Justia Insurance Law Opinion Summaries

On June 28, 2010, Appellant Maria Gomez filed a Worker’s Compensation Complaint with the Industrial Commission (Commission) claiming benefits for an accident that occurred in 2009, when she injured her lower back lifting sixty-pound boxes. The injury occurred at Blackfoot Brass (Dura Mark). Appellant had previously suffered two work-related accidents while working with Dura Mark, one in 2002, the other in 2006, but had returned to work without restrictions after participating in physical therapy for both injuries. The issue before the Supreme Court centered on a Commission order denying reconsideration of Appellant's motion to reopen the record to allow for additional evidence on the issue of causation. The Industrial Commission previously ordered that Appellant had failed to prove the medical treatment she received for a back injury was related to an industrial accident and injury. At the emergency hearing pursuant to the Judicial Rules of Practice and Procedure adopted by the Commission, Appellant introduced evidence regarding her entitlement to reasonable and necessary medical care pursuant to I.C. 72-432, but the referee denied Appellant's claim on the grounds of causation. Upon review, the Supreme Court affirmed the Commission's judgment. In doing so, the Court wanted to provide a "clear message that without a specific stipulation that causation will be a contested issue at the hearing pursuant to I.C. 72-713, and especially if there is a difference of opinion as to causation by opposing parties and their experts, claimant’s attorneys should no longer be lulled by anything other than a stipulation to all legal prerequisites and elements for recovery and be prepared to present evidence of a causal connection between the industrial injury or sickness and the required treatment."

Plaintiffs-Respondents father and daughter Jose and Nayeli Carrillo, father and daughter, sued Boise Tire Co. (Boise Tire), alleging that Boise Tire improperly performed a tire rotation on their vehicle and that as a result, the Carrillos and Marisela Lycan, Jose’s wife and Nayeli's mother, were in a motor vehicle accident. Marisela was killed, Jose was injured, and eighteen-month old Nayeli underwent testing that revealed no physical injury. A jury found that Boise Tire's conduct was reckless. Boise Tire moved for new trial on the grounds that: (1) the Carrillos' pleadings merely alleged negligence and therefore the court committed legal error by permitting the Carrillos to argue that Boise Tire's conduct was reckless; (2) the jury verdict was excessive and the result of passion or prejudice; and (3) the jury verdict was not supported by sufficient evidence. The district court issued a remittitur as to Nayeli's noneconomic damage award but otherwise denied the motion. Boise Tire appealed that denial and the court's holding that I.C. 6-1606 did not require the Carrillos' damage awards to be reduced by the subrogation interest transferred from the Carrillos' insurer to their attorney, nor by social security benefits obtained by the Carrillos. Upon review, the Supreme Court affirmed the district court's denial of Boise Tire's motion for a new trial, vacated the judgment and remanded the case for the district court to reduce Jose's personal injury reward by the value of his social security benefits when judgment was originally entered.

Plaintiffs-Appellants Randolph Farber, Scott Becker, and Critter Clinic (Farber) alleged that the Manager of the Defendant-Respondent State Insurance Fund (SIF or "the Fund") failed to comply with I.C. 72-915, which provides the means by which the SIF Manager may distribute a dividend to policyholders. The district court determined that the gravamen of Farber's claim implicated the statute and held that the three-year statute of limitation provided by I.C. 5-218(1) barred all claims that accrued prior to July 21, 2003. Farber timely appealed. Upon review, the Supreme Court held that the five-year statute of limitation in I.C. 5-216 applied to Farber's claim. Therefore, the Court reversed the trial court's decision and remanded the case for further proceedings.

This was an insurance coverage dispute between the County of Boise and its Insurer, Idaho Counties Risk Mangement Program (ICRMP). ICRMP refused to defend the County in Fair Housing Act (FHA) litigation in federal court, which the County claimed breached its insurance agreement. The district court determined the FHA claims against the County were excluded from the policy and granted summary judgment to ICRMP. Upon review, the Supreme Court concluded the district court properly granted summary judgment to ICRMP based on the land use exclusion in the Policy, and it therefore affirmed the district court's judgment.

Claimant David Tarbet worked for Employer J.R. Simplot Company for thirty-six years until an accident in 2007 left him totally and permanently disabled. The issue before the Industrial Commission (Commission) was whether Employer was liable for all or only a part of Claimant’s income benefits. If Claimant’s total disability resulted solely from the last accident, Employer would be liable for all of the income benefits. If his total disability resulted from the combined effects of both that injury and impairments that pre-existed that injury, then Employer was liable only for that portion of the income benefits for the disability caused by the accident, and the Industrial Special Indemnity Fund (ISIF) would be liable for the remainder. The Industrial Commission found that the April 2007 accident was Claimant’s final industrial accident, that he was totally and permanently disabled as a result of the final accident, and that the impairments that existed prior to that accident did not contribute to his total disability. It found that ISIF was not liable for Claimant’s benefits and dismissed the complaint against it. Employer then appealed. Upon review of the Commission's record, the Supreme Court affirmed the Industrial Commission's order.

Claimant Floyd Fife appealed a decision of the Industrial Commission that found he had failed to prove that his medical condition requiring back surgery was caused by an industrial accident rather than by pre-existing degenerative changes in his thoracic and lumbar spine. An evidentiary hearing was held before a hearing officer on November 5, 2009, but the hearing officer left the employment of the Industrial Commission before submitting proposed findings of fact and conclusions of law. The Commission then reviewed the record and issued its findings of fact, conclusions of law, and order on June 8, 2010. It found the testimony of Claimantâs surgeon unpersuasive, characterizing it as "unclear, to the point of opacity, as to the actual nature of the injury which he claims is responsible for the need for surgery." When the surgeon had been asked whether he could point to any objective pathological findings in any of the diagnostic studies he had performed on Claimant that related to recent trauma, the surgeon answered that he could not. The Commission found convincing the testimony of the physician who conducted the independent medical examination of Claimant. On appeal, Claimant contended that the Commission erred as a matter of law in rejecting the testimony of his surgeon. Upon review, the Supreme Court concluded that because the Commission, as the trier of fact, was not required to accept the testimony of Claimantâs treating physician, the Court affirmed its decision.

Claimant Patrick Williams appealed the Industrial Commission's determination that I.C. 72-802 does not prohibit Respondent Blue cross of Idaho from seeking to exercise its contractual right of subrogation against his lump sum settlement proceeds. Claimant's insurance contract with Blue Cross contained several subrogation and reimbursement provisions. In addition to seeking payment from Blue Cross, Williams filed a complaint with the Industrial Commission seeking workersâ compensation for the medical expenses incurred as a result of two shoulder surgeries, as well as benefits for temporary and permanent disability as a result of such injuries. Claimant entered into a lump sum settlement agreement with the State Insurance Fund. After the agreement was finalized before the Commission, Blue Cross sent a letter to counsel for Williams demanding that, pursuant to Blue Crossâ right of subrogation, he withhold money from the workersâ compensation proceeds for payment to Blue Cross. The Commission ultimately concluded that I.C. 72-802 did not prohibit Blue Cross from seeking to exercise a contractual right of subrogation because Blue Cross is a subrogee, and not a creditor, within the meaning of the statute. However, the Commission found it did not have jurisdiction to consider a breach of contract claim by Blue Cross against Williams and, therefore, determined that Blue Cross must pursue its remedy in district court. Upon review of the applicable legal authority and the Commission's record, the Supreme Court affirmed the Commissionâs determination that Blue Cross was a subrogee under I.C. 72-802.