Justia Insurance Law Opinion Summaries

A hotel worker fell and injured her back while cleaning a room. Her employer initially paid benefits, but it filed a controversion of benefits after its doctor doubted the accident’s occurrence and said any work injury was not the substantial cause of the worker’s continuing need for medical care. The Alaska Workers’ Compensation Board decided that the fall was the substantial cause of the worker’s disability, finding the worker’s testimony about the injury credible and the employer’s doctor’s testimony not credible. Based on the testimony of the worker and her treating physician, as well as an MRI showing a herniated disc, the Board decided that the injury was compensable. The Alaska Workers’ Compensation Appeals Commission reversed the Board’s decision because, in the its view, substantial evidence did not support the decision. Because the Commission incorrectly decided the substantial evidence question, the Supreme Court reversed the Commission’s decision. View "Sosa de Rosario v. Chenega Lodging" on Justia Law

Two employees of Connections CSP, Inc. were killed in an automobile collision during the course and scope of their employment. Connections owned the vehicle and had purchased underinsured motorist insurance (UIM) for the vehicle and also worker's compensation insurance which covered the employees. The UIM insurer paid its policy limit of $1,000,000. The worker's compensation insurer also paid benefits to the representatives of the decedents. The worker's compensation insurer then sought to enforce a lien upon the UIM payment equal to the worker's compensation benefits it paid. But the UIM policy specifically excluded the direct or indirect benefit of any insurer or self-insurer under a worker's compensation claim. Notwithstanding this exclusion, the Superior Court enforced the lien based upon its interpretation of 19 Del. C. 2363(e), which allows reimbursement of a worker's compensation carrier "from the third party liability insurer." The UIM insurer appealed. Upon review, the Supreme Court held that General Assembly eliminated the ability of a worker's compensation insurer to assert a lien against the UIM payments made pursuant to the employer's UIM policy. Because the Superior Court erred as a matter of law in enforcing a lien, the Supreme Court reversed its decision and remanded the case for further proceedings. View "Simendinger v. National Union Fire Insurance Co." on Justia Law

The issue before the Supreme Court in this case was one of first impression: whether the Louisiana Workers’ Compensation Law (specifically La. R.S. 23:1036) as the exclusive remedy for a volunteer firefighter in claims for personal injury against the "fire company," similarly applies to claims for personal injury against fellow volunteer members. After reviewing the record and the law, the Court found the defendant failed to establish that the Workers’ Compensation Law granted immunity to fellow volunteer members of a volunteer fire company from suits in tort. Accordingly, the Court affirmed the decisions of the lower courts in denying the defendants’ motion for summary judgment. View "Champagne v. American Alternative Ins. Corp." on Justia Law

While serving time in the county jail, plaintiff labored in a county work program under the sheriff's supervision. At issue was whether plaintiff was covered under the Mississippi Workers' Compensation Act (MWCA), Mississippi Code 47-5-417, -567, and thus was entitled to compensation benefits for injuries sustained while he was on work detail. The county and the medical corporation that treated plaintiff sought reimbursement of medical expenses from the Mississippi Public Entities Workers' Compensation Trust (MPE), the provider of workers' compensation insurance from the county. The court concluded as a matter of law that the county had no enforceable contract to hire plaintiff, a prerequisite of coverage, and therefore, the court affirmed the district court's summary judgment in favor of MPE. View "Vuncannon, et al v. United States" on Justia Law

Plaintiff was an additional insured on a commercial general liability insurance policy, which was issued to Plaintiff's tenant (Tenant) by Defendant, Travelers Property Casualty Company (Travelers). Plaintiff sought to invoke Travelers' duty to defend under the policy after Sarah Middeleer was injured in a fall on Plaintiff's property and brought the underlying action against Plaintiff. Plaintiff's insurer, the Netherlands Insurance Company (Netherlands), provided a defense to Plaintiff after Travelers denied any duty to defend Plaintiff in the underlying action. Plaintiff then brought the present action claiming Travelers had a duty to defend Plaintiff in the underlying action and Travelers was obligated to reimburse Netherlands for the defense costs it had expended. The trial court granted Plaintiff's motion for summary judgment. The appellate court reversed, concluding that Middeleer's injuries did not arise out of the use of the leased premises under the terms of the policy. The Supreme Court affirmed, holding that the appellate court correctly construed the governing policy language and properly concluded that Travelers did not have a duty to defend Plaintiff. View "Misiti, LLC v. Travelers Prop. Cas. Co. of Am." on Justia Law

While receiving workers' compensation benefits for an injury, an employee periodically endorsed benefit checks that included a certification that she had "not worked in any employment or self-employment gainful or otherwise." Her employer obtained surveillance videos of her activities at an herb store owned by her boyfriend and filed a petition with the Workers' Compensation Board alleging that she had fraudulently misrepresented her employment status for the purpose of obtaining benefits. The Board denied the petition, finding credible the employee's testimony that she did not consider her activities to be work that needed to be reported. On appeal, the Alaska Workers' Compensation Appeals Commission concluded that the Board erred in determining that the employee had not "knowingly" misrepresented her work status, but it affirmed the Board's denial of the petition on the alternative ground that the employer had not shown the requisite causal link between the allegedly fraudulent check endorsements and the payment of benefits. Upon review of the matter, the Supreme Court concluded that the Commission erred in its interpretation of the "knowingly" element of the test for fraud. Nevertheless, the Court affirmed the Commission's decision because, based on the Board's binding credibility determination, the employee's statements were not knowingly false and therefore not fraudulent. View "ARCTEC Services v. Cummings" on Justia Law

