Justia Insurance Law Opinion Summaries

Appellant Mary E. Spellman ("Spellman") petitioned the Industrial Accident Board (the "Board") for a workers' compensation award against her employer, Appellee Christiana Care Health Services ("Christiana"). The Board denied the petition and the Superior Court affirmed. Appellant worked as a home health aide, where she used her personal vehicle to attend to Christiana's clients at their homes. While Appellant was reimbursed for mileage between client appointments, she was not reimbursed for travel to the first appointment, from the last appointment, or "off the clock" when she attended to personal business. In the middle of her work day, Appellant was off the clock when her car hit a patch of ice causing Appellant to crash her car. She sustained injuries to her head and hip. In her petition, Appellant argued that her status as a traveling employee exempted her from the "going and coming" rule that precludes workers' compensation for injuries suffered while going or coming from work. Alternatively, Appellant argued her injuries were compensable because she was engaged in a "mixed purpose" trip at the time of her accident. Having "no difficulty" sustaining the judgment of the Superior Court, the Supreme Court affirmed. View "Spellman v. Christiana Care Health Services" on Justia Law

Upon Marcus Degen's purchase of a home, Marcus purchased a homeowner's insurance policy with Hanson Farm Mutual Insurance Company of South Dakota (HFMIC). Marcus, Tina Sellers, and Tina's two daughters moved into the house. One evening, while Marcus was leveling dirt on the property with a skid loader, Marcus hit and killed one of the girls, Adrianna. Tina pursued a wrongful death action against Marcus a year later. HFMIC filed a declaratory judgment action asking the trial court to determine whether it had an obligation to indemnify or defend Marcus in the underlying wrongful death action. The trial court ruled in favor of HFMIC, determining that Adrianna was in Marcus's care and was therefore excluded from coverage under a household exclusion contained in the policy. Both Tina, as the personal representative of her daughter's estate, and Marcus appealed. The Supreme Court affirmed, holding (1) the trial court correctly concluded that the phrase "in your care" was unambiguous and in concluding that Adrianna was in Marcus's care; and (2) because she was in Marcus's care, Adrianna was excluded from coverage under the household exclusion contained in the policy. View "Hanson Farm Mut. Ins. Co. of S.D. v. Degen" on Justia Law

Aetna, Inc. filed a coordinated complaint with Kaiser Foundation Health Plan and Kaiser Foundation Hospitals (together, Kaiser) and Guardian Life Insurance Company (Guardian) against Pfizer, Inc. and Warner-Lambert Company (together, Pfizer). The coordinated plaintiffs asserted that they had suffered injury from the fraudulent marketing of Neurontin for off-label uses, and alleged violations of, inter alia, the Racketeer Influenced and Corrupt Organizations Act (RICO) and the Pennsylvania Insurance Fraud Statute (PIFS). The district court dismissed the claims of Guardian and Aetna but denied summary judgment as to Kaiser's claims. The court then entered judgment against Guardian and Aetna and in favor of Pfizer. The First Circuit Court of Appeals (1) reversed the dismissal of Aetna's RICO claim, as Aetna presented evidence of causation and damages sufficient to survive summary judgment; and (2) vacated the district court's dismissal of Aetna's claim under the PIFS. Remanded. View "Aetna, Inc. v. Pfizer, Inc." on Justia Law

Betty Lu Hughes appealed the district court's grant of summary judgment declaring Owners was not obligated to cover her claim for damages caused by an underinsured motorist. The court concluded that the Owners policy's underinsured motorist coverage did not cover Hughes's claims because the underinsured motorist's liability insurance bodily limit was not "less than" $100,000 as required by the policy's unambiguous definition of "underinsured automobile." The court need not reach the alternative argument that, even if the underinsured motorist's vehicle was "underinsured," the Owners policy set-off provision reduced the amount available under the Owners policy to zero. Accordingly, the court affirmed the judgment. View "Owners Ins. Co. v. Hughes" 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

An employee filed an affidavit of readiness for hearing in her workers' compensation case approximately four years after her employer filed a controversion of her written workers' compensation claim. The employer petitioned to dismiss her claim based on the statutory deadline for a hearing request. After a hearing, the Alaska Workers' Compensation Board dismissed her claim, and the Alaska Workers' Compensation Appeals Commission affirmed the Board's decision. Because the employee did not file a timely request for a hearing and was not excused from doing so, the Supreme Court affirmed the Commission's decision. View "Pruitt v. Providence Extended Care" on Justia Law

