Justia Insurance Law Opinion Summaries

The Workers’ Compensation Commission and an Administrative Judge (AJ) had ordered Gamma Healthcare and Employers Insurance Company of Wausau (Employer/Carrier) to replace Sharon Grantham’s septic and HVAC systems and to pay for insurance on a handicapped-accessible van. The Commission, sua sponte, issued a separate order sanctioning the Employer/Carrier for causing an unnecessary delay by appealing the AJ’s order to the full Commission without reasonable grounds. The Employer/Carrier appealed. While this case was pending before the Court of Appeals, Sharon Grantham died. Thereafter, the Court of Appeals dismissed the case as moot. The Court of Appeals applied the general rule followed by federal courts by vacating the outstanding Commission and AJ orders. The appeals court reversed and rendered the Commission’s sanctions order against the Employer/Carrier, determining that the Commission had abused its discretion by its imposition of the sanction, reasoning that the Employer/Carrier had a reasonable legal argument for its appeal. Grantham’s estate filed a petition for a writ of certiorari, which the Mississippi Supreme Court granted. The Supreme Court concluded that in light of Grantham’s untimely death and the concession by her estate, it agreed with the Court of Appeals that this case was moot. "However, the main issue is not whether the case is moot. Rather it is whether the Court of Appeals erred by vacating the Commission’s and the AJ’s valid orders to replace the septic and HVAC systems in a case that became moot on appeal due to circumstances beyond the control of the parties. Additionally, did the court err by following federal vacatur law instead of existing Mississippi law?" These were issues of first impression. the Supreme Court found that the Court of Appeals did not err and that the federal vacatur rule was appropriate. The Commission’s orders were vacated properly. Furthermore, the Supreme Court affirmed the Court of Appeals’ reversing and rendering of the Commission’s sanctions award. View "Gamma Healthcare Inc., et al. v. Estate of Sharon Burrell Grantham" on Justia Law

In 2011, during the course and scope of his employment as a shipwright, Claimant Robert Arlet slipped and fell on an icy sidewalk on the premises of his employer, Flagship Niagara League (Employer), sustaining injuries. Employer had obtained a Commercial Hull Policy from Acadia Insurance Company (Insurer). Through the policy, Insurer provided coverage for damages caused by the Brig Niagara and for Jones Act protection and indemnity coverage for the “seventeen (17) crewmembers” of the Brig Niagara. Employer had also at some point obtained workers’ compensation insurance from the State Workers’ Insurance Fund (SWIF). Insurer paid benefits to Claimant under its Commercial Hull Policy’s “maintenance and cure” provision. Claimant filed for workers’ compensation benefits. Employer asserted Claimant’s remedy was exclusively governed by the Jones Act. Employer also filed to join SWIF as an additional insurer in the event the Workers' Compensation Act (WCA) was deemed to supply the applicable exclusive remedy, and Employer was found to be liable thereunder. SWIF denied coverage, alleging Employer’s policy was lapsed at the time of Claimant’s injury. Thereafter, Claimant filed an Uninsured Employers Guaranty Fund (UEGF) claim petition, asserting the fund’s liability in the event he prevailed, and Employer was deemed uncovered by SWIF and failed to pay. The Workers’ Compensation Appeals Board (WCAB) found that as a land-based employee, Claimant did not meet the definition of seaman under the Jones Act and was, therefore, entitled to pursue his workers’ compensation claim. The issue this case presented for the Pennsylvania Supreme Court's review was one of first impression: the right of an insurer to subrogation under the WCA. The Supreme Court concluded Insurer’s Commercial Hull Policy did not cover Claimant, because Claimant was not a “seaman” or crew member. The WCA’s exclusive remedy applied, but Insurer was seeking subrogation for payment it made on a loss it did not cover. "[T]he 'no-coverage exception' to the general equitable rule precluding an insurer from pursuing subrogation against its insured comports with the purposes and public policy supporting the rule and hereby adopt it as the law of this Commonwealth. ... any equitable rule precluding an insurer from seeking subrogation against its insured is best tempered by the exception adopted herein today." View "Arlet v. WCAB (L&I)" on Justia Law

