Justia Insurance Law Opinion Summaries

The Supreme Court granted certiorari in this case to address two issues: (1) whether a political-subdivision employer may be required to provide workers' compensation benefits to an off-duty employee injured while providing services to a private entity; and (2) whether, under the facts presented, the claimant's salaries from his full-time employment as a deputy sheriff and his part-time job as a security officer may be combined when determining the amount of benefits to which the employee is entitled. Respondent-claimant John David Waldenville was injured while acting as a security guard for petitioner Cattlemen's Steakhouse, Inc. Initially, Cattlemen's contended that Waldenville was an independent contractor but later conceded that it had workers' compensation coverage for him through their insurer. Nevertheless, the employer continued to assert that Waldenville was an employee of respondent, Oklahoma County Sheriff's Department when injured. The trial court determined that: Cattlemen's was the employing entity when the employment-related injury occurred; Oklahoma County should be dismissed pursuant to 85 O.S. 2001 sec. 2b(G); Cattlemen's was estopped to dispute employee status based on the payment of workers' compensation premiums associated with Waldenville's employment; no evidence existed indicating that the employee was acting in his official capacity as a Deputy Sheriff at the time of the incident; and because the duties that Waldenville was carrying out at the time of his injury were the same or similar to those he executed as a Deputy Sheriff, the claimant's salaries were to be combined for establishment of weekly rates. The Supreme Court held that: (1) the "plain, clear, unmistakable, unambiguous, mandatory, and unequivocal" language of 85 O.S. 2011 sec. 313(G) mandated that private employers, hiring off-duty municipal employees, alone shall be responsible for the payment of workers' compensation benefits arising from incidents occurring during the hours of actual employment by the private employer; and (2) under the facts of this case, claimant was engaged in the same, or substantially similar, employment to that of his profession as a Major with the Oklahoma County Sheriff's Department when he was injured, warranting the combination of salaries for purposes of determining workers' compensation benefits. View "Cattlemen's Steakhouse, Inc. v. Waldenville" on Justia Law

Plaintiff filed suit against Prudential, the plan administrator, and BioMerieux, her employer, after Prudential denied her long-term disability and short-term disability benefits. The district court entered summary judgment in favor of Prudential and BioMerieux. Plaintiff appealed. The court concluded that the language at issue in both plans was ambiguous and did not clearly confer discretionary decision-making authority on the plan administrator. Therefore, the administrator's eligibility determinations denying benefits to a covered employee were subject to de novo judicial review, and the district court erred in reaching a contrary conclusion. The court further held that the district court erred in concluding that the employer's group insurance plan required objective proof of disability in order for an employee to qualify for plan benefits. Accordingly, the court vacated and remanded for further proceedings. View "Cosey v. The Prudential Ins. Co." on Justia Law

The City of Gadsden and certain members of the State Employees' Insurance Board appealed two circuit court orders that granted injunctive relief to John Boman. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. In 2000, Gadsden elected to join the 'Local Government Health Insurance Plan,' a health benefit plan administered by the Board. When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and other ailments. After his 65th birthday, Blue Cross began denying his claims for medical treatment based on the failure to provide Blue Cross with a 'record of the Medicare payment.' However, Boman had no Medicare credits. When the dispute over coverage arose, Boman sought review by the Board. The Board denied Boman's request for an appeal. Boman and 18 other active and retired Gadsden police officers sued Gadsden, alleging, among other things, that they had 'been deprived of Social Security and Medicare protection which other police officers have been provided' and that, after 20 years of service, they were being required to pay a higher pension charge or percentage of base pay than their counterparts who were hired after April 1, 1986. In 2011, Boman filed a 'motion for immediate relief for medical care.' The Supreme Court found that the circuit court issued preliminary injunctive relief against Gadsden without requiring Boman to give security and without making any specific findings. As such, the Supreme Court had "no alternative but to reverse" the preliminary injunction issued against Gadsden and remanded the case for further proceedings. View "City of Gadsden v. Boman " on Justia Law

Petitioner's decedent, Freda Bradley, purchased a named perils homeowners insurance policy from Farmers and Mechanics Mutual Insurance Company of West Virginia (Farmers). Bradley filed a claim under the policy for damage to her kitchen and bathroom floor. Farmers denied the claim citing a policy exclusion for water damage below the surface of the ground, fungi, wet or dry rot, or bacteria. Bradley filed a complaint against Farmers alleging several causes of action stemming from Farmers' denial of coverage under an insurance policy Bradley had purchased from Farmers. The circuit court granted summary judgment in favor of Farmers, concluding (1) damage done to Bradley's kitchen floor did not constitute a "collapse" as required by the policy; and (2) the alleged collapse was not caused by "hidden decay." Petitioner appealed. The Supreme Court reversed, holding (1) the circuit court erred in finding that the term "collapse" in the insurance policy was not ambiguous and that Bradley's kitchen floor did not collapse; and (2) whether Bradley should have known that decay was causing her kitchen floor to sink was a genuine issue of material fact to be decided by a jury. Remanded. View "Chafin v. Farmers & Mechanics Mut. Ins. Co. of W. Va." on Justia Law

