Justia Insurance Law Opinion Summaries

During a fight in a bar, the insured hit an individual with a glass mug, resulting in emergency surgery and permanent scars. The parties negotiated a settlement of civil liability that included the injured party's promise not to pursue criminal charges. The homeowner's insurance policy at issue covers only accidental injuries and prohibits the insured from making voluntary payments. The company invoked the voluntary payment clause and refused to pay the settlement or attorney fees. The district court ruled in favor of the company. The First Circuit affirmed, finding that, even if there was a duty to defend, the company did not breach that duty. The company had investigated the claim, as required, and the actions of the parties' efforts to avoid criminal prosecutions prevented its participation in negotiations.

Appellant Margerita Cervantes allegedly contracted hepatitis C as a result of treatment she received at the Endoscopy Center of Southern Nevada (ECSN). Appellant obtained treatment at ECSN as part of the health care benefits she received through her culinary union. The union operated a self-funded ERISA health care plan and retained Respondents, Health Plan of Nevada and other health and life insurance entities, as its agents to assist in establishing a network of the plan's chosen medical provider. Appellant filed a lawsuit alleging that Respondents were responsible for her injuries because they failed to ensure the quality of care provided by ECSN and referred her to a blatantly unsafe medical provider. The district court concluded that Cervantes' claims were preempted by ERISA section 514(a). The Supreme Court affirmed, holding that state law claims of negligence and negligence per se against a managed care organization contracted by an ERISA plan to facilitate the development of the ERISA plan's network of health care providers were precluded by ERISA section 514.

Charles Rawlings suffered injuries as he was rolling straps beside his tractor-trailer while it was being unloaded. Thirteen months after the accident, Rawlings filed an action against Defendants, his employer and the companies involved in loading and unloading the trailer. The trial court granted summary judgment in favor of Defendants and dismissed the action based on the one-year statute of limitations for personal injury claims in Ky. Rev. Stat. 413.140(1)(a). The court of appeals reversed, applying the two-year statute of limitations in the Motor Vehicle Reparations Act. At issue on appeal was whether Rawlings was in fact unloading his truck at the time of the accident, which would determine whether the one- or two-year statute of limitations applied. The Supreme Court reversed, holding (1) Rawlings's activity in releasing the straps and rolling them qualified him as a participant in the unloading process; and (2) therefore, the trial court correctly applied the one-year personal injury statute of limitations found in section 413.140(1)(a). Remanded.

This case arose when plaintiff, who was exposed to various chemicals during his employment with defendant and subsequently became legally blind in both eyes, sought workers compensation benefits under the Longshore and Harbor Workers' Compensation Act (LHWCA), 33 U.S.C. 901-950. At issue was which date - the date on which disability occurred, or the date one which the injured employee was awarded benefits for such disability - determined the maximum weekly rate of compensation for a permanently totally disabled employee who was "newly awarded compensation." The court applied long-standing principles of statutory construction and found that the maximum weekly rate of compensation was governed by the rate in effect at the time of the award. Therefore, the court reversed the decision of the district court and remanded for calculation of the sum to be paid.

Defendant contractor entered into a contract to replace a roof. When the newly installed roof developed leaks, Defendant hired an independent contractor to make repairs. While performing the work, the independent contractor caused a fire, resulting in a large insurance claim by the homeowners. As subrogor to the homeowners' rights and claims arising out of the fire, Plaintiff insurance company sued Defendant in tort and contract. The trial court granted Defendant's motion for summary judgment on all claims, finding that because Defendant had subcontracted the work, he could not be liable. The court of appeals reversed. The Supreme Court affirmed, holding that Defendant had an implied non-delegable duty to install the roof in a careful, skillful, diligent, and workmanlike manner. Remanded.

Hospital records state that decedent died of a nonsurvivable head injury following an accidental fall at a casino. An insurer refused to pay, claiming that the fall was likely caused by a stroke, so that death was not "accidental" within the meaning of the policy. The company's expert testified accordingly. The district court entered judgment in favor of the company. The First Circuit affirmed. The district court did not err in admitting the expert's testimony; it fell within the scope of his previously disclosed report. The estate was not prejudiced by any difference between the report and testimony.

