Justia Insurance Law Opinion Summaries

Laura Miller appeals from a summary judgment entered by the Jefferson Circuit Court ("the circuit court") in favor of the City of Birmingham ("the City"), Sandy Roberts, and Alice Crutchfield (collectively, "the City defendants"). Robert Miller, Laura's husband, was employed by the City as a firefighter. Unum Life Insurance Company of America ("Unum") issued a group life and accidental death and dismemberment policy. According to the summary of benefits, the policy included different life-insurance benefits for active employees and for retired employees. Under the policy, as an active employee, the City paid Robert's insurance premiums, thereby entitling him to a life-insurance benefit of $151,000. However, if Robert were to retire, he would be required to pay his life-insurance premiums and would be entitled to only a $50,000 life-insurance benefit. The summary of benefits specified that, in order to be eligible for a waiver of the life-insurance premiums, the insured had to "be disabled through your elimination period," which was nine months. In 2012, Robert was diagnosed with brain cancer and soon became unable to perform the duties of his job. Laura contended once the Millers learned of Robert's condition, they "sought to obtain information about [Mr. Miller's] life insurance benefit and all other benefits that might be available." The Millers did not have a copy of the policy or the summary of benefits at that time. The Millers and Ed Bluemly, Mrs. Miller's brother-in-law, met with Sandy Roberts, the assistant benefit administrator and the pension coordinator for the Jefferson County Personnel Board, and Alice Crutchfield, a personnel technician for the Jefferson County Personnel Board, to learn about the available benefits. The Millers asked for a copy of the policy, and there was a dispute over whether the Crutchfield gave the Millers a copy. The Millers ultimately sued the City for negligence with respect to the policy and collection of the benefits to which Robert was entitled. After review of this matter, the Supreme Court affirmed the circuit court's summary judgment in favor of the City insofar as the circuit court based its summary judgment in favor of the City on the City defendants' argument that the City was entitled to immunity from Laura's claim alleging wanton and reckless misrepresentation. However, the Court reversed the circuit court's summary judgment in favor of the City defendants in all other respects. The Case was remanded for further proceedings. View "Miller v. City of Birmingham et al." on Justia Law

Plaintiff were a class of state employees and retirees who were enrolled in an Anthem Insurance group health insurance plan at the time of the 2001 demutualization of Anthem Insurance Companies. Plaintiffs brought suit against former Governor John Rowland, the State, Anthem Insurance, and other insurance company defendants alleging that their participation in the plan entitled them to membership in Anthem Insurance and a share of the demutualization proceeds. Plaintiffs claimed that Anthem Insurance and the other insurance company defendants breached their contractual obligations by not paying Plaintiffs for their membership interests and instead distributing their share of the proceeds to the State. The Supreme Court concluded that Plaintiffs’ claims against Rowland and the State were barred by the doctrine of sovereign immunity or otherwise should have been dismissed. After a trial, the trial court rendered judgment for the remaining defendants. The Supreme Court affirmed, holding that the trial court correctly concluded that the relevant contract provisions were ambiguous as to Plaintiffs’ eligibility for membership in Anthem Insurance and their entitlement to a share of the demutualization proceeds and properly considered extrinsic evidence to determine their meaning. View "Gold v. Rowland" on Justia Law

The issue in this workers’ compensation case was whether claimant was entitled to benefits for his “combined condition” claim. Claimant filed- and his employer’s insurer, SAIF Corporation, initially accepted-a claim for a lumbar strain combined with preexisting lumbar disc disease and related conditions. SAIF later denied the combined condition claim on the ground that the lumbar strain had ceased to be the major contributing cause of the combined condition. Claimant objected. He did not contest that his lumbar strain had ceased to be the major contributing cause of his combined condition. Instead, he argued that the otherwise compensable injury was not limited to the lumbar strain that SAIF had accepted as part of his combined condition claim. In claimant’s view, an “otherwise compensable injury” within the meaning of ORS 656.005(7)(a)(B) referred not just to the condition that SAIF accepted, but also includes any other conditions not accepted that might have resulted from the same work-related accident that caused the lumbar strain, and that larger group of work-related conditions continued to be the major contributing cause of his combined condition. As a result, claimant contended that an employer could not close a combined condition claim if any of those non accepted conditions remained the major cause of the combined condition claim. The Workers’ Compensation Board rejected claimant’s argument and upheld SAIF’s denial of claimant’s combined condition claim, concluding that existing precedent defined the “otherwise compensable injury” component of combined conditions to consist of the condition or conditions that the employer has accepted as compensable. The Court of Appeals reversed, acknowledging that its holding was “potentially at odds” with existing precedents from both that court and the Oregon Supreme Court. It nevertheless concluded that those precedents were either distinguishable or should be reconsidered. The Supreme Court concluded that the Court of Appeals erred and that the Workers’ Compensation Board was correct. View "Brown v. SAIF Corp." on Justia Law

Employee-appellant Tracy Meeks sued an insurer for bad faith refusal to timely comply with several orders of the Workers' Compensation Court awarding employee temporary total disability benefits after the insurer, without good cause, withheld employee's benefits on twenty-six separate occasions. Insurer moved for dismissal, asserting employee failed to obtain a certification order from the Workers' Compensation Court (a jurisdictional prerequisite for commencing a bad-faith action in district court). The District Court granted insurer's motion, but the Supreme Court reversed. Because the certification requirements were met here, employee was free to proceed in district court on his bad-faith claim against insurer for insurer's alleged bad faith refusal to provide temporary total disability benefits as ordered by the WCC. View "Meeks v. Guarantee Insurance Co." on Justia Law

