Justia Insurance Law Opinion Summaries

Petitioner Carolyn Holmes began working for linen company Respondent National Service Industries (National). According to Petitioner, the work environment at the facility was "very hot" and "sticky" with "a lot of lint and dust in the air," and was poorly ventilated. Petitioner was exposed to the fumes of bleach and did not wear a protective mask. In 1992, she began experiencing breathing and sinus problems. Petitioner never experienced breathing or sinus problems prior to working for National. In 1995, Petitioner was diagnosed with sarcoidosis, a respiratory and pulmonary condition. Petitioner testified that her doctor did not know what caused her sarcoidosis and that, in light of this statement, she took no further steps to determine the cause of her condition. In July 2005, Petitioner got a second opinion. Petitioner's second doctor stated in his report that it was unclear whether Petitioner's work exposure at National caused her sarcoidosis, but that it was more likely that her exposure to the airborne particles and fumes worsened her condition, which had previously developed. Based on this, Petitioner filed a workers' compensation claim alleging a compensable injury by accident to her lungs and respiratory system arising out of and in the scope of her employment with National on July 12, 2005, the date she alleges she first discovered her sarcoidosis was related to her employment. A single commissioner found Petitioner sustained a compensable injury. The full commission reversed the commissioner, finding petitioner's claim was barred by a two-year statute of limitations. Specifically, the full commission found petitioner was aware of her working conditions and, with some diligence on her part, could have discovered she had a claim more than two years before her filing date. Petitioner appealed. The circuit court and Court of Appeals affirmed the full commission's determination that petitioner failed to file her claim within the statute of limitations. Upon review, the Supreme Court found that the trial and appellate courts correctly found substantial evidence in the record to support the full commission's findings that Petitioner's claim was barred by the statute of limitations. Accordingly, the Court affirmed the appellate courts' decisions.

In this discretionary appeal, the Supreme Court was asked to address whether the "regular use" exclusion in a personal automobile insurance police was valid to preclude payment of underinsured motorist benefits (UIM) to a police officer injured in the course of employment while operating his police vehicle for which the officer did not have an ability to obtain UIM coverage. Appellant Robert Williams was a Pennsylvania State Trooper seriously injured in an accident involving his police vehicle. At the time of the accident, Appellant maintained a personal automobile insurance policy with Government Employees Insurance Company (GEICO). He sought to recover UIM benefits from GEICO from the accident, but GEICO denied coverage citing the "regular use" exclusion contained in the policy. The trial court granted GEICO's motion to dismiss, and the Superior Court affirmed in an unpublished memorandum. Appellant argued on appeal that because of the special factual circumstances and challenges he faces as a state trooper, his insurer should have provided him with UIM coverage "despite the unambiguous policy exclusion because Pennsylvania has a strong public policy of protecting police officers and other first responders such that they are entitled to special treatment." Upon review, the Supreme Court concluded "Appellant's argument simply fails." The Court held that the trial and superior courts were correct in denying Appellant coverage under his UIM policy, and affirmed their decisions.

At issue before the Supreme Court was whether an opinion rendered by a medical expert was sufficient to rebut the presumption of disease causation under the Pennsylvania Workers' Compensation Act. Joseph Kriebel worked for the City of Philadelphia as a firefighter from 1974 to 2003. He died in 2004 from liver disease caused by hepatitis C. His widow Appellant Patricia Kriebel, filed a claim petition under the Act in 2005, alleging that her husband contracted hepatitis C in the course of his employment. Appellant sought to raise the presumption of occupational exposure. In support of her claim, Appellant presented the testimony of her husband's treating physician. The City rebutted the presumption of disease causation with testimony of its own medical expert. Upon review, the Supreme Court held that an expert's opinion does not constitute substantial competent evidence where it is based on a series of assumptions that lack the necessary factual predicate. Since the medical opinions in this case were based on unfounded suppositions, they were legally insufficient to overcome the presumption of disease causation. The Supreme Court reversed the Commonwealth Court that held that the City overcame the presumption with its' medical expert's testimony, and reinstated the order of the superior court which held in favor of Appellant.

At issue before the Supreme Court was whether it was a violation of public policy to exclude from underinsured motorist coverage (UIM) a claim by an individual eligible for workers' compensation benefits. Appellant Frank Heller was severely injured from an automobile accident that happened during the course of his employment as a police officer for Sugarcreek Borough. Workers' Compensation covered his medical expenses and two-thirds of his salary. The Borough paid the remainder of Appellant's salary. Appellant's losses and damages far exceeded the policy limit from the tortfeasor's insurance carrier. Accordingly, Appellant notified his insurer of a potential UIM claim and sought UIM benefits from the Borough pursuant to a policy issued by the Pennsylvania League of Cities and Municipalities. Ultimately, Appellant's claim was denied. Upon review, the Supreme Court concluded that an exclusion in Appellant's workers' compensation policy violated public policy and was therefore unenforceable. The Court reversed the Commonwealth Court which held that the policy considerations favored the insurer: "Invalidating the workers' compensation exclusion would not force [the UIM insurer] to underwrite an unknown risk for which it did not receive compensation. The Borough voluntarily elected to purchase optional UIM coverage. .. [W]e find [Appellant's] assertion that the Borough purchased illusory coverage persuasive… the vast majority of all UIM claims likely will be made by Borough employees who are eligible for workers' compensation. The subject exclusion operates to deny UIM benefits to anyone who is eligible for workers' compensation."

