Justia Insurance Law Opinion Summaries

Employee received workers' compensation benefits for a neck and back injury he suffered in 2002 while working for Employer. After his benefits were discontinued in 2004, Employee sought treatment for a low back condition and petitioned the Department of Labor for workers' compensation benefits. The Department denied the petition, ruling that Employee did not prove his low back condition was related to his original 2002 work injury. The circuit court affirmed. The Supreme Court affirmed, holding that the Department correctly denied workers' compensation benefits where Employee failed to establish by a preponderance of the evidence that the 2002 injury was a major contributing cause of his current low back condition.

Employee submitted a workers' compensation claim to his Employer after suffering a reaction that some doctors attributed to work-related exposure. Employee petitioned the Department of Labor for a hearing on his workers' compensation claim. The Department denied Employee's claim, concluding that Employee failed to demonstrate that he sustained a compensable injury arising out of and in the course of his employment. The circuit court affirmed. At issue on appeal was whether Employee's efforts to prove causation were thwarted by Employer's refusal to allow collection of samples of various materials in areas around the plant and its later destruction of potential samples. The Supreme Court reversed, holding that the Department failed to properly consider the spoliation question and Employee was entitled to a new hearing before the Department.

The South Dakota Public Assurance Alliance (SDPAA), a local government risk pool, negotiated with Aurora County to provide what was essentially insurance coverage. After coverage was finalized, a local dairy farm sued the County over a pre-existing zoning dispute. The County was found liable for damages. SDPAA then sought a declaration that it did not have a duty to defend or indemnify, arguing, inter alia, that the County failed to disclose material facts relating to the claim. In a jury trial, the circuit court excluded as parol evidence the parties' pre-contract communications regarding coverage for zoning issues, including communications that could be interpreted as having disclosed the dairy farm zoning dispute. The jury found for SDPAA. The Supreme Court reversed and remanded for a new trial, holding that because the excluded coverage communications were not offered to alter or contradict any written terms of the agreement, their admission would not have violated the parol evidence rule.

After self-insured Employer filed for bankruptcy, it continued to take payroll deductions from Employees for medical coverage but stopped paying the provider hospital for the covered charges. The hospital then directly billed Employees for services that should have been paid by Employer. Employees filed suit to stop the hospital's attempts to collect payment, seeking relief under the theories of declaratory judgment, injunction, breach of contract, negligent infliction of emotional distress, and bad faith breach of contract. The circuit court granted summary judgment in favor of the hospital on all of Employees' claims. The Supreme Court reversed, holding (1) Employees had standing as third party beneficiaries to enforce the provisions of the hospital agreement and payer agreement; and (2) Employees were not obligated to pay for covered medical services under the agreements. Remanded.

Tabitha Pourier was seriously injured in an automobile accident and suffered damages in excess of $250,000. After receiving $25,000 from the tortfeasor's liaility carrier and $100,000 in underinsured motorist coverage from her primary insurer, Pourier sought an additional $100,000 in underinsured coverage from her excess carrier, De Smet Insurance Company. De Smet denied coverage, asserting that an exclusion in the policy precluded coverage. On cross motions for summary judgment, the circuit court granted summary judgment in favor of De Smet, ruling that the policy exclusion was valid and enforceable. At issue on appeal was whether De Smet's owned-but-not-insured exclusion was void as against public policy because it prohibited Pourier, who was riding in a vehicle owned by her but insured by another company, from recovering for uncompensated damages by De Smet as the secondary insurer. The Supreme Court affirmed, holding that the policy exclusion was not against public policy.

Appellees Floyd Demaray and James Hagemann were sued for repeated tortious activity in discharging of pollutants into lakes and streams of a nearby property. Appellees, who owned separate but identical insurance policies with De Smet Farm Mutual Insurance, notified De Smet of the lawsuit. De Smet declined defense of the suit, asserting it owed no duty to defend under the insurance contract. Appellees obtained their own defense counsel and defended the matter through trial, where a jury ruled in their favor. Appellees then sued De Smet, alleging that the company breached its duty to defend them in the previous lawsuit and seeking indemnification for all costs and fees incurred as a result. The trial court granted Appellees' motion for summary judgment, holding that De Smet owed Appellees a duty to defend because the alleged claim, if true, fell within policy coverage. On appeal, the Supreme Court reversed, holding that the policy language was unambiguous and the complaint asserted no claim that would arguably invoke coverage. Remanded with directions to grant summary judgment for De Smet.

After a fire damaged Oscar Batiz's residential rental property, Batiz filed a claim with his carrier, Fire Insurance Exchange. Exchange initially tendered to Batiz $33,182 representing the actual cash value of the damaged property, later raising that amount to $8,415 after both parties chose an impartial appraiser and an umpire determined the cost to repair the property was $43,921. Batiz did not cash the payment and brought a declaratory action against Exchange. Both parties filed cross motions for summary judgment. The circuit court granted Exchange's motion for summary judgment, dismissing Batiz's action without prejudice. On appeal, the Supreme Court affirmed, holding that (1) the circuit court did not err in determining that a declaratory judgment against Exchange was unwarranted because the insurance policy unambiguously provided what rights and obligations the parties had; and (2) the circuit court was correct in ruling that Batiz's assertion that the vast difference between his appraiser's and the umpire's valuations presented a justiciable issue requiring the court to determine the amount of loss was premature as Batiz had not yet repaired or replaced the damaged property. Remanded.

Carlin Jewett was employed as a welder by Real Tuff where Jewett often worked on his knees. In 2006, Jewett suffered a right knee injury. Jewett received arthroscopic surgery, during which the surgeon found pre-existing bilateral osteoarthritis in Jewett's knee. Jewett subsequently filed a petition with the state Department of Labor, seeking workers' compensation for a right knee replacement. Two years later, Jewett suffered a second work-related injury to his left knee. Jewett added a workers' compensation claim for diagnostic treatment of his left knee. The Department and the circuit court ruled that Jewell failed to sustain his burden of proof on the alternate theories that (1) work-related injuries to both knees were a major contributing cause of the need for medical treatment, and (2) the cumulative effect of Jewett's work-related activities was a major contributing cause of the osteoarthritis. On appeal, the Supreme Court affirmed, holding the Department and circuit court did not err in finding (1) Jewett's first injury was not a major contributing cause of Jewett's need for a right knee replacement, and (2) Jewett did not prove that working on his knees was a major contributing cause of his osteoarthritis.