Justia Insurance Law Opinion Summaries

After an insolvent employer's insurance company also became insolvent, the Mississippi Workers' Compensation Self-Insurers Guaranty Association (SIGA) made workers' compensation payments to an injured worker. SIGA sued the Mississippi Insurance Guaranty Association (MIGA) for reimbursement of those payments, and the trial court ordered reimbursement. The issue came before the Supreme Court who, after consideration, concluded that SIGA's claim against MIGA did not fall within the statutory definition of a "covered claim," and reversed the trial court’s reimbursement decision.

Appellant Beverly Fetzer appealed a district court judgment that affirmed a Workforce Safety and Insurance (WSI) order denying her request for benefits. While walking down a hallway on her employer's premises and during work hours, Appellant thought she heard someone call her name. Turning in response, she caught her foot and fell, fracturing her left hip and wrist. No cause of the fall was apparent. Appellant filed a claim for workers' compensation benefits with WSI, and WSI denied her claim. Appellant submitted a request for reconsideration; WSI issued an order consistent with its prior decision, determining Appellant’s injury "occurred in the course of, but did not arise out of" her employment. WSI added, "Mere walking, without more, is not an activity that is sufficiently linked to Claimant's employment so that the injury can be deemed to have arisen from employment." Upon review, the Supreme Court affirmed: “If merely being at work was sufficient to show causation, the legislature need not have required the 'arising out of' test." Appellant was unable to prove a causal connection between her employment and injury.

Employee, a truck driver, resigned from his employment with Employer after he developed arthritis. Employee later filed an occupational disease claim, which the Montana State Fund (MSF) denied. The Workers' Compensation Court (WCC) concluded that Employee's job duties were the major contributing cause of his arthritic condition, and therefore, Employee was suffering from an occupational disease. The Supreme Court affirmed, holding that the WCC did not err in concluding that Grande was suffering from a compensable occupational disease arising out of and in the course and scope of his employment, as the WCC's findings of fact were supported by substantial, credible evidence, and its conclusions of law were correct.

Plaintiff-Appellant Allen Perius appealed a district court judgment following a jury verdict in favor of Appellee Nodak Mutual Insurance Company. In 2004, Plaintiff was involved in a motor vehicle accident with an uninsured driver, Jacob Kessler. Plaintiff insured his vehicle with Nodak for basic no-fault benefits and uninsured motorist benefits. Nodak paid Plaintiff no-fault benefits as a result of the accident. Plaintiff did not seek further medical treatment until March 2005, when he saw a chiropractor. Plaintiff submitted the bills to Nodak for payment as no-fault benefits. After Plaintiff submitted to an independent medical examination, Nodak denied him payment for any medical treatment after December 31, 2004, concluding such treatment was unrelated to the accident. In 2007, Plaintiff brought suit against Kessler, alleging he negligently operated his motor vehicle and caused Plaintiff's injuries. Plaintiff also sued Nodak, alleging the company breached its insurance contract with him. Nodak denied liability, and asserted a cross-claim against Kessler regarding Plaintiff's uninsured motorist claim. Kessler did not answer the claims against him. In 2009, Nodak moved for summary judgment, arguing no competent, admissible evidence established his claimed injuries were caused by the accident. Plaintiff resisted the motion, and submitted the affidavits of two of his treatment providers who stated their belief that Plaintiff's injuries and treatment were due to the accident. The district court granted Nodak's motion for summary judgment, and this Court reversed and remanded, finding disputed issues of material fact existed. A trial was set on remand. Shortly after, Plaintiff sent Nodak amended responses to Nodak's interrogatories. Prior to trial, Nodak was informed of Plaintiff's intent to call a chiropractor, as an expert witness. Nodak filed a motion in limine seeking to exclude the expert witness, alleging the expert was not properly disclosed.The district court granted Nodak's motion, but ordered the doctor would still be allowed to testify as a fact witness. The jury returned a verdict in Nodak's favor. The Supreme Court concluded that Plaintiff did not properly disclose his witness and that the district court did not abuse its discretion excluding the expert's testimony as a discovery sanction.

Appellant Valerie Joy Tronnes appealed a judgment that affirmed the Job Service of North Dakota's decision to deny her claim for unemployment benefits. In 2002, Appellant began working part-time at the Wal-Mart Vision Center. In 2010, Appellant received her paycheck (via a debit-card style card), and purchased a few items at Wal-Mart's customer service center. The amount of the purchase was mistakenly credited to Appellant's account by a different employee rather than deducted, which resulted in a substantial benefit to Appellant. Appellant met with the vision center manager about the extra money on her card, but later testified she believed the amount to be correct. The store gave Appellant the option of resigning as a result of her spending the extra money, but believed the paid time off she was given ( a "D-day"-- so named to give Appellant a day to decide whether to remain employed at Wal-Mart) meant she would be fired soon. Store management negotiated a payment plan for Appellant to repay the amount she was credited and allowed her to return to work. Ultimately the "repayment plan" took the form of the store withholding Appellant's subsequent paychecks to cover the indebtedness. Appellant did not report to work after that payday, and subsequently filed for unemployment benefits. The Job Service determined Appellant was ineligible for benefits because she voluntarily quit her job. Upon review, the Supreme Court concluded the evidence in the record supported the Job Service's denial of benefits to Appellant.

Appellant Michael Beall received preauthorization from the Wyoming Workers' Safety and Compensation Division for an orchiectomy, a procedure to remove his left testicle, which he claimed was related to a workplace injury. Beall's employer, Sky Blue Enterprises, objected to the preauthorization and the matter was referred to the Medical Commission Hearing Panel for a contested case hearing. Beall elected to undergo the surgery prior to the scheduled hearing. The Commission denied Beall's claim for reimbursement of medical expenses on the basis that the surgery was not reasonable or necessary medical care resulting from his workplace injury. The district court affirmed. The Supreme Court affirmed, holding (1) the burden of proving that the orchiectomy was reasonable and necessary medical care as related to Beall's alleged workplace injury rested with Beall; and (2) substantial evidence supported the Commission's determination that Beall failed to meet this burden.