Tiara Condominium Association (Tiara) retained Marsh & McLennan (Marsh) as its insurance broker. Marsh secured windstorm coverage through Citizens Property Insurance Corporation (Citizens), which issued a policy that contained a loss limit in an amount close to $50 million. Tiara's condominium subsequently sustained damages caused by two hurricanes. After being assured by Marsh that the loss limits coverage was per occurrence, Tiara spent more than $100 million in remediation efforts. However, when Tiara sought payment from Citizens, Citizens claimed that the loss limit was $50 million in the aggregate, not per occurrence. Tiara filed suit against Marsh, alleging, inter alia, breach of contract, breach of fiduciary duty, and negligence. The trial court granted summary judgment for Marsh on all claims. The appeals affirmed with the exception of the negligence and breach of fiduciary claims, as to which it certified a question to the Supreme Court to determine whether the economic loss rule prohibits recovery, or whether an insurance broker falls within the professional services exception that would allow Tiara to proceed with the claims. The Court answered by holding that the application of the economic loss rule is limited to products liability cases. View "Tiara Condo. Ass'n, Inc. v. Marsh & McLennan Cos. " on Justia Law

Petitioner Michael Crisp, Jr. worked for Employer SouthCo, Inc., seeding grass and performing odd construction jobs. In 2004, Petitioner and other workers were installing silt fencing to combat ground erosion. Petitioner held a pole while another worker operated the Bobcat. As Petitioner bent down to reach for a pole, the bucket of the Bobcat fell on Petitioner, covering him. Petitioner suffered injuries to his head and hands. At the emergency room, Petitioner was treated for abrasions and bruises to the back of the head and neck and a complex fracture in his right hand. There was no mention of a brain injury in Petitioner's hospital records. Nearly two years after his injury, Petitioner's doctor opined that Petitioner sustained physical brain injury as a result of his 2004 injury. Petitioner's eventual workers' compensation claim for the brain injury was denied, and he petitioned the Supreme Court for review of an appellate court's decision to reverse a circuit court's finding that he sustained a compensable brain injury. Upon review, the Supreme Court reversed the appellate court and remanded the case for further consideration of whether Petitioner sustained physical brain damage as contemplated under the Workers' Compensation Act which would entitle him to benefits for life. View "Crisp v. SouthCo." on Justia Law

Palmetto Hardwood, Inc. employed Petitioner Clifton Sparks as a saw operator. Petitioner suffered three work-related injuries during this employment, the first two of which injured Petitioner's lower back. In the third incident, Petitioner was required to remove a piece of metal from under a gang saw. In the process, the metal exploded and a three- to four-inch cubic piece struck him in the head. Petitioner subsequently sought workers' compensation for his injuries. Six doctors opined regarding whether Petitioner had suffered a physical brain injury. The Commission found that Petitioner had sustained a compensable injury to his head. It also found him to be totally and permanently disabled. The Commission ruled that Petitioner should receive only five hundred weeks of compensation as a result of his total and permanent disability and medical expenses causally related to the three compensable injuries. On appeal, the circuit court remanded to the Commission for it: (1) to explain whether the "physical brain injury" it found "border[ed] on the frivolous" was intended to be the same as or different from "physical brain damage" as used in section 42-9-10 (C); and (2) to reconcile the order's seemingly contradictory findings that Petitioner suffered a compensable injury to the head with its finding of no physical brain injury. On appeal, the circuit court affirmed the Commission's order. Petitioner subsequently appealed to the Court of Appeals, which affirmed in an unpublished opinion. On appeal to the Supreme Court, Petitioner argued that the Court of Appeals erred when it applied an improper definition of "physical brain damage" within the meaning of section 42-9-10(C). The Supreme Court disagreed and affirmed the circuit court. View "Sparks v. Palmetto Hardwood" on Justia Law

Plaintiffs, Katherine and Michael, were living together in a home that was destroyed by a fire in 1998. Seeking to rebuild their home, Michael and Katherine completed an application for property insurance with American Family Mutual Insurance Company. American Family issued the policy. In 2003, Plaintiffs' garage was destroyed in a fire, and Plaintiffs filed a claim with American Family. During follow-up investigations, Michael disclosed the 1998 fire to American Family. American Family, treating the prior fire loss nondisclosure as a misrepresentation, voided the insurance policy ab initio and denied Plaintiffs' claim. Plaintiffs filed suit against American Family claiming breach of contract and intentional infliction of emotional distress. The trial court granted summary judgment for American Family. Plaintiffs appealed, challenging the grant of summary judgment on grounds that American Family failed to return the premiums paid by Plaintiffs. The Supreme Court affirmed, holding that Plaintiffs' assignment of error was not properly before the Court on appeal. View "Dodd v. Am. Family Mut. Ins. Co." on Justia Law