Justia Insurance Law Opinion Summaries

Plaintiff Mahmoud Alzayat, on behalf of the People of the State of California, filed a qui tam action against his employer, Sunline Transit Agency, and his supervisor, Gerald Hebb, alleging a violation of the Insurance Frauds Prevention Act (IFPA or the Act). (Ins. Code, sec. 1871 et seq.) Alzayat alleged Hebb made false statements in an incident report submitted in response to Alzayat’s claim for workers’ compensation, and Hebb repeated those false statements in a deposition taken during the investigation into Alzayat’s claim for compensation. Hebb’s false statements resulted in Alzayat’s claim being initially denied. Defendants filed motions for judgment on the pleadings contending: (1) this lawsuit was based on allegedly false and fraudulent statements Hebb made in connection with a workers’ compensation proceeding and was, therefore, barred by the litigation privilege under Civil Code section 47(b); and (2) Alzayat’s claim was barred by the workers’ compensation exclusivity rule. The superior court concluded the workers’ compensation exclusivity rule was inapplicable, but ruled the litigation privilege barred Alzayat’s claim. Alzayat appealed, contending the litigation privilege only applied to tort claims and not to statutory claims such as an action under the IFPA, and the IFPA was a specific statute that prevailed over the general litigation privilege. The Court of Appeal agreed with Alzayat that his lawsuit was not barred by the litigation privilege. Furthermore, the Court concluded this lawsuit was not barred by the workers’ compensation exclusivity rule. The trial court erred by granting judgment on the pleadings for defendants, so we reverse the judgment. View "California ex rel. Alzayat v. Hebb" on Justia Law

Respondent Denise Duncan sued Wal-Mart Stores, Inc. (Wal-Mart) for personal injuries she sustained at one of Wal-Mart’s stores while acting within the course and scope of her employment with Acosta, Inc. (Acosta). The trial court entered judgment finding Wal-Mart liable for Duncan’s injuries. Under Labor Code sections 3852 and 3856, appellant Hartford Accident & Indemnity Company (Hartford) applied for a lien on Duncan’s judgment to obtain reimbursement for the workers’ compensation benefits it paid Duncan, including medical expenses and temporary disability payments for lost wages. Although the judgment included compensation for Duncan’s medical expenses, it did not include compensation for Duncan’s lost wages because she did not seek those damages at trial. The court granted Hartford a lien on Duncan’s judgment, but reduced the lien amount to exclude the indemnity payments for lost wages. Hartford appealed the trial court’s postjudgment order, arguing the court exceeded its authority by reducing the lien amount for any item other than reasonable attorney fees and costs. The Court of Appeal agreed because section 3856’s plain language and the case law applying it granted Hartford a first lien on the judgment in the amount it paid Duncan for worker’s compensation benefits. Duncan’s choice not to seek lost wages at trial did not diminish Hartford’s lien rights under the workers’ compensation statutory scheme. View "Duncan v. Wal-Mart Stores, Inc." on Justia Law

At issue was whether an insurer was obligated to indemnify a business owner under a personal insurance policy for liability arising form his false imprisonment of his company’s employee at her workplace. The business owner appealed, challenging the appellate court’s determination that such liability fell under the business pursuits exclusion to coverage under his personal umbrella policy. The Supreme Court reversed, holding (1) neither the appellate court nor the trial court employed the correct standard for determining whether the business owner’s tortious conduct was an occurrence “arising out of” the business pursuits of the insured; (2) remand was necessary to determine whether the business pursuits exception applied under the correct standard; and (3) Plaintiffs could not prevail on their alternative grounds regarding other exclusions and public policy as a matter of law. View "Nationwide Mutual Insurance Co. v. Pasiak" on Justia Law

Plaintiff-appellant State Farm Automobile Insurance Company, as subrogee of its insured, sued for damages arising out of an automobile accident between the insured and Defendant-appellee Nicholas Payne. The insured, Tori Ukpaka, originally brought this action, but voluntarily dismissed it after the statute of limitations had run. Whether State Farm could revive that claim depended on whether it could take advantage of the Oklahoma savings statute at 12 O.S. sec. 100, which gives "the plaintiff" up to one year from the date of a non-merits-based termination in which to refile an otherwise time-barred claim. In light of the Oklahoma Supreme Court’s “historic” interpretation of that statute, it concluded that because State Farm was "substantially the same, suing in the same right" as its insured for purposes of a subrogation claim, it should be entitled to the same treatment as its insured for purposes of the savings statute. Accordingly, the Court held State Farm’s, filed within one year after its insured voluntarily dismissed the same, was timely. View "State Farm Mutual Automobile Ins. Co. v. Payne" on Justia Law

The Supreme Court reversed the order of the district court granting Jennifer Teeter’s motion for summary judgment in this declaratory action filed by Teeter against Mid-Century Insurance Company, Teeter's insurer, seeking payment of medical expenses and lost wages after an accident. The district court concluded that Teeter made a prima facie showing that it was reasonably clear that her medical expenses and wage losses were causally related to the accident and that the opinions of certain doctors did not create a disputed issue of material fact as to medical causation and damages. The Supreme Court disagreed and remanded the case for further proceedings, holding that there was a clear dispute of material fact regarding causation because it was not reasonably clear if Teeter’s expenses were causally related to the accident. View "Teeter v. Mid-Century Insurance Co." on Justia Law