Appellant Peggy Hodge sought to compel Appellee, the administrator of the Bureau of Workers' Compensation, to pay Vicki Hulbert, a licensed practical nurse, higher wages for the in-home care that Hulbert provided to her. A staff hearing officer (SHO) determined that he had no jurisdiction to order an increase. A few months later, Hodge again moved the Commission to increase Hulbert's wages. A district hearing officer (DHO) dismissed the motion of jurisdictional grounds, citing the SHO order. Thereafter, a different SHO affirmed the DHO's order. Hodge then sought a writ of mandamus against the bureau. The court of appeals denied the writ after finding, among other things, that Hodge's failure to appeal the SHO orders constituted a failure to exhaust her available administrative remedies. The Supreme Court affirmed, holding that the court of appeals was correct in denying the writ, as Hodge's failure to exhaust her administrative remedies precluded mandamus.

The Supreme Court granted certiorari to determine whether a "statement made or action taken" language in La. R.S. 17:439(A) precludes a cause of action against school employees for negligent acts of omission and to ascertain whether an action may be filed pursuant to La. R.S. 17:439(D) directly against a school employee for the negligent operation of a motor vehicle to the extent his or her liability is covered by insurance or self-insurance. Nakisha Credit, mother of Adrianne Breana Howard (Breana), sued on behalf of Breana's half-siblings and herself stemming from a fight Breana had on school grounds. Breana was involved in "an ongoing feud" with Courtney McClain. Breana was dropped off in the rear of Rayville High School after school had been dismissed for the day at Richland Career Center and began to walk home. Plaintiffs contend LeBaron Sledge instigated a fight between Breana and Courtney whereby the two girls began fighting on the sidewalk in the rear of the school. During the altercation, Breana was either pushed by Courtney or fell off the sidewalk, and was struck by an oncoming Richland Parish school bus. Breana died as a result of her injuries. Among other allegations, Plaintiffs' petition alleged Defendants the School District, State Farm Mutual Automobile Insurance Company, the school board's insurer, the school superintendent and the bus driver were negligent in a variety of ways by failing to supervise the children, failing to timely respond to the fight, and failing to adequately staff the bus area with teachers or school employees. Upon review, the Supreme Court reversed the appellate court's decision to hold that La. R.S. 17:439(A) precludes a cause of action against school employees for certain negligent acts, including acts of commission and acts of omission. The Court otherwise affirmed the court of appeal's ruling that La. R.S. 17:439(D) permits an action directly against a school bus driver for the negligent operation of a school bus to the extent the driver’s liability is covered by insurance or self-insurance.

Medicaid recipient John Doe and the State appealed a trial court's decision allowing the State to partially recover the amount of its lien against Doe's settlement with a third party. In 1992 when Doe was nine years old, he was catastrophically injured and paralyzed in an automobile accident.  Due to Doe's injuries, his mother applied for Medicaid on his behalf in 1994.  Doe later brought suit in New York Supreme Court against the alleged third-party tortfeasors.  He also sued New York State Transit Authority (NYSTA) in the New York Court of Claims.  The State of Vermont notified Doe in January 2001 that it claimed a lien against any award, judgment, or settlement stemming from the accident.  In 2001, Doe settled the lawsuit against the third parties for $8.75 million. Doe's suit against NYSTA went to trial, and in 2004, the Court of Claims awarded Doe approximately $42 million and allocated approximately $2.9 million to Doe's past medical expenses from the date of injury to the date of trial. Between the 2001 and 2006 settlements, the State paid approximately $771,111 in medical expenses for Doe's care, in addition to the medical expenses paid up to the date of the first settlement.  The State claimed a lien on the 2006 settlement for $506,810, which was the difference between the amount the State paid for Doe's medical care under Medicaid and the State's share of litigation expenses. Doe sued the State of Vermont, seeking a declaratory judgment that he satisfied the State's lien by partial payment.  On summary judgment, the court concluded that it would not undo the 2001 settlement because it was an accord and satisfaction of all claims paid for medical expenses incurred to that point in time. The State argued on appeal to the Supreme Court that the trial court should have reduced the Court of Claims' findings of future economic damages to present value before making its lien allocation. Upon review, the Supreme Court concluded the parties' agreement resolved the issues surrounding the State's lien on Doe's first settlement, while leaving open the possibility that Doe would obtain a judgment against or settlement with the NYSTA.. On these facts, the Court agreed with the trial court that there was an accord and satisfaction, and that the State accepted $594,209.03. The case was reversed and remanded to recalculate the State's lien against $771,111 in medical expenses and reasonable attorney's fees, but affirmed in all other respects. 

This case required the Supreme Court to answer a threshold question concerning whether an appeal in this insurance company rehabilitation case could go forward. The court of appeals granted the motion of the Office of the Commissioner of Insurance to dismiss the appeal by the United States. The Commissioner had argued that the appeal should be dismissed either on the grounds that the notice of appeal was fundamentally defective such that the court of appeals had no jurisdiction or on the grounds that the United States had waived its right to appeal issues by failing to appear in the circuit court. The court of appeals concluded that the notice of appeal did not include a signature of an "attorney of record" as Wis. Stat. 802.05 required and dismissed on jurisdictional grounds without deciding the waiver issue. The Supreme Court affirmed on the basis of waiver, holding that the U.S.'s failure to litigate any issues involved in the circuit court precluded the U.S. from pursuing relief in the court of appeals.