Justia Insurance Law Opinion Summaries

Respondent suffered a work-related back injury. Respondent and her employer entered into a “full, final, and complete” settlement of Respondent’s claims for workers’ compensation benefits related to that injury. Respondent later filed a claim petition seeking additional benefits for the back injury, alleging a lumbar spine injury with consequential depression and anxiety. The employer moved to dismiss the petition on the ground that Respondent was first required to bring a motion to vacate the existing settlement agreement before bringing a new claim. The workers’ compensation judge denied the motion, concluding that the settlement agreement did not foreclose a later claim for consequential psychological injury. The Workers’ Compensation Court of Appeals affirmed, concluding that the settlement agreement did not foreclose claims from the same incident that were not mentioned in the agreement without evidence that those claims were contemplated by the parties at the time they entered into the agreement. The Supreme Court reversed, holding that the language of the settlement agreement was sufficient settle conditions and complications that arise out of, and are a consequence of, Respondent’s workers’ compensation injury. View "Ryan v. Potlatch Corp." on Justia Law

Both of the injured employees in these cases, Charles Morris and Charles Poole, were treated at the Lafayette Bone & Joint Clinic (“LB&J”); Morris was treated by Dr. Louis Blanda and Poole by Dr. John Cobb. Louisiana United Business SIF (“LUBA”), sent letters to LB&J and its doctors stating that LUBA would no longer pay for prescription medications directly dispensed by LB&J and directing LB&J doctors to issue future prescriptions for the instant injured employees that could be filled at local retail pharmacies. Despite these notices and subsequent denials of requests for reimbursement of dispensed prescription medications, LB&J doctors continued to dispense prescription medications to these injured employee patients throughout 2008 and to submit requests for reimbursement to LUBA. LUBA declined payment for these requests, citing its prior notice. LB&J and the treating physicians thereafter filed disputed claim forms with the Office of Workers’ Compensation (OWC), seeking to recover the cost of the medications dispensed, along with penalties and attorney fees. Following a joint trial in these two cases, the OWC judge ruled that the plaintiff/health care providers’ recovery for medications dispensed after the 2008 notice were nonemergency treatment dispensed without consent of the payor. Further, the OWC judge found that no penalties or attorney fees were warranted because LUBA had clearly advised the plaintiff/health care providers that no further reimbursement would be made for prescription medications dispensed by LB&J doctors after the date of the notice. The plaintiff/health care providers appealed, seeking an increase in the amount awarded and an award of penalties and attorney fees. The Louisiana Supreme Court granted writs to review the appellate court decisions, which awarded unreimbursed prescription medication costs beyond the $750 limitation set forth in LSA-R.S. 23:1142(B) and awarded penalties and attorney fees. The Court reversed the appellate court's modification of the amount awarded by the OWC, and affirmed in part, the decision to award penalties and attorney fees. View "LaFayette Bone & Joint Clinic v. Louisiana United Business SIF" on Justia Law

Norma Hoff owned a home she rented through a property management agency. The roof sustained hail damage, and she contracted with Alliance Construction & Restoration, Inc. (Alliance) to make the repairs. Alliance subcontracted the roof repairs to MDR Roofing, Inc. (MDR). MDR employed Hernan Hernandes as a roofer. While working on Hoff's roof, Hernandez fell from a ladder and suffered serious injuries. He filed a workers' compensation claim against MDR, but MDR's insurer, Pinnacol Assurance, denied the claim because MDR's insurance coverage had lapsed. The issue this case presented for the Supreme Court's review was whether Pinnacol had a legal obligation to notify MDR of a certificate of insurance when the policy evidenced by the certificate was cancelled. Based on the certificate at issue in this case and the applicable statute, the Colorado Supreme Court concluded that the insurer had no such obligation. Therefore, the Court reversed the appellate court's judgment to the contrary. View "Pinnacol Assurance v. Hoff" on Justia Law