This case arose from an automobile collision in which a police officer employed by the City of Newman was driving a City police car when it was struck by a motor vehicle owned and operated by the insured, who had $25,000 of motor vehicle liability coverage. The City had a Member Coverage Agreement (Agreement) with the Georgia Interlocal Risk Management Agency (GIRMA), established under OCGA 36-85-1 et seq. The officer subsequently sued the insured in tort and served a copy of the complaint on GIRMA to notify GIRMA that it might be held responsible as an uninsured motorist carrier pursuant to OCGA 33-7-11. The court subsequently granted a writ of certiorari to the court of appeals to consider whether that court properly determined that a municipality's motor vehicle liability coverage secured through an interlocal risk management agency was not statutorily obligated to satisfy the requirements for uninsured and underinsured motorist coverage that were applied to commercial insurance policies and private self-insurance plans. The court held that the district court reached the correct conclusion when it determined that there was no authority for the conclusion that an interlocal risk management program such as that offered by GIRMA must include uninsured motorist coverage pursuant to OCGA 33-7-11. Therefore, the Agreement was limited to its express terms and did not include the underinsured motorist protection that the police officer sought. Accordingly, the judgment was affirmed.

In two consolidated cases, Liberty Mutual Fire Insurance Company denied personal injury protection (PIP) benefits to Chung Ahn and Kee Kim (collectively, Insureds) for treatments after motor vehicle accidents. Insureds each sought administrative reviews with the Insurance Division of the Department of Commerce and Consumer Affairs (DCCA). The DCCA granted summary judgment to Liberty Mutual based on the holding in Wilson v. AIG Hawaii Insurance Company, which stated that unless an insurer's non-payment of PIP benefits jeopardizes an insured's ability to reach the minimum amount of medical expenses required to file a tort lawsuit, insureds are not real parties in interest allowed to pursue lawsuits seeking payment of PIP benefits to providers. The circuit court reversed, concluding that Act 198 of 2006 had legislatively overruled Wilson. The intermediate court of appeals (ICA) upheld the circuit court. On appeal, the Supreme Court (1) overruled Wilson, holding that insureds are real parties in interest in actions against insurers regarding PIP benefits; and (2) vacated the ICA and circuit court judgments because at the time of judgment, Act 198 of 2006 was not retrospective, and the real party in interest holding of Wilson was still in effect. Remanded.

Defendant-Appellant Alan Tukes appealed his federal conviction for bank robbery, arguing that the government’s evidence was insufficient to prove that the bank was insured by the Federal Deposit Insurance Corporation (“FDIC”) at the time of the crime. At trial, a prosecutor asked the bank’s branch manager: “Now, the Compass Bank, is that a bank that is federally insured by the [FDIC]?” She responded: “Yes, it is.” When asked whether the bank “has” any documentation proving its insured status, she replied: “Yes. We have a certificate.” When asked whether the certificate “hangs” in the branch, the manager replied in the affirmative. The district court admitted the certificate, dated November 8, 1993, into evidence. The government offered no additional evidence of the bank’s insured status. At summation, Defendant argued that the government had not proven that the bank was FDIC insured at the time of the robbery. The jury returned a guilty verdict. Viewing the evidence in the light most favorable to the government, the Tenth Circuit concluded "it is clear that a rational juror could have concluded beyond a reasonable doubt that the bank was insured at the time of the robbery." The Court affirmed Defendant's conviction.

Appellant appealed the district court's grant of summary judgment in favor of Sun Life in an Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., benefits case. At issue was whether Sun Life was entitled to offset from appellant's employer-provided long-term disability benefits the amount that appellant received in Department of Veterans Affairs (VA) benefits each month. The court held that VA benefits, for a wartime service-related disability, as a matter of statutory construction, did not derive from an act that was "similar to" the SSA or RRA, which were both federal insurance programs based upon employment and the amount of an award under their terms depended upon how much had been paid in. Accordingly, the court reversed and remanded to the district court with directions to enter judgment in favor of appellant.

Mallory Warburton was working for the City of North Las Vegas when she was involved in a car accident and suffered numerous injuries. The City started paying workers' compensation benefits to Warburton at a rate of $10 an hour. At the time of the accident, Warburton was expected to make $12 an hour because of a promotion to manager of one of the City's pools. After an administrative appeal, a hearing officer instructed the City to redetermine Warburton's benefits using the $12-an-hour rate of pay for a pool manager. An appeals officer reversed, concluding Warburton's benefits should be based on the $10-an-hour rate of pay she was actually receiving at the time of the accident. The district court reversed the appeals officer's decision. The Supreme Court affirmed, holding that the appeals officer's conclusion was not supported by substantial evidence and that substantial evidence supported the district court's determination that (1) Warburton's primary job at the time of the accident was that of pool manager, and (2) Warburton's workers' compensation benefits must be determined using an average monthly wage calculation at the $12-an-hour rate of pay.

In 1970, while working for Employer, Employee was injured. In 1989, Employee retired. In 2008, Employee applied for permanent total disability (PTD) compensation. The Industrial Commission of Ohio concluded that Employee was permanently and totally disabled without ruling on the credibility of the assertion that Employee retired because of his injury or determining whether his retirement was voluntary or involuntary. The court of appeals granted Employer a limited writ of mandamus that vacated the Commission's order and ordered the Commission to reconsider the matter. The Supreme Court affirmed the court of appeals, holding that because a voluntary retirement from the work force prior to asserting PTD precludes the payment of compensation for that disability, the court of appeals was correct in ordering further consideration of whether Employee retired because of his injury and whether his retirement was voluntary.