Justia Insurance Law Opinion Summaries

Doctors' Associates, Inc. (DAI) owns the "Subway" trademark and franchises the right to operate Subway sandwich shops nationwide. A claimant sought workers' compensation benefits for a work-related injury sustained while working for an uninsured Subway franchisee. The DAI and Uninsured Employers' Fund (UEF) were later joined as parties. The sole issue submitted for a decision by the ALJ was whether DAI was a contractor and, thus, liable to the employee of its uninsured subcontractor. The ALJ dismissed the UEF's claim against DAI, ruling that Ky. Rev. Stat. 342.610, which provides that a contractor can be liable to the employee of its uninsured subcontractor, imposed no liability on DAI because the statute did not encompass franchise relationships. The workers' compensation board affirmed. The court of appeals reversed, holding that the ALJ committed by legal error by concluding that the legislature did not intend for section 34.610 to encompass the franchisor-franchisee relationship simply because the statute failed to mention the relationship. The Supreme Court reversed, holding (1) the ALJ erroneously interpreted section 342.610, but (2) the error did not require reversal of the ALJ's ruling because the ALJ properly analyzed the facts of the case under the statute.

Employee suffered a work-related injury to his back in 2004. Employee had also suffered previous accidents resulting in injuries to his lower back. A rating physician determined that Employee's permanent partial disability (PPD) benefits for the 2004 injury should be calculated using a net twenty-six percent impairment rating. Employer's Insurer offered an award to Employee based on a net seventeen percent impairment rating. An appeals officer ordered Insurer to offer Employee a PPD award based on the original impairment rating. The district court affirmed, concluding that Employee's prior impairment rating, which was calculated using an older version of the AMA Guides, should be deducted from his current impairment rating, which was calculated using the current edition of the AMA Guides. The Supreme Court reversed, holding (1) the governing statute required the rating physician to reconcile the different editions of the AMA Guides by first recalculating the percentage of the previous impairment rating using the current edition and then subtracting that recalculated percentage from the current level of impairment; and (2) the district court and appeals officer erred in determining the amount due, and therefore, the PPD award based on the seventeen percent impairment rating for the current injury was proper.

Petitioners sought review of the decision of the First District Court of Appeal in Geico Indemnity Co. v. Shazier on the basis that it conflicted with the decisions of the court in Susco Car Rental System of Florida v. Leonard and Roth v. Old Republic Insurance Co. In Shazier, the district court resolved a question regarding an insurer's duty to defend and indemnify its insured in favor of the insurer. In doing so, the First District relied on a very constricted definition of "consent" and employed an unauthorized driver provision in contradiction of the court's clear precedent to the contrary under Florida's dangerous instrumentality doctrine to defeat coverage. Accordingly, the court quashed the First District's decision and directed that judgment be entered in favor of the insureds and injured parties.

This matter came before the court on the basis of two competing motions related to a petition for the appointment of a receiver under 8 Del. C. 279 for Kraft-Murphy Company, Inc., a defunct Delaware corporation that had been dissolved for more than twelve years. The first motion was a motion to perfect service on the company brought by petitioners, who were claimants in various asbestos-related tort suits filed against the company in various jurisdictions in the mid-Atlantic region. The second motion was a motion to dismiss, filed by the company's insurers on behalf of the company. The court held that service of process could be perfected on the dissolved corporation and that petitioners conceivably could be able to show that a receiver should be appointed for the corporation to enable it to respond to claims brought against it, because the corporation's informal plan of dissolution contemplated using its insurance contracts for that purpose. Therefore, the court granted petitioners' motion to perfect service and denied the company's motion to dismiss.

Employee submitted a claim for workers' compensation under Employer's policy with Insurer, which claim was paid in full. Employee also filed a deliberate intent lawsuit against Employer. After assuming the attorney's fees and costs associated with defending and settling the action, Employer filed a complaint against Insurer, alleging various claims related to Insurer's denial of coverage in the defense of the deliberate intent action. The circuit court granted Employer's motion for partial summary judgment on its bad faith claim against Insurer and awarded damages to Employer. The Supreme Court reversed, holding (1) Insurer met its obligation under W. Va. Code 23-4C-6 to make deliberate intent coverage available to Employer upon the Employer's voluntary request; and (2) because the language of the policy was plain, and the exclusion of deliberate intent coverage was clear, the circuit court erred in concluding that the policy was ambiguous and therefore resulted in deliberate intent coverage being included in the policy under the doctrine of reasonable expectations.