State Farm filed a complaint for negligence against Appellant, alleging that Appellant was at fault in an automobile accident with State Farm's insured. Appellant counterclaimed, alleging that State Farm was unjustly enriched as a result of having engaged in the deceptive and unlawful business practice of causing collection-style letters to be mailed in an attempt to collect unadjudicated, potential subrogation claims as debts. Appellant's counterclaim identified two putative classes. State Farm filed a motion to strike the class allegations. Rather than granting the motion to strike class allegations, the circuit court denied class certification "for the reasons stated in State Farm's motion." The Supreme Court reversed, holding that the circuit court acted without due consideration of the Court's foregoing case law on typicality, commonality, and predominance and therefore abused its discretion in prematurely denying class certification at the early pleading stage of this case. Remanded. View "Kersten v. State Farm Mut. Auto. Ins. Co." on Justia Law

Brothers Thomas and Michael Tessier allegedly swindled brothers Frederick and Thaddeus Jakobiec and the estate of their mother out of millions of dollars. This lawsuit covered the Tessiers' theft of almost $100,000 in life insurance proceeds due to a trust benefitting Thaddeus. Thaddeus and various persons affiliated with the trust and estate (collectively, Plaintiffs) filed this action against Merrill Lynch, the company that issued the life insurance policy, claiming that Merrill Lynch made out the insurance proceeds check to the wrong trust entity in breach of the insurance contract, thus allowing the Tessiers to steal the money. The First Circuit Court of Appeals granted summary judgment for Merrill Lynch, concluding that even if Merrill Lynch did breach the contract, its breach was not the cause of Plaintiffs' losses because the Tessiers would have stolen the money even if the check had been made out correctly. The First Circuit Court of Appeals affirmed, holding (1) because the extensive groundwork laid by the Tessiers for their criminal scheme, they could have and would have stolen the insurance money regardless of how Merrill Lynch made out the check; and (2) therefore, the district court correctly granted summary judgment for Merrill Lynch. View "Jakobiec v. Merrill Lynch Life Ins. Co." on Justia Law

Claimant Dorothy Robinson was a police officer for the City of Pittsburgh. In 1997, she sustained a work-related injury, and the City placed her on light-duty. In 2001, while traveling for treatment of her injury, Claimant was involved in an automobile accident in which she sustained new injuries. After the accident, Claimant did not return to her light-duty position nor was she offered any other light-duty work. In late 2004, Claimant received a disability pension. In connection with Claimant’s claim of entitlement to a disability pension, she was examined by three physicians who certified that Claimant was unable to perform her pre-injury job as a police officer. Nearly three years later, an independent medical examiner concluded that although Claimant was not fit to perform her prior job as a police officer, she could perform modified-duty work. The City filed a Petition to Suspend Compensation Benefits, asserting that Claimant was capable of working, "but has voluntarily removed herself from the work force as she has not looked for or sought employment in the general labor market." Claimant filed a response, denying the averments of the suspension petition and asserting that she remained attached to the workforce and had registered for work with the Pennsylvania Job Center. She further claimed that she was not presently working only because of the unavailability of work and because the City had eliminated her light-duty position. The Workers' Compensation Judge denied the suspension petition, concluding that Claimant had not voluntarily removed herself from the workforce. The issue before the Supreme Court in this appeal concerned the assignment of the burden of proof when the employer sought to modify or suspend a claimant's benefits on the basis that the claimant had retired. The Commonwealth Court plurality devised a "totality of the circumstances" test and concluded that the City failed to show that the injured worker had voluntarily withdrawn from the workforce. The City appealed, but the Supreme Court concurred with the Commonwealth Court and affirmed. View "City of Pittsburgh v. WCAB (Robinson)" on Justia Law

Judge, who worked as an airline baggage handler and ramp agent for 20 years, underwent surgery to repair an aortic valve and a dilated ascending aorta. He applied for disability benefits under a group insurance policy issued by MetLife. MetLife denied benefits, finding that Judge was not totally and permanently disabled under the terms of the Plan. After exhausting internal administrative procedures, Judge sued to recover benefits under 29 U.S.C. 1132(a)(1)(B), the Employee Retirement Income Security Act (ERISA). The district court granted judgment on the administrative record in favor of MetLife. The Sixth Circuit affirmed, rejecting arguments that MetLife applied the wrong definition of “total disability,” erred in failing to obtain vocational evidence before concluding that Judge was not totally and permanently disabled, erred in conducting a file review by a nurse in lieu of having Judge undergo independent medical examination, and that there was a conflict of interest because MetLife both evaluates claims and pays benefits under the plan. View "Judge v. Metro. Life Ins. Co." on Justia Law