Bonnie Jones was injured during the course of her employment. Her employer’s comp carrier, American Home Assurance Company, paid her various benefits but did not pay her supplemental income benefits (SIBs) for the fourteenth quarter of 2011. Jones sued, and the parties settled. Under the Texas workers’ compensation regime, where SIBs are concerned, settlements cannot bypass a statutory formula or facilitate benefits were none were due as a matter of law. In this case, the settlement was noncompliant. The trial court approved the proposed settlement, and the court of appeals affirmed. The Supreme Court reversed, holding that a court cannot condone a noncompliant settlement regarding an SIBs award. View "Tex. Dep’t of Ins., Div. of Workers’ Comp. v. Jones" on Justia Law

Plaintiff was injured in accident while working for Speed Mining LLC. Plaintiff and his wife (together, Plaintiffs) filed suit against Speed Mining. Plaintiffs also named as defendants related companies and individuals (collectively, the Baughan defendants). At the time of the accident, Speed Mining was a named insured on a workers’ compensation policy of insurance issued by Old Republic. Plaintiff received workers’ compensation benefits under Speed Mining’s workers’ compensation policy. Plaintiffs later amended their complaint to add a declaratory judgment action against Old Republic, as it had asserted a statutory subrogation lien with respect to any settlement obtained by Plaintiffs from the Baughan defendants. Old Republic asserted its own declaratory judgment action against Plaintiffs. The circuit court entered summary judgment in favor of Plaintiffs. Old Republic subsequently filed a W. Va. R. Civ. P. 60(b) motion for relief from entry of judgment order. The Supreme Court reversed in part and affirmed in part, holding (1) the circuit court erred in denying Old Republic’s Rule 60 motion; but (2) the circuit court correctly granted summary judgment in favor of Plaintiffs because Old Republic’s claim for subrogation failed. View "Old Republic Ins. Co. v. O'Neal" on Justia Law

In 1993, Willie Barnes suffered an amputation of his left leg below the knee in an industrial accident at the Georgia-Pacific (GP) wood processing plant where he worked. GP, its insurer Georgia Conversion Primary Ins. Co. and its workers’ compensation servicing agent CCMSI, accepted the claim as catastrophic and began paying temporary total disability (TTD) benefits. Barnes was fitted with a prosthetic leg and returned to lighter duty work in January 1994. On January 30, 1994, GP stopped paying TTD benefits to Barnes, and the TTD benefits were replaced with permanent partial disability (PPD) benefits. The PPD benefits continued until May 1998. In 2006, the GP plant was sold to Roseburg Forest Products Company (Roseburg). Barnes continued working for Roseburg, but was laid off on September 11, 2009. On November 13, 2009, Barnes consulted a doctor regarding chronic knee pain. Two years later, he was fitted for a new prosthetic leg, which was paid for by CCMSI, the company that continued as the workers’ compensation servicing agent for Roseburg and Roseburg’s insurer, ACE American Insurance Co. (ACE American). On August 30, 2012, Barnes filed a claim to resume TTD benefits, asserting the date of his original workplace accident August 13, 1993 as the date of injury. On November 30, 2012, Barnes filed a separate notice of claim, alleging a fictional new injury based on the date that he was terminated from his employment, September 11, 2009. The Administrative Law Judge denied the claims as barred by the applicable statutes of limitation set out in OCGA 34-9-104 (b) and 34-9-82. The State Board of Workers’ Compensation (Board) affirmed, as did the trial court. However, the Court of Appeals reversed, finding that both of Barnes’ claims were not barred by the applicable statutes of limitation. The Supreme Court concluded the appellate court erred in its interpretation of the applicable statutes of limitations in these cases, and reversed. View "Roseburg Forest Products Co. v. Barnes" on Justia Law