In separate petitions, the Hampton Insurance Agency and Ginger Spencer, Acceptance Indemnity Insurance Company and Ashland General Agency all defendants in an action filed by Mary Alice Patton, d/b/a Hole in the Wall Lounge, petitioned the Supreme Court for a writ of mandamus to direct the trial court to transfer the action to the Tuscaloosa Circuit Court. Ms. Patton purchased insurance for her lounge from Ms. Spencer, an independent insurance agent for Hampton. At issue was the nature and extent of the coverage Ms. Patton sought. The lounge was destroyed by fire in 2009. Upon filing her insurance claim, Ms. Patton was informed that her policy did not include coverage for property damage. Accordingly, Ms. Patton sued because "defendants were negligent and/or wanton in their procurement of full coverage insurance for [Patton] on her lounge building and its contents." Hampton responded with a motion to dismiss or in the alternative, to transfer the case on grounds that the case was filed in an improper venue. Upon review, the Supreme Court found that the defendant insurance companies met the requirements for the writ of mandamus. The Court directed the trial court to vacate its order denying defendants' motions to transfer, and to enter orders granting those motions to transfer to the Tuscaloosa Circuit Court.

Appellant Alexander Michau appealed a ruling by the Appellate Panel of the South Carolina Workers' Compensation Commission (Commission) denying his claim for repetitive trauma injuries to his shoulders. Specifically, Appellant challenged the Commission's interpretation and application of section 42-1-172 of the South Carolina Code. Prior to his injury in 2008, Appellant did not report any work-related problems with his arms to his employer, although he sought outside treatment. The Commission denied Appellant's claim on the grounds that "the greater weight of the medical evidence reflects [Appellant's] upper extremity and shoulder problems are related to pre-existing osteoarthritis and/or rheumatoid arthritis and not caused or aggravated by his employment with Georgetown County." Appellant disputed the admissibility of the Commission's expert doctor's report under South Carolina Code section 42-1-172 because it was not stated "to a reasonable degree of medical certainty." Appellant argued that without this evidence, the remaining competent evidence would support his claim of sustaining a compensable repetitive trauma injury. The Supreme Court concluded after a review of the Commission's record that the doctor was not Appellant's treating doctor, and his employer sought a medical "opinion" to decide the compensability of Appellant's claim. In this instance, the Court concluded that the doctor's testimony was indeed an "opinion" within the meaning of the Code, and therefore inadmissible against Appellant in adjudicating his claim. The Court reversed the Commission's decision to admit the doctor's medical opinion and remanded the case to determine whether the remaining competent evidence supported Appellant's claim of injury.

This case stemmed from a controversy between the insured and their insurer over whether the insurer breached its obligations under a commercial general liability insurance policy that the insureds had with the insurer at the time of the accident. The coverage dispute arose out of a personal injury lawsuit filed against the insured by an injured homeowner. Because the case involved unanswered questions of Florida law that were central to the appeal and because these questions were determinative of the cause in this case and there were no controlling precedents from the Supreme Court of Florida, the court certified these questions for resolution.

Hit by a vehicle in 2004, plaintiff had medical bills of $82,036 that were paid in full by Medicare. The owner of the vehicle settled with plaintiff for $125,000. Medicare sought reimbursement of $62,338 under 42 U.S.C. 13955y(b)(2)(B)(i)., which plaintiff paid under protest. An ALJ rejected plaintiff's argument that an unknown motorist was responsible for 90 percent of the damage so that only 10 percent of the settlement was for medical expenses and the rest was for pain and suffering. The Medicare Appeals Council, district court, and Sixth Circuit affirmed, noting that plaintiff presented no evidence of hardship.

Appellant Indiana Spine Group provided medical services to employees of various businesses for injuries the employees sustained arising out of and during the course of their employment. The employers authorized the services and made partial payments. In each case, more than two years after the last payments were made to the injured employee, Appellant filed with the worker's compensation board an application for adjustment of claim seeking the balance of payments. The Board dismissed the applications as untimely. In each case the court of appeals reversed and remanded. At issue on appeal was what limitation period was applicable to a medical provider's claim seeking payment of outstanding bills for authorized treatment to an employer's employee when the Worker's Compensation Act was silent on the question. The Supreme Court reversed the Board, holding (1) the limitation period contained in the general statute of limitation enumerated in Ind. Code 34-11-1-2 controlled; and (2) because Appellant's claim was timely under the statute, the Board erred by dismissing Appellant's application.