Justia Insurance Law Opinion Summaries

Gear Automotive appealed from the district court's grant of summary judgment in favor of its insurer. Gear Automotive's sole owner suffered an injury that resulted in substantial medical and disability loss. Gear Automotive subsequently sought coverage from its insurer for the owner's injuries. The court concluded that the owner was an employee for purposes of employing the Employee exclusion and that the owner's injury arose out of and in the course of his employment with Gear Automotive. Because the undisputed facts established both elements of the Employee exclusion, Gear Automotive was not entitled to coverage. Ultimately, the owner, as an employee, attempted to recover under a policy of insurance that was not intended to cover Gear Automotive's liability to its employees. Accordingly, the court affirmed the district court's grant of summary judgment. View "Gear Automotive v. Wilshire Ins. Co." 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

Tompkins began working in 1978 and was a participant in the Fund, a multi-employer pension fund established and administered under the Employee Retirement Income Security Act, 29 U.S.C. 1001. In 1999, Tompkins was granted a disability pension based on chronic asthmatic bronchitis, which he attributed to working with cement dust for 22 years. Tompkins’s application included agreement to be bound by all the Fund’s rules and regulations, although he did not inquire about those rules or make any effort to find out what they were. Upon receiving his first monthly payment of $2,115.43, he was required to sign a Retirement Declaration that provided notice of disqualifying employment for plan participants receiving retirement pensions but did not include the rules and regulations specific to disability pensioners. In 2007, the Fund suspended his disability pension, claiming that his full-time employment in 2005 and 2006 indicated that he no longer met the definition of “total and permanent disability.” The district court granted summary judgment in favor of the Fund. The Seventh Circuit affirmed. Although the Fund acknowledged ambiguity, it based its decision on a reasonable interpretation. View "Tompkins v. Cent. Laborers' Pension Fund" 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

K&D Enterprises, through its manager, Mid-America, contracted to purchase an apartment complex. Prior to the closing, K&D Enterprises created a new company, Euclid-Richmond Gardens, and assigned its rights under the purchase agreement to that new company. Euclid-Richmond Gardens hired K&D Group, Inc., a property-management company, to manage the apartment. K&D Group hired former employees of Mid-America and assumed the operations of the complex. The Bureau of Workers' Compensation later conducted an audit and determined K&D Group was the successor in interest to the business operations of Mid-America, a determination that authorized the Bureau to base K&D Group's experience rating, in part, on Mid-America's past experience, which included a large workers' compensation claim. After K&D Group's administrative appeal was denied, K&D Group unsuccessfully filed a mandamus action in the court of appeals. The Supreme Court reversed the judgment of the court of appeals and issued the writ of mandamus, holding that K&D Group was not a successor in interest for purposes of workers' compensation law, and thus, the Bureau abused its discretion when it transferred part of Mid-America's experience rating to K&D Group. View "State ex rel. K&D Group, Inc. v. Buehrer" 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

Petitioner Jose Cardoza brought this lawsuit pursuant to the Employee Retirement Income Security Act of 1974 (ERISA), to challenge United of Omaha Life Insurance Company’s calculation of his long-term disability benefits (LTD benefits). United of Omaha answered, asserting its calculation was appropriate, and counterclaimed, demanding that Petitioner reimburse it for payments of short-term disability benefits (STD benefits) which it claimed were miscalculated. On cross-motions, the district court granted Petitioner's motion for summary judgment and denied United of Omaha’s motion, concluding United of Omaha’s decision to calculate Petitioner's LTD benefits and recalculate his STD benefits as it did was arbitrary and capricious. United of Omaha appealed. Upon review, the Tenth Circuit concluded that the district court erred in granting Petitioner's motion for summary judgment with respect to United of Omaha’s LTD benefits calculation: "[t]he plain language of the long-term disability benefits policy instructed United of Omaha to base its calculation of Cardoza’s LTD benefits on his earnings as verified by the premium it received. Thus, United of Omaha’s decision to do so was reasonable and made in good faith." The district court did not err, however, in granting Petitioner's motion for summary judgment with respect to United of Omaha’s recalculation of his STD benefits and demand for reimbursement "United of Omaha’s decision to recalculate Cardoza’s STD benefits based on his earnings verified by premium rather than his actual earnings was not reasonable." The Court therefore reversed in part, affirmed in part, and remanded the case to the district court for further proceedings. View "Cardoza v. United of Omaha Life Insurance" on Justia Law

Pagliara, a licensed securities broker for more than 25 years, maintained a spotless record with the Financial Industry Regulatory Authority (FINRA) except for this case. Under a 2002 licensing agreement, Pagliara served both Capital Trust and NBC until 2008. During that time, Butler followed Pagliara’s recommendation to invest $100,000 in bank stocks that later lost value. Butler’s attorney threatened to sue NBC and Pagliara. NBC retained JBPR for defense. Unbeknownst to NBC and JBPR, Pagliara offered to settle the claim for $14,900, $100 below FINRA’s mandatory reporting threshold. Butler refused. Pagliara then informed NBC of his intent to defend the claim in FINRA Arbitration and objected to any settlement of the “frivolous claim.” NBC insisted that Pagliara not have any contact with Butler, based on the License Agreement signed by the parties, which stated that: “NBCS, at its sole option and without the prior approval of either [Capital Trust] or the applicable Representative, may settle or compromise any claim at any time.” JBPR finalized a $30,000 settlement without obtaining a release for Pagliara. Pagliara sued, alleging breach of fiduciary duty, violation of the Tennessee Consumer Protection Act, and intentional infliction of harm. The district court rejected the claims. The Sixth Circuit affirmed. View "Pagliara v. Johnston Barton Proctor & Rose, LLP" on Justia Law

Insured was injured in an accident. Insured's policy with Insurer included uninsured motorist (UM) bodily injury coverage and personal injury protection (PIP) coverage. Insured's Employer's third-party workers' compensation (WC) administrator asserted a subrogation right against any PIP or UM recovery by Insured. At issue in this case was the correct interpretation of Md. Code Ins. 19-513. The district court asked the Court of Appeals to determine whether section 19-513(e) requires an insurance company to deduct WC benefits payable to an insured for UM and PIP when the insured has not reimbursed its provider and the insured intends to reimburse the WC provider in the future. The Court of Appeals held (1) under the plain meaning of section 19-513(e), an insured's benefits payable under UM and PIP coverage shall be reduced to the extent that the insured recovered benefits under WC and the WC provider has not been reimbursed; and (2) if the applicable workers' compensation law treats "write-downs" of medical bills as WC benefits, and the WC benefits have not been reimbursed, then the insurer shall deduct those benefits, calculated as discounts, from its benefits payable to the insured under section 19-513(e). View "Travco Ins. Co. v. Williams" on Justia Law