While employed by Employer, Appellant sustained an injury. Appellant filed an industrial injury claim. Employer's insurer (Insurer) partly accepted the claim but later closed Appellant's claim. After unsuccessfully filing three requests to reopen his claim, Appellant filed a fourth request, which was again denied by Insurer. A hearing officer affirmed the denial. Appellant administratively appealed. Insurer moved to dismiss, arguing that Appellant was precluded from reopening his claim under the doctrine of res judicata. The appeals officer granted Insurer's motion. The district court denied Appellant's petition for judicial review, concluding that Apellant failed to state a new cause of action that could withstand the application of res judicata. The Supreme Court reversed, holding that because the district court failed to provide any findings of fact or conclusions of law, the court could not properly review the appeals officer's determination that there was no change of circumstances warranting reopening under Nev. Rev. Stat. 616C.390. Remanded. View "Elizondo v. Hood Machine, Inc." on Justia Law

The issue before the Supreme Court in this case arose from an alleged breach of contract and bad-faith denial of Dr. Jack and Margaret Hoover’s homeowner’s insurance claim against United Services Automobile Association (USAA) following Hurricane Katrina. The trial judge granted USAA’s motion for directed verdict as to the Hoovers’ claims for: (1) the unpaid portion of losses; (2) mental anguish and emotional distress; and (3) punitive damages. The trial court further determined that there were issues of fact for the jury as to whether the Hoovers’ roof structure was damaged, and as to the Hoovers’ claim for additional living expenses. The jury found for the Hoovers and granted compensatory damages. The Hoovers appealed and USAA cross-appealed. After its review of the record, the Supreme Court found that trial court applied an incorrect legal standard and improperly shifted a burden of proof to the Hoovers. Therefore the Court reversed the directed verdict as to the unpaid damages, and remanded the case for a jury to determine whether USAA proved by a preponderance of the evidence that the unpaid loss was caused by an excluded storm surge. The trial court did not err, however, in directing a verdict for USAA as to the Hoovers’ claims for mental anguish, emotional distress, and punitive damages. View "Hoover v. United Services Automobile Association" on Justia Law

After Opal Corn was rear-ended by Martha Gafford, she settled with Gafford and Gafford's insurer. Opal and L.B. Corn subsequently filed an underinsured motorist (UIM) claim with their insurer, Farmers Insurance Company, for the remaining damages from the accident. The Corns then filed suit against Farmers and a driver and company also involved in the accident (collectively, Eden). The Corns settled their claims with Eden, but their settlement was for less than the limits of Eden's insurance policy. Farms refused to offer UIM benefits and moved for summary judgment, arguing that because the Corns had failed to exhaust Eden's liability policy, they had not triggered UIM coverage under their policy with Farmers. The circuit court entered summary judgment for Farmers, finding that, based on the exhaustion requirement of UIM coverage and the policy language, the Corns were not entitled to UIM benefits. The Supreme Court affirmed, holding (1) insured persons are required to exhaust all liability insurance policies of all tortfeasors before they are entitled to receive UIM benefits; and (2) under the terms of the policy, UIM coverage was not triggered until all policy limits had been exhausted. View "Corn v. Farmers Ins. Co., Inc." on Justia Law

Plaintiff was injured operating his employer's truck and came to a settlement with the tortfeasors. Then plaintiff and his wife filed suit against Continental for underinsured motorist (UIM) coverage in his employer's policy. The district court granted Continental's motion for partial summary judgment, concluding that plaintiffs could not stack their claims. The court concluded that the district court erred in finding a $2 million UIM limit where there was no ambiguity in the policy's selection form because the declarations page and UIM coverage endorsement specify a $500,000 UIM limit and the selection form did not contradict this limit. The court concluded that plaintiffs' failure to timely file their cross petition did not preclude review of the stacking claim. However, the court concluded that plaintiffs' arguments lacked merit and affirmed the district court's denial of plaintiffs' stacking claim. Accordingly, the court affirmed in part, reversed in part, and remanded for further proceedings. View "Munroe, et al. v. Continental Western Ins." on Justia Law

After discovering that she had lung cancer that had spread to her brain, Killian underwent aggressive treatment on the advice of her doctor. The treatment was unsuccessful and she died. Her husband submitted medical bills for the cost of the treatments to her health insurance company. The company denied coverage on most of the expenses because the provider was not covered by the insurance plan network. The husband filed suit, seeking benefits for incurred medical expenses, relief for breach of fiduciary duty, and statutory damages for failure to produce plan documents. The district court dismissed denial-of-benefits and breach-of-fiduciary-duty claims, but awarded minimal statutory damages against the plan administrator. In 2012, the Seventh Circuit affirmed the dismissals, rejecting an argument that the plan documents were in conflict, but remanded for recalculation of the statutory damages award. On rehearing, en banc, the Seventh Circuit affirmed the denial of benefits and statutory penalties holdings, but reversed on the breach of fiduciary duty claim. The instructions given in plan documents were deficient and a reasonable trier of fact could rule in favor of Killian, based on telephone conversations in which Killian attempt to determine whether the physicians who were about to perform surgery were within the network. View "Killian v. Concert Health Plan" on Justia Law

Michael Cullen sued State Farm Mutual Automobile Insurance Company requesting class certification and a declaratory judgment that State Farm failed to disclose all benefits available to policyholders who made claims for damaged windshields. The trial court certified the class, concluding that Cullen and the class satisfied the requirements of Ohio R. Civ. P. 23. The court of appeals affirmed the order certifying the class but reversed the portion of the decision defining the class and remanded with instructions to the trial court to redefine it. The Supreme Court reversed, holding (1) because the declaratory relief at issue here was incidental to an individualized claim for monetary damages, Cullen failed to meet the requirement for certification set forth in Rule 23(B)(2); and (2) Cullen failed to prove that this action satisfied Rule 23(B)(3) because individual questions predominated over the questions common to the proposed class. Remanded. View "Cullen v. State Farm Mut. Auto. Ins. Co." on Justia Law