Justia Government & Administrative Law Opinion Summaries

Relator Gilbert Ellinger brought a qui tam suit on behalf of the People of the State of California against Zurich American Insurance Company (Zurich), ESIS, Inc. (ESIS), and Stephanie Ann Magill, under Insurance Code section 1871.7, a provision of the Insurance Frauds Prevention Act (IFPA). In January 2016, Ellinger injured his back while working, and he immediately informed his supervisor. The following month, Ellinger reported to his employer’s human resources manager that he had sustained a work-related injury and had told his supervisor about it. The human resources manager created a “time line memorandum” summarizing the conversations she had with Ellinger about the injury. She placed the memorandum in Ellinger’s personnel file. Ellinger filed a workers’ compensation claim. Magill worked as a senior claims examiner for ESIS and was the adjuster assigned to investigate Ellinger’s claim. ESIS denied Ellinger’s claim on an unspecified date. Magill later testified that she denied the claim because of a written statement from Ellinger’s supervisor in which the supervisor claimed that Ellinger had not reported the injury to him. When the human resources manager was deposed in November 2016, she produced the time line memorandum, which Ellinger’s counsel in the workers’ compensation action did not know about until then. Nearly eight months after that disclosure, in July 2017, ESIS reversed its denial of the claim and stipulated that Ellinger was injured while working, as he had alleged. Contrary to Magill’s testimony, her email messages showed that the human resources manager had emailed Magill the time line memorandum in March and April 2016, and Magill thanked the manager for sending it. Ellinger alleged that Magill’s concealment of or failure to disclose the time line memorandum violated Penal Code section 550 (b)(1) to (3). On the basis of those alleged violations, Ellinger alleged that defendants were liable under section 1871.7. Against each defendant, Ellington sought a civil penalty and an assessment of no greater than three times the amount of his workers’ compensation claim. The trial court sustained defendants’ demurrers without leave to amend, concluding defendants could not be held liable under section 1871.7 for any failures of Magill in the claims handling or review process. Finding no reversible error in sustaining the demurrers, the Court of Appeal affirmed. View "California ex rel. Ellinger v. Magill" on Justia Law

The Louisiana Supreme Court granted certiorari in this case to decide whether the district court had jurisdiction over a claim for penalties against an insurer arising from its failure to provide a defense in workers’ compensation proceedings, and, if so, whether the insurer violated its duties of good faith and fair dealing, thereby making it liable for damages and penalties. After review of the trial court record, the Supreme Court concluded the district court had jurisdiction over the claim and correctly found that the insurer breached its duties to its insured. However, the Court found the district court’s damage award rose to the level of an abuse of discretion. The judgment of the court of appeal was amended to award damages in favor of Cox, Cox, Filo, Camel & Wilson, LLC and against Louisiana Workers’ Compensation Corporation in the total amount of $61,655.00, representing $20,550.00 in special damages and $41,100.00 in penalties. View "Cox, Cox, Filo, Camel & Wilson, LLC v. Louisiana Workers' Compensation Corporation" on Justia Law

North Dakota Insurance Reserve Fund (“NDIRF”) appealed a judgment and orders granting Lance Hagen’s amended petition for a writ of mandamus requiring NDIRF to disclose documents under the open records law. NDIRF argued: (1) the amended petition was untimely; (2) NDIRF was not a public entity subject to open records requests; and (3) the documents sought were protected from disclosure under North Dakota court rules. Hagen cross appealed, arguing the district court erred by not requiring NDIRF to disclose all of the documents he sought and by denying him costs and attorney’s fees. After review, the North Dakota Supreme Court affirmed in part, concluding the amended petition was timely, NDIRF was a public entity for purposes of the open records law, and the records sought were not exempt from disclosure. The Court reversed the part of the judgment and orders excluding records from disclosure, and remanded to the district court to review in camera those previously excluded records and those records identified in Appellant’s Brief to determine whether they were exempt from disclosure under the potential liability exception in N.D.C.C. 44-04-19.1(8). The Court affirmed the denial of costs and attorney’s fees. View "Hagen v. North Dakota Insurance Reserve Fund" on Justia Law

The Workers’ Compensation Commission and an Administrative Judge (AJ) had ordered Gamma Healthcare and Employers Insurance Company of Wausau (Employer/Carrier) to replace Sharon Grantham’s septic and HVAC systems and to pay for insurance on a handicapped-accessible van. The Commission, sua sponte, issued a separate order sanctioning the Employer/Carrier for causing an unnecessary delay by appealing the AJ’s order to the full Commission without reasonable grounds. The Employer/Carrier appealed. While this case was pending before the Court of Appeals, Sharon Grantham died. Thereafter, the Court of Appeals dismissed the case as moot. The Court of Appeals applied the general rule followed by federal courts by vacating the outstanding Commission and AJ orders. The appeals court reversed and rendered the Commission’s sanctions order against the Employer/Carrier, determining that the Commission had abused its discretion by its imposition of the sanction, reasoning that the Employer/Carrier had a reasonable legal argument for its appeal. Grantham’s estate filed a petition for a writ of certiorari, which the Mississippi Supreme Court granted. The Supreme Court concluded that in light of Grantham’s untimely death and the concession by her estate, it agreed with the Court of Appeals that this case was moot. "However, the main issue is not whether the case is moot. Rather it is whether the Court of Appeals erred by vacating the