Justia Insurance Law Opinion Summaries

Barbara Potter suffered a repetitive trauma injury as a result of her employment as a dental hygienist over a period of more than 30 years. In late 2007 or early 2008, while working in a dental clinic for Dr. Patrick McCulla, Potter began experiencing pain in her neck. Potter received medical treatment for her pain 12 times between October 17, 2008, and January 20, 2009. By this time, McCulla had sold the dental practice to Dr. Tracy Garcia. Potter’s duties and hours remained the same during and after the ownership change. Potter filed a petition in the Nebraska Workers’ Compensation Court seeking benefits. That court found Potter had preexisting conditions in her neck which were aggravated by her duties as a dental hygienist and awarded benefits based on a 40-percent loss of earning capacity. It determined that the date of the injury was February 11, 2009, as that was the date she first missed work to be treated for her injury. Because Garcia was Potter’s employer on the date of the injury, the court held Garcia and FirstComp liable for all of Potter’s medical expenses and compensation benefits. Garcia appealed. The Supreme Court concluded Nebraska Workers’ Compensation Court properly determined that her injury manifested itself on February 11, 2009, during Potter’s employment with Garcia, and that Garcia and Garcia’s workers’ compensation carrier are liable for all of Potter’s medical expenses and compensation benefits. View "Potter v. McCulla" on Justia Law

In June 2011, fourteen-year-old Jean-ah Leon was seriously injured while operating a Bad Boy Buggy ( an off-road vehicle used for outdoor recreation). A year later, Jean-ah’s parents, Vincent and Mandi Leon, filed a products liability and personal injury lawsuit in Louisiana against the owner of the Bad Boy Buggy, a Louisiana resident. They also named the owner’s insurer, the Textron Parties, and several other entities and individuals. Within a few days, the Leons dismissed all parties except the vehicle owner and his insurer from the Louisiana case. The Leons filed suit in Adams County, Mississippi, against the Textron Parties and the others previously named in the Louisiana suit, seeking damages of “an amount not yet determined” but greater than $10,000,000. The Leons served that complaint and summonses on the Textron Parties through their registered agents in Mississippi. They amended their complaint, adding claims for gross negligence and punitive damages. The Leons did not issue new summonses to the Textron Parties with the amended complaint; instead, they sent copies to the Textron Parties’ headquarters by certified mail with accompanying letters addressed “To Whom it May Concern.” The Textron Parties’ attorney in the Louisiana case also requested and received a copy of the amended complaint by email. The Textron Parties’ answer was due thirty days after they were served with the original complaint. They did not file an answer to the original complaint or the amended complaint. The Leons then sought a default judgment against the Textron Parties based on the amended complaint. An entry of default and default judgment were entered the same day. The issue this case presented for the Mississippi Supreme Court's review arose from that default judgment: the Textron Parties claimed that the default judgment was void and should have been set aside because they did not receive proper service of the amended complaint, they were not given notice of the default judgment, and the plaintiffs failed to state a claim against them. Additionally, the Textron Parties asserted that a three-pronged balancing test for relief from default judgments required that it be set aside because they had a colorable defense and the plaintiffs would not be prejudiced. The Supreme Court held that the default judgment was not void, but it should have been set aside under the three-pronged test. View "BB Buggies, Inc. v. Leon" on Justia Law