Munoz sued general contractor, Bulley & Andrews, for injuries he sustained while an employee of its subcontractor, Bulley Concrete. Bulley & Andrews had paid workers’ compensation insurance premiums and benefits for the subcontractor and its employees. Each company has its own distinct federal tax identification number and files separate federal and state income tax returns. The companies have different presidents and employ different workers.The circuit court dismissed, finding that the genderal contractor was immune from the lawsuit under the exclusive remedy provisions of the Workers’ Compensation Act (820 ILCS 305/5(a). The appellate court affirmed.The Illinois Supreme Court reversed. The exclusive remedy provisions do not extend to a general contractor who is not the employee’s immediate employer. Immunity does not hinge on the payment of benefits. Bulley & Andrews had no legal obligation to provide workers’ compensation insurance for Bulley Concrete employees. The fact that Bulley Concrete was a subsidiary of Bulley & Andrews is of no import. If a parent company and its subsidiary are operated as separate entities, only the entity that was the immediate employer of the injured worker is entitled to immunity. The Act bars an employee from bringing a civil suit directly against his employer but does not limit the employee’s recovery from a third-party general contractor. View "Munoz v. Bulley & Andrews, LLC" on Justia Law

Taleetha Fuentes filed a worker's compensation complaint against her employer Cavco Industries and Cavco’s surety, Sentry Casualty Company (collectively, Defendants). Fuentes filed her complaint in July 2019, and the Defendants denied the claim. During discovery, the Defendants filed a motion to compel in October 2019, which was granted. Following no response from Fuentes, the Defendants filed a motion for sanctions, and Fuentes again did not respond. On December 19, 2019, the full Idaho Industrial Commission issued an Order Dismissing Complaint, citing Industrial Commission Judicial Rule of Procedure (JRP) 12(B). Five months later, in May 2020, Fuentes responded to the initial discovery requests and moved to retain the case on the active calendar, but her filing and motion were returned “unfiled” as explained in an email from the assigned Referee. Fuentes also moved for reconsideration of the dismissal and filed a petition to vacate the order of dismissal under JRP 15. The Commission denied both motions. The Idaho Supreme Court determined the Commission acted in excess of its powers when it misapplied JRP12(B) in the initial dismissal order, and in applying JRP 16 to Fuentes' case. Accordingly, the Court reversed the Commission’s decision to dismiss Fuentes’ case, and vacated the order. The case was remanded for further proceedings. View "Fuentes v. Cavco Industries, Inc." on Justia Law

The Supreme Judicial Court affirmed the decision of the appellate division of the Workers' Compensation Board affirming the decision of an administrative law judge (ALJ) granting Plaintiff's petition for award of compensation, holding that an employee is not required to give notice of his occupational disease claim to his former employer's insurer when the employer no longer exists.Nearly twenty years after retiring from his employment Plaintiff underwent surgery for lung cancer and was later diagnosed with asbestosis. Plaintiff filed five petitions for award of compensation, each alleging a different date of injury and naming and different employer and insurer pairing. The ALJ (1) found that Plaintiff's last injurious exposure to asbestos occurred when he was working for Auburn Sheet Metal, which was insured by Maine Employers' Mutual Insurance Company (MEMIC) but no longer existed, and (2) granted Plaintiff's petition for an award of compensation. The appellate division concluded that Plaintiff was not required to provide notice to MEMIC. The Supreme Court affirmed, holding that the appellate division did not err in concluding that the workers' compensation statute does not impose on an injured employee whose employer no longer exists the duty to give notice to the insurer. View "Desgrosseilliers v. Auburn Sheet Metal" on Justia Law

Avenoso, a maintenance supervisor, had long-term disability insurance under a Reliance policy, governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1132(a)(1)(B). The policy provided two years of benefits if the claimant showed that he was unable to perform the material duties of his current occupation and provided continued benefits if the claimant showed that he was unable to perform the material duties of any occupation. Avenoso left his job due to lower-back pain and underwent back surgery. Reliance approved two years of benefits. At the end of the two years, Reliance informed Avenoso that it would discontinue benefits because Avenoso had not shown that he was unable to perform the material duties of any occupation.Avenoso had an MRI; the results appeared relatively mild. Avenoso sent Reliance a note from his physician, recommending that Avenoso “avoid lifting, bending and prolonged sitting” due to his lower back condition. He was receiving Social Security disability benefits. Following a “functional-capacity evaluation,” a physical therapist concluded Avenoso did not demonstrate an ability to tolerate an 8-hour workday. An independent medical evaluation concluded that Avenoso retained sedentary-work capacity and was “able to work 8 hours a day but was engaging in “symptom magnification.” A vocational-rehabilitation specialist identified five “viable sedentary occupational alternatives” consistent with Avenoso’s physical capacities. The Eighth Circuit affirmed summary judgment in favor of Avenoso. The district court’s finding that Avenoso lacks sedentary-work capacity was not clearly erroneous. View "Avenoso v. Reliance Standard Life Insurance Co" on Justia Law