In Employers Insurance Co. of Nevada v. Chandler, the Supreme Court held that an insurer may refuse to pay additional funds when a claimant reopens a workers’ compensation claim until the claimant demonstrates that he or she has exhausted any third-party settlement funds. In the instant case, Appellant, a construction driver, was injured by another driver during the course of his employment. Appellant filed a workers’ compensation claim, which his employer, through a workers’ compensation administrator (collectively, Employer), accepted. Employer eventually closed the claim. When Appellant was unable to return to work, he sought to reopen his claim, but Employer denied it. Appellant filed an administrative appeal. An appeals officer granted Employer summary judgment. At issue on appeal was whether Chandler precluded Appellant from reopening his claim because he spent settlement funds on expenses other than medical costs. The Supreme Court reversed, holding (1) a claimant may reopen his workers’ compensation claim after exhausting his settlement funds on nonmedical expenses; and (2) the appeals officer erred when issuing a decision without detailed findings of fact and conclusions of law. View "Poremba v. Southern Nevada Paving" on Justia Law

Plaintiff was seriously injured while working for Employer. Plaintiff’s injury was caused by the use of her personal vehicle. Plaintiff was able to recover benefits under her auto insurance policy but also sought benefits under Employer’s commercial auto policy. Employer’s insurer (Insurer) denied coverage. Plaintiff brought a claim for coverage, arguing that she was a named insured under Employer’s policy and that she was occupying a temporary substitute for an insured vehicle at the time of her injury. The district court granted summary judgment in favor of Insurer. The Supreme Court (1) affirmed the grant of summary judgment on the issue of whether Plaintiff was a named insured under Employer’s commercial auto policy; but (2) reversed the district court’s order granting Insurer’s motion for summary judgment on the issue of whether Plaintiff’s pickup was a temporary substitute for a covered auto and directed the district court to enter judgment in favor of Plaintiff on her coverage claim, as the evidence was sufficient to establish that Plaintiff’s pickup was a temporary substitute for an insured vehicle, entitling her to judgment on her coverage claim.. View "Stonehocker v. Gulf Ins. Co." on Justia Law

Care West and Ullico, two insurers, were jointly and severally liable for claims arising from an employee’s workplace injury. In a compromise and release agreement, they settled the employee’s claims and apportioned between themselves roughly 50/50 liability for any remaining third party charges. When Ullico became insolvent and was liquidated, responsibility for third party claims against it was assumed by CIGA. The Appeals Board subsequently denied CIGA's motion to dismiss on the ground that the Care West/Ullico agreement limited Care West’s liability to roughly half of any third party claims, thereby rendering Care West’s insurance unavailable as to the remaining half. CIGA petitioned for a writ of review. The court denied the petition, but the Supreme Court granted review and remanded back to the court with directions to hear the matter on the merits. The court now concludes that the Care West/Ullico compromise and release agreement did not relieve Care West of its several liability for third party claims. Accordingly, the court annulled the Appeals Board's decision. View "CA Ins. Guarantee Assoc. v. Workers' Comp. Appeals Bd." on Justia Law

Employee was severely injured while traveling abroad on a business trip. Employer had purchased two workers’ compensation policies from two different insurers, the Insurance Company of the State of Pennsylvania (ISOP) and Great Northern Insurance Company (Great Northern). Both policies provided primary coverage. Employee pursued a workers’ compensation claim. Employer gave notice of the claim only to ISOP. ISOP began making payments pursuant to the policy and defended the claim. When ISOP learned that Employer also had workers’ compensation coverage under its Great Northern policy, ISOP filed a complaint against Great Northern seeking a judgment declaring that the doctrine of equitable contribution required Great Northern to pay one-half of the past and future defense costs and indemnity payments related to Employer’s claim. A federal district court granted summary judgment for Great Northern. ISOP appealed, and the United States Court of Appeals for the First Circuit certified a question to the Supreme Court. The Court answered that, where two primary workers’ compensation insurance policies provide coverage for the same loss arising from an injury to an employee, the insurance company that pays that loss has a right of equitable contribution from the coinsurer, regardless of whether the insured gives notice of the injury only to one insurer. View "Ins. Co. of State of Penn. v. Great N. Ins. Co." on Justia Law