In Spring 2008, Williams Company Construction, Inc. entered into a construction contract to remodel the Friendly Smiles Cosmetic Dentistry Office owned by Dr. Brenda Barfield. Dr. Barfield previously leased the building from Williams Company owner Glen Williams for approximately five years before she purchased the property from him in 2008. Dr. Barfield hired Williams to remodel the building because of its construction experience and familiarity and knowledge of the building. When Dr. Barfield hired Williams, she did not know whether the remodeling work would be done by Williams or subcontractors. Dr. Barfield did not deal directly with any subcontractors during the remodeling project nor did she direct Williams to hire any specific subcontractors. During the remodel, Williams served as the general contractor and hired subcontractors to do various construction tasks. In December 2008, a section of a copper water pipe froze and burst. The frozen water pipe caused minor water damage and was repaired by plumbing subcontractor Home Heating. During the repair process, a Home Heating employee cut a hole in the wall to locate the leak and discovered that the air in the plumbing wall was cold. The employee was concerned the pipe could freeze again and notified the Friendly Smiles Cosmetic Dentistry Office about the cold air. Dr. Barfield contacted Williams to express her concern about the pipes re-freezing from the cold air. According to testimony, Williams told Dr. Barfield not to worry about the pipes freezing again because of circulating warm air around the hole. Dr. Barfield also wanted the hole in the wall patched, but had difficulty in securing Williams or Home Heating to fix it. Dr. Barfield made repeated requests for Williams or Home Heating to resolve the cold air issue, but they did not fix the problem. Approximately one week after the pipe was fixed, the water pipe froze and broke again, this time causing extensive water damage to the dental office. Dr. Barfield and her insurance company, Travelers Insurance, brought suit against Williams, Home Heating (and other subcontractors) for negligence, and breach of contract. Before trial, the parties stipulated that the total amount of damages was $220,046.09. Williams requested the trial court to include a jury instruction concerning the independent contractor distinction (C-55.25), and a jury instruction pertaining to the failure of a party to produce witnesses (C-80.30). The court denied the two requests. At the pretrial hearing, the parties stipulated that the case would be tried before the jury based on comparative fault. The jury was given a special verdict form and found Williams seventy percent at fault, Home Heating twenty-five percent at fault, and Dr. Barfield five percent at fault. Judgment was entered against Williams. Williams subsequently filed a motion for a new trial arguing the court erred in denying its requested jury instructions and there was insufficient evidence for the jury to find Williams seventy percent at fault for the damages. Following a hearing, the district court denied the motion. Williams appealed the district court's judgment, but finding no reversible error, the Supreme Court affirmed. View "Travelers Cas. Ins. Co. of America v. Williams Co. Construction" on Justia Law

In 2007, appellant Brent McCormick suffered a back injury while pushing a net reel aboard the F/V CHIPPEWA, owned by Chippewa, Inc. The day after his injury McCormick was treated with ibuprofen. Later that night rough seas caused him to fall out of his bunk and hit his head. McCormick continued to suffer back pain and dizziness and later was treated by medical specialists. In 2010, McCormick filed a complaint against Chippewa, Inc. and Louis Olsen (the vessel’s captain), alleging “unseaworth[i]ness” of the F/V CHIPPEWA and negligence in failing to ensure workplace safety and provide proper medical care. Chippewa had a liability insurance policy with a $500,000 per occurrence limit, including a “cannibalizing” provision specifying that costs and expenses spent “investigating and/or defending any claim” would be deducted from the policy limit. The parties ultimately agreed to settle the case for the "policy limit," but were unable to agree on what "policy limit" meant. Each side sought to enforce the agreement based on their respective understandings of the term. During summary judgment proceedings, one party asked for time to conduct discovery regarding the parties’ intent. The superior court granted summary judgment to the other party and denied the discovery request as moot. Because it was an abuse of discretion not to allow discovery before ruling on the summary judgment motion, the Supreme Court vacated the summary judgment order and remanded the case so that appropriate discovery could be conducted. View "McCormick v. Chippewa, Inc." on Justia Law

Claimant Johnny Adger suffered an accidental injury to his left knee on while working as a police officer with the Manning Police Department. As a result, he was treated using various non-operative methods, including steroid injections. In January 2008, Claimant reached maximum medical improvement (MMI) and was assigned a 32% permanent impairment rating to his lower left extremity. However, in April 2008, Claimant returned to the doctor because he continued to experience swelling and pain in his left knee. Ultimately, Claimant underwent knee replacement surgery. Claimant continued to experience swelling and pain in his left knee, and Claimant followed up with the orthopaedic center for several months after the surgery. At the time of his injury, Claimant suffered from preexisting diabetes, which Claimant's employer was aware of prior to the injury. Claimant experienced problems with his diabetes for years before the accident and required medication to control the condition. Claimant's diabetes was medically controlled around the time of the injury; however, Claimant's diabetes was uncontrolled on several occasions during the course of his knee treatment. The State Accident Fund appealed an order from the Appellate Panel of the South Carolina Workers' Compensation Commission denying its request for reimbursement from the South Carolina Second Injury Fund for benefits paid to Claimant. The Supreme Court reversed and remanded. The Commission denied Appellant's claim for reimbursement in full. Without mentioning medical payments, the Commission stated that "Claimant's preexisting diabetes did not create substantially greater liability for permanent disability nor did it result in substantially greater lost time from work." However, these facts fell under the compensation liability prong of the applicable statute. Furthermore, the Supreme Court found that the Commission ignored expert opinion that Claimant's injury most probably aggravated his diabetes and resulted in substantially greater medical costs than would have resulted from his work-related injury alone. The Second Industry Fund presented no evidence or expert opinion that contradicted the statement concerning medical costs. Therefore, based on the fact that the medical evidence supported the conclusion that the Claimant's work-related injury aggravated his diabetes and resulted in increased medical costs, the Court held that the State Accident Fund satisfied the requirements of section 42-9-400(a), and the Commission's decision to deny its claim for reimbursement of medical payments was clearly erroneous. View "State Accident Fund v. SC Second Injury Fund" on Justia Law

The widow of a man killed in an automobile accident with an uninsured motorist (UM) sued her and her husband’s automobile liability insurance carrier seeking UM coverage for her husband’s wrongful death. The trial court granted summary judgment for the insurer, ruling that the insurer’s liability was limited to an “owned-vehicle” partial exclusion in the couple’s policies that limited coverage when the insured was injured while occupying a vehicle owned by the insured but not covered by the policy. The Supreme Court affirmed, holding that, because the partial exclusion was clear and unambiguous, the trial court did not err in finding that the partial exclusion limited the insurer’s liability in this case.View "Floyd-Tunnell v. Shelter Mut. Ins. Co." on Justia Law

The health care service plan in this case, Kaiser Permanente, covered three patients who received care at an emergency room operated by Dameron Hospital Association. The patients were injured due to the negligence of third party tortfeasors who had automobile liability insurance with California Automobile Association Inter-insurance Bureau (AAA) and Allstate Insurance Company. Unlike Kaiser, neither AAA nor Allstate had contracts with Dameron. In the absence of an agreement for negotiated billing rates, Dameron sought to collect from AAA and Allstate its customary billing rates by asserting liens filed under the Hospital Lien Act (HLA). AAA and Allstate, however, ignored Dameron’s HLA liens when paying settlements to the three Kaiser patients. Upon learning of the settlements, Dameron sued AAA and Allstate to recover on its HLA liens. The trial court granted insurers’ motions for summary judgment on grounds the patients’ debts had already been fully satisfied by their health care service plans. Reasoning the HLA liens were extinguished for lack of any underlying debt, the trial court dismissed the case. The trial court further found dismissal was warranted because Dameron failed to timely file some of its HLA liens against AAA. The question this case presented to the Court of Appeal was whether the health care service plan’s payment of a previously negotiated rate for emergency room services insulated the tortfeasor’s automobile liability insurer from having to pay the customary rate for medical care rendered. AAA and Allstate argued they were not responsible for any amount after Kaiser paid in full the bill for the emergency room services provided by Dameron. Dameron argued that it contracted with Kaiser to preserve its rights to recover the customary billing rates from tortfeasors and their automobile liability insurers, and that the tortfeasors and their liability insurers were responsible for the entire bill for medical services at the customary rate - not just the difference between the reimbursement received from Kaiser and the customary billing rate. The Court of Appeal concluded that the Dameron/Kaiser contract did not contain the term described by case law as sufficient to preserve the right to recover the customary billing rate for emergency room services from third party tortfeasors. Consequently, the trial court properly granted summary judgment in favor of AAA and Allstate. View "Dameron Hosp. Assn. v. AAA Nor. Cal., Nev. & Utah Ins. Exc." on Justia Law

