implied obligations. Supreme Court rejected the four theories advanced by Plaintiffs to support State or City liability for NYC OTB retiree health benefits. The appellate division affirmed. The Court of Appeals affirmed, holding (1) Plaintiffs did not demonstrate a likelihood of success on the merits of their claim against the City; and (2) because NYC OTB had a legal identity separate from the State, Plaintiffs stated no viable theory under which the State could be held liable in this case. View "Roberts v. Paterson" on Justia Law

In a 5-4 ruling, the Supreme Court has upheld the 2010 Patient Protection and Affordable Care Act. While only four Justices found its requirement that certain individuals pay a financial penalty for not obtaining health insurance (26 U.S.C. 5000A) constitutional under the Commerce Clause, Chief Justice Roberts found it constitutional by reasonably characterizing it as a tax. Chief Justice Roberts wrote: “it is not our role to forbid it, or to pass upon its wisdom or fairness." The penalty is to be paid to the IRS, along with the individual’s income taxes. In a limited ruling, the Court held that the Act’s “Medicaid expansion” is unconstitutional in threatening states with loss of existing Medicaid funding if they decline to comply, but that the penalty provision is severable (which means that failure of that provision does not cause the entire Act to fail). The Act requires that state programs provide Medicaid coverage by 2014 to adults with incomes up to 133 percent of the federal pov­erty level, (many states now cover adults with children only if their income is considerably lower, and do not cover childless adults at all) and increases federal funding to cover states’ costs, 42 U.S.C. 1396d(y)(1). The decision leaves intact less controversial provisions, protecting individuals with preexisting conditions, allowing children to be covered by parents’ insurance until age 26, and prohibiting higher costs for insuring women. View "Nat'l Fed'n of Indep. Bus. v. Sebelius" on Justia Law