Mark Furia was injured while working for Ajax Construction Company. After Furia filed a petition against Ajax in the Workers’ Compensation Court, Ajax petitioned the Workers’ Compensation Court to determine which insurer - Beacon Mutual Insurance Company or Liberty Mutual Insurance Company - was obligated to pay Furia’s claim. The trial judge concluded that Ajax was liable to Furia and that Beacon was primarily liable to Furia. The judge also found that Ajax had dual or overlapping coverage regarding Furia’s claim and, given the overlapping coverage, Liberty must reimburse Beacon for fifty percent of the benefits that Beacon paid to Furia. The Appellate Division vacated the trial judge’s decree and ordered that Beacon be held fully responsible for paying workers’ compensation benefits to Furia and to reimburse Liberty for any benefits paid to beacon by Liberty under the prior decree. The Supreme Court quashed the Appellate Division’s decree, holding that the Appellate Division erred in finding Beacon solely responsible for the payment of Furia’s benefits. View "Ajax Construction Co. v. Liberty Mutual Insurance Co." on Justia Law

Adrian Burdette was seriously injured when he fell while attempting a controlled descent from a cell-phone tower in contravention of instructions by his employer, Chandler Telecom, LLC (“Chandler”), that technicians must climb down from towers. This case presented the question of whether an employee could, in deliberate disobedience of his employer’s explicit prohibition, act in a knowingly dangerous fashion with disregard for the probable consequences of that act, and still recover workers’ compensation when injured by that disobedient act. The Supreme Court concluded that OCGA 34-9-17(a) could bar recovery in such cases. View "Chandler Telecom, LLC v. Burdette" on Justia Law

Kara Sidebottom was injured during the course of her employment. Sidebottom filed a workers’ compensation claim in connection with the work-related injury. In determining Sidebottom’s weekly compensation benefit, the administrative law judge (ALJ) applied Ky. Rev. Stat. 342.140(1)(d). The ALJ determined that Sidebottom was a variable wage employee working on a “wage plus tips” arrangement at the time of her injury. The Uninsured Employers’ Fund appealed, arguing that, at the time of her injury, Sidebottom was a salaried, or fixed wage, employee whose average weekly wage should have been determined in accordance with Ky. Rev. Stat. 342.140(1)(a). The Workers’ Compensation Board disagreed and affirmed the ALJ’s decision. The court of appeals affirmed. The Supreme Court affirmed, holding that the ALJ, and hence the Board, applied the correct statute to the facts in determining Sidebottom’s average weekly wage. Remanded. View "Commonwealth, Uninsured Employers’ Fund v. Sidebottom" on Justia Law

William Poremba (Appellant) was injured in an accident during the course of his employment with Southern Nevada Paving. Southern Nevada Paving, through S&C Claims (collectively, Respondents), accepted Appellant’s workers’ compensation claim and eventually closed the claim. Approximately four years later, Appellant sought to reopen his claim. Respondents denied the request. Appellant administratively appealed. The appeals officer denied Appellant’s attempt to reopen his claim. The district court denied Appellant’s petition for judicial review. The appeals officer and the district court apparently resolved the petition to reopen based on whether Appellant exhausted his funds from a settlement with third-parties involved in the accident on medical expenses. Appellant appealed, arguing, inter alia, that the appeals officer erred in granting summary judgment because he was not required to prove that he spent his excess recovery on medical expenses. The Supreme Court reversed, holding (1) Nev. Rev. Stat. 616C.390 does not require exhaustion or reimbursement as a condition precedent to reopening a workers’ compensation claim; and (2) insurers are only entitled to reimbursement from the portions of third-party recovery allocated to expenses within the scope of workers’ compensation. View "Poremba v. Southern Nevada Paving" on Justia Law

Charlotte Suzor injured her knees in a workplace accident in 1982 and settled her workers’ compensation claims in 1987 with her self-insured employer, reserving the right to seek future medical benefits for ongoing complications from her injury. In 2009, Suzor broke her hip after her knees gave out. Suzor’s physical filed a claim with Sedgwick Claims Management Services (Sedgwick), the third-party administrator for the workers’ compensation plan now funded by her employer’s successor in interest, International Paper Company (International). After Sedgwick denied the claim, Suzor sued International, Sedgwick, and two of Sedgwick’s employees (collectively, Defendants), alleging bad faith and breach of fiduciary duty. The district court entered judgment in favor of Defendants. The Supreme Court affirmed, holding (1) Defendants did not owe Suzor a fiduciary duty; (2) the district court did not abuse its discretion in denying Suzor’s jury instruction on causation; (3) the mistaken association of a wrong juror questionnaire with a juror was not a structural error necessitating a new trial; (4) the jury’s award of no damages was supported by sufficient evidence; and (5) the district court did not abuse its discretion in its award of attorney’s fees. View "Suzor v. International Paper Co." on Justia Law

Bruce Evertson was killed in a two-vehicle accident during the course and scope of his employment. Bruce’s estate filed a wrongful death claim against the insurer of the other driver. The county court accepted a settlement in the matter and allocated the proceeds among Bruce’s widow, Darla Evertson, and adult children. Darla received workers’ compensation benefits from Travelers Indemnity Company as a result of Bruce’s death. Travelers filed a subrogation claim to Darla’s settlement proceeds. The county court ordered that Travelers was not entitled to any distribution of Darla’s proceeds and did not provide Travelers any future credit against the workers’ compensation benefits it owed Darla. The court of appeals affirmed. The Supreme Court vacated the decision of the court of appeals and remanded with directions to vacate the order of the county court, holding that the county court lacked subject matter jurisdiction to hear and decide the subrogation matter. View "In re Estate of Evertson" on Justia Law