The Alaska Workers' Compensation Board denied a death benefit claim filed by the decedent's same-sex partner because the death benefit statute grants benefits only to a worker’s "widow or widower" as defined by statute. The Board construed these terms by applying the Marriage Amendment to the Alaska Constitution, which defined marriage as "only between one man and one woman," thus excluding a decedent's same-sex partner. Because this exclusion lacked a fair and substantial relationship to the purpose of the statute, the Supreme Court concluded that this restriction on the statutory definition of "widow" violated the surviving partner's right to equal protection under the law. View "Harris v. Millennium Hotel" on Justia Law

The issue this case presented for the Supreme Court's review centered on the proper allocation of the burden of proof between an employer and a workers' compensation claimant regarding the injured employee's legal eligibility under federal immigration law to obtain suitable employment whenever the employer seeks to suspend workers' compensation disability benefits. The Court held that in this case, the Commonwealth Court correctly determined that Appellant, Kennett Square Specialties bore the burden to prove that the loss of earning power of its employee, David Cruz, was due to his lack of United States citizenship or other legal work authorization in order to obtain a suspension of his workers' compensation disability benefits. Furthermore, the Court held that Claimant's invocation of his Fifth Amendment right against self-incrimination when questioned at the hearing before the Workers' Compensation Judge did not constitute substantial evidence of his alleged lack of legal authorization to be employed in the United States, and thus could not, standing alone, furnish sufficient evidence for the WCJ to suspend Claimant's benefits. View "Cruz v. Workers' Compensation Appeal Board" on Justia Law

Seventy-year-old James Higginbotham was employed by Industrial Contractors, Inc. ("ICI") as a welder and pipefitter in May 2010 when he sustained an injury to his left rotator cuff. The medical records demonstrated that Higginbotham's injury arose out of and in the course of his work for ICI. Prior to his injury, Higginbotham made $34.61 per hour, but only worked part time. He often traveled to work sites some distance from his home near Hazen, including a site north of Mandan. Since his injury, Higginbotham was no longer able to make the trip from Hazen to Bismarck without stopping, and he could no longer perform welding or pipefitting work. Higginbotham lived in a mobile home near Hazen, approximately 70 miles from Bismarck and 80 miles from Minot. He indicated he was having difficulty paying bills, which he did not have before the injury, and he wanted to maintain the lifestyle he had prior to his injury. Following left rotator cuff surgery, WSI referred Higginbotham to vocational rehabilitation with Kim Hornberger, a vocational rehabilitation consultant, who identified the first appropriate rehabilitation option for Higginbotham and developed a vocational consultant's report ("VCR"). The VCR concluded that it was appropriate for Higginbotham to return to an occupation in the statewide job pool suited to his education, experience, and marketable skills: cashier, telephone sales representative, gaming dealer, and greeter, and the expected income of $332 per week exceeded 90% of Higginbotham's pre-injury income of $227 per week. WSI approved the vocational plan and notified Higginbotham that it intended to discontinue his benefits. Higginbotham asked for reconsideration, and WSI issued an order affirming the rehabilitation plan and denying further disability benefits. Higginbotham appealed, and an ALJ affirmed the WSI order. Higginbotham appealed the ALJ's decision, and the district court affirmed. Higginbotham now appeals the district court judgment. Finding no reversible error, the Supreme Court affirmed. View "Higginbotham v. WSI" on Justia Law