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.

Plaintiff ProSelect Insurance Company filed this declaratory relief action to determine its duty to indemnify its insured in a lawsuit alleging medical malpractice and sexual assault. The trial court construed a policy exclusion to bar coverage and entered judgment in favor of ProSelect. Plaintiff Robyn Levy appealed that judgment, asserting that: (1) the malpractice claims are covered under the concurrent causation doctrine; and (2) the policy exclusion as interpreted by the trial court contravenes public policy. Plaintiff alleged she began psychiatric counseling with Defendant's insured, Dr. Peter McKenna from 2003-2005. In that time, Plaintiff alleged Dr. McKenna negligently failed to properly diagnose her psychological disorder, prescribed harmful medications, encouraged her to pursue "unhealthy lifestyle choices," failed to refer her to a community-based mental health program, and engaged in treatment "at variance with accepted professional protocols." In a separate count, Levy alleged that, "[i]n the course of . . . treatment," Dr. McKenna had committed sexual assault and battery. ProSelect filed suit seeking a declaration that its professional liability policy excluded coverage of Plaintiff's suit. The trial court reasoned that the underlying action was indisputably a "suit" that contains an allegation of sexual assault. Therefore, by its plain terms the policy barred coverage of the complaint in its entirety, "[e]ven assuming" that the medical malpractice count was—as Plaintiff claimed—"totally unrelated" to the sexual assault and therefore otherwise covered. The trial court thus granted ProSelect’s motion and entered judgment in its favor. Upon review, the Supreme Court found that Plaintiff's malpractice and assault claims could not be viewed as separate or independent causes, and coverage can not be grounded on the "concurrent causation doctrine." Furthermore, without a basis in the concurrent causation doctrine, there was no violation of public policy Accordingly, the Court affirmed the trial court's judgment.

Plaintiffs Thomas and Margaret McGoff appealed a superior court order that granted Defendant Acadia Insurance Company summary judgment with respect to Plaintiffs’ underinsured motorists (UIM) claim arising from an automobile accident in which Thomas McGoff was injured. Thomas McGoff was employed by A.R. Sandri, Inc., a Massachusetts corporation that operates gas stations and other businesses in New England and New York. At the time of the accident that led to the instant lawsuit, Sandri had supplied McGoff with a company car which he kept at his Barre, Vermont home. The Plymouth was owned by Sandri, registered in Massachusetts, and insured by Acadia. Sandri had two fleet insurance policies with Acadia—one for vehicles registered in Massachusetts and one for vehicles registered in other states. The Plymouth was covered by the policy issued for vehicles registered in Massachusetts. The policy listed the vehicles as being garaged in Massachusetts, apparently based on Sandri’s representation. McGoff made a claim against the other driver and a claim for additional UIM coverage against Acadia. Acadia denied coverage because the policy’s UIM coverage was less than the alleged tortfeasor’s liability coverage. Based on this, Acadia moved for summary judgment. In May 2010, the court granted Acadia’s motion, ruling that Vermont’s uninsured/underinsured (UM/UIM) insurance requirements do not apply to the Acadia fleet policy because the policy was not "delivered or issued for delivery in this state." Without setting forth "[a] statement of the issues presented for review," Plaintiffs generally claimed on appeal that the superior court erred by granting Acadia summary judgment. Specifically, Plaintiffs argued the court erred in ruling that Vermont’s UIM requirements do not apply to the instant policy on grounds that the policy was not delivered or issued for delivery in Vermont. Because the Plymouth was garaged in Vermont rather than in Massachusetts (as indicated in the Acadia policy), they maintained the vehicle should have been registered in Vermont rather than Massachusetts and the Vermont UIM requirements should apply. Upon review of the parties briefs and the trial record, the Supreme Court found that Plaintiffs' position was contrary to the plain language of the UIM statute as well as the nearly unanimous relevant case law, and therefore the Court decline to adopt it under the present circumstances. The Court affirmed the superior court's grant of summary judgment to the insurer.

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.