In 1993, the County and the Orange County Employee Retirement System (OCERS) entered into a Memorandum of Understanding (MOU), allowing the County to access surplus investment earnings controlled by OCERS and depositing a portion of the surplus into an account to pay for county retirees' health insurance. The county adopted the Retiree Medical Plan, funded by those investment earnings and mandatory employee deductions. The Plan explicitly provided that it did not create any vested rights. The labor unions then entered into MOUs, requiring the county to administer the Plan and that retirees receive a Medical Insurance Grant. In 1993-2007, retired employees received a monthly grant benefit to defray the cost of health insurance. In 2004, the county negotiated with its unions to restructure the underfunded program, reducing benefits for retirees.Plaintiffs filed suit. The Ninth Circuit affirmed summary judgment in favor of the county. The 1993 Plan explicitly provided that it did not create any vested right to benefits. The Plan was adopted by resolution and became law with respect to Grant Benefits, part of the MOUs. The MOUs expired on their own terms by a specific date. Absent express language providing that the Grant Benefits vested, the right to the benefits expired when the MOUs expired. The Plan was not unilaterally imposed on the unions and their employees without collective bargaining; the unions executed MOUs adopting the Plan. The court rejected an assertion that the Grant Benefit was deferred compensation and vested upon retirement, similar to pension benefits. View "Harris v. County of Orange" on Justia Law

In this insurance coverage dispute, at issue is who counts as an "employee" under the Texas Anti-Indemnity Act (TAIA). The Fifth Circuit certified the following question to Supreme Court of Texas: Whether the employee exception to the TAIA, Texas Insurance Code 151.103, allows additional insured coverage when an injured worker brings a personal injury claim against the additional insured (indemnitee), and the worker and the indemnitee are deemed "co-employees" of the indemnitor for purposes of the TWCA. View "Maxim Crane Works, LP v. Zurich American Insurance Co." on Justia Law

A minor was severely injured in an all-terrain vehicle collision in which the other driver was at fault. The minor had medical benefits coverage through a health care plan provided by her father’s employer, the Fairbanks North Star Borough. As allowed by the terms of the plan, the Borough refused to pay the minor’s medical bills until she signed an agreement that included a waiver of certain defenses to the Borough’s subrogation rights, such as the common fund and made-whole doctrines. The minor refused to sign the agreement without reservation and filed suit, seeking a declaration that the Borough could not condition payment of her medical bills on her signature. The superior court decided on summary judgment that the Borough’s health care plan was not a true insurance plan and that, regardless of whether it was interpreted as an insurance policy or an ordinary contract, the parties could lawfully reject subrogation defenses. The minor appealed. The Alaska Supreme Court held that the health care plan was a bargained-for employee benefit rather than a true insurance policy, and that the superior court’s interpretation of it was correct. The Court therefore affirmed the superior court's judgment. View "Best v. Fairbanks North Star Borough" on Justia Law

In this case involving the In-Home Supportive Services (IHSS) program the Supreme Court affirmed the judgment of the court of appeal concluding that sections 631 and 683 of the Unemployment Insurance Code exclude from coverage a provider who is the recipient's minor child, parent, or spouse under the state's unemployment insurance program, holding that the court of appeal did not err.The IHSS program authorized certain Californias, who were disabled or elderly, to receive in-home services from third parties or family members paid for with public funds. Under one program option, service recipients hire their own providers and the providers are paid either by a public entity or by the recipients with funds they have received from a public entity. At issue was whether such a provider qualified for unemployment benefits. The Supreme Court answered the question in the negative, holding that provider who is the recipient's minor child, parent, or spouse is not covered by the state's unemployment insurance program. View "Skidgel v. California Unemployment Insurance Appeals Board" on Justia Law