The Supreme Court’s decision in West v. Shelby County Healthcare Corp., 459 S.W.3d 33 (Tenn. 2014), holding that “reasonable charges” for medical services under Tennessee’s Hospital Lien Act are the discounted amounts a hospital accepts as full payment from patients’ private insurer and not the full, undiscounted amounts billed to patients, does not apply in personal injury cases. Further, the collateral source rule applies in this personal injury case, in which the collateral benefit at issue is private insurance. Therefore, Plaintiffs may submit evidence of the injured party’s full, undiscounted medical bills as proof of reasonable medical expenses, and Defendants are precluded from submitting evidence of discounted rates accepted by medical providers from the insurer to rebut Plaintiffs’ proof that the full, undiscounted charges are reasonable. The Supreme Court thus affirmed in part and reversed in part the decision of the court of appeals, which concluded that West did not apply to personal injury cases but that evidence of discounted amounts accepted by the injured’s medical providers may be admissible to rebut Plaintiffs’ expert testimony on the reasonableness of the amount of the full, undiscounted bills. View "Dedmon v. Steelman" on Justia Law

United Fire & Casualty Company appealed a district court judgment awarding Carol Forsman $249,554.30 in her garnishment action against United Fire, commenced after she settled claims in the underlying suit against Blues, Brews and Bar-B-Ques, Inc., d.b.a. Muddy Rivers. Muddy Rivers was a bar in Grand Forks that was insured by United Fire under a commercial general liability ("CGL") policy. In 2010, Forsman sued Muddy Rivers and Amanda Espinoza seeking damages for injuries to her leg allegedly sustained while a guest at a February 2010 private party at Muddy Rivers. Muddy Rivers notified United Fire of the suit and requested coverage. United Fire denied defense and indemnification based on the policy's exclusions for assault and battery and liquor liability. However, after appeals and reconsideration, the court ruled in Forsman's favor, finding the settlement amount was reasonable. The North Dakota Supreme Court concluded the court erred in granting summary judgment because material fact issues existed on whether exclusions for "assault and battery" and "liquor liability" in the CGL policy excluded coverage of Forsman's negligence claim against Muddy Rivers. Furthermore, the Court concluded further conclude the court properly granted summary judgment to Forsman holding United Fire had a duty to defend Muddy Rivers under the CGL policy in the underlying suit. Therefore, the Court affirmed in part, reversed in part, and remanded for further proceedings. View "Forsman v. Blues, Brews & Bar-B-Ques Inc." on Justia Law

In this case alleging that Memorial Hospital of Sweetwater County was vicariously liable for the acts or omissions of a physician who worked at the hospital as an independent contractor, the Supreme Court reversed the judgment of the district court finding that the Hospital waived its immunity by purchasing liability insurance. The Hospital had moved for summary judgment on the ground that the physician was not a Hospital employee, and therefore, the Hospital was immune from liability for his acts or omissions. The district court denied the Hospital’s motion, finding that the Hospital waived its immunity to ostensible agency claims under the insurance exception at Wyo. Stat. Ann. 1-39-118(b). The Supreme Court reversed, holding (1) the Hospital’s liability insurance did not provide coverage for liability beyond the liability defined by the Wyoming Governmental Claims Act, and (2) the Hospital’s liability insurance therefore did not extend the Hospital’s liability to include liability for its apparent agents. View "Memorial Hospital of Sweetwater County v. Menapace" on Justia Law

In this case, we deny relief on a petition for review of an award of benefits made by the Workers' Compensation Appeals Board (WCAB). In 2006, while working at Pearson Ford, Leopoldo Hernandez accidentally slammed the trunk of a car on his left hand and crushed one of his fingers. Although no bones in his hand were broken, he was unable to continue working at Pearson Ford because of continuing pain in his hand and shoulder. Hernandez applied for and received workers' compensation benefits. Pearson Ford's workers' compensation carrier retained the services of a private investigator, who conducted video surveillance of Hernandez following each of the three visits to his doctor in early 2010. Following each visit, Hernandez was observed taking off his sling, using his left hand to get in and out of his truck or a car, using his left hand to steer his truck or car, and on one occasion stopping at a grocery store and using his left hand to carry a bag of groceries. After the investigator witnessed other instances of Hernandez using his allegedly injured left hand, the carrier notified the district attorney, who in turn, commenced its own investigation. In specified circumstances, a worker who engages in criminal fraud in attempting to recover workers' compensation benefits and is convicted of doing so is thereafter barred from recovering benefits growing out of the fraud. However, in given circumstances where, independent of any fraud, a worker is able to establish his or her entitlement to benefits, benefits may be awarded. Here, the WCAB found evidence, independent of a worker's fraud, that he had suffered a compensable injury and was entitled to benefits. In doing so the WCAB relied on the determination of a medical expert. The Court of Appeal found no error in the WCAB's determination the workers' claim was not barred by the eventual misdemeanor conviction for workers' compensation fraud and in the WCAB's adoption of the expert's finding of a permanent disability. The Court denied the petitioner any relief on its petition asking that it vacate the WCAB's award. View "Pearson Ford v. Workers' Comp. Appeals Bd." on Justia Law

Douglas Ghee, as personal representative of the estate of Billy Fleming, deceased, appealed a circuit court order dismissing his wrongful-death claim against USAble Mutual Insurance Company d/b/a Blue Advantage Administrators of Arkansas ("Blue Advantage"). The Alabama Supreme Court dismissed this appeal as being from a nonfinal order. View "Ghee v. USAble Mutual Insurance Co." on Justia Law