Justia Insurance Law Opinion Summaries

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

Vicki Blasing was the named insured in an automobile liability insurance policy issued by American Family Insurance Company. Blasing was injured when lumber fell on her foot that was being loaded into her pickup truck by an employee of Mernard, Inc. Blasing filed a personal injury lawsuit against Menard and Menard’s insurer. Menard, in turn, claimed its employee was an insured under the American Family policy as a permissive user of Blasing’s pickup truck. At issue in this case was whether American Family had a duty to defend and indemnify Menard when Menard’s employee was a permissive user of the injured insured’s vehicle. The court of appeals concluded that permissive user coverage was required in this case under the omnibus statute. The Supreme Court affirmed, holding that the American Family policy explicitly provided coverage in the present case.View "Blasing v. Zurich Am. Ins. Co." on Justia Law

Velicia Carter was injured in an automobile collision with Jeova Oliviera. It was alleged that Oliviera was under the influence of alcohol at the time. Oliviera had an auto liability insurance policy with GEICO General Insurance Company with a $30,000 per person liability limit. Carter was insured by Progressive Mountain Insurance Company, including uninsured/underinsured motorist (UM) coverage of $25,000 per person. Carter sued Oliviera and served Progressive as her UM carrier, and entered into a settlement in which GEICO paid the $30,000 limit of Oliviera's policy, and Carter executed a limited liability release. It allocated $29,000 of GEICO's payment to punitive damages and $1,000 to compensatory damages. Progressive answered the suit as Carter's UM carrier and sought summary judgment on the UM claim, which the trial court granted, ruling that, by imposing the condition that $29,000 of the liability coverage limit be allocated to the payment of punitive damages, Carter failed to meet a prerequisite for recovery of the UM benefits. The Court of Appeals affirmed, finding that, by allocating a portion of the payment to punitive damages, rather than allocating all of the payment to compensatory damages, Carter failed to exhaust the limits of Oliviera's liability policy, and, therefore, forfeited the ability to make a claim on her UM policy. The Supreme Court granted a writ of certiorari to the Court of Appeals to determine if that Court properly applied the motor vehicle insurance limited liability release provision of OCGA 33-24-41.1. Finding that the Court of Appeals erred, the Supreme Court reversed that Court's judgment. View "Carter v. Progressive Mountain Ins." on Justia Law

An employee (Isack) was injured during the course and scope of his employment with his employer. Acuity, the employer’s workers’ compensation insurer, paid workers’ compensation benefits to Isack. Isack then retained attorney John Knight for legal representation in a suit against the tortfeasor and his employer. In turn, Acuity retained an attorney to represent its statutory rights of recovery and offset in Isack’s claim. Isack and the tortfeasor’s employer reached a litigation settlement. The trial judge subsequently awarded Knight one-third of Acuity’s recovery and offset award. Acuity appealed, arguing that the circuit court erred by giving Knight a thirty-three percent contingent fee from Acuity’s settlement portion because Acuity retained its own attorney to represent its interests. The Supreme Court affirmed, holding that the circuit court’s application of S.D. Codified Laws 62-4-39 and its allocation of the entire contingent fee to Knight was not clearly erroneous.View "Isack v. Acuity" on Justia Law

Claimant Andres Carbajal alleged he was injured when scaffolding he was on was blown over and he fell while working on a construction project in Okmulgee. He filed a claim in the Workers' Compensation Court and alleged that he was an employee of Precision Builders, Inc., and/or Mark Dickerson (Precision) when he fell. The tribunal denied the claim upon determining that claimant was an independent contractor and not an employee. The three-judge panel affirmed the trial tribunal and the panel's order was affirmed by the Court of Civil Appeals. The issue this case presented to the Oklahoma Supreme Court on certiorari was whether petitioner was an employee or independent contractor. "Considering each of the factors on which the evidence was presented leads us to the conclusion that claimant met his burden to show that he was an employee of Precision." The Court of Appeals' decision was vacated and the case remanded for further proceedings. View "Carbajal v. Precision Builders, Inc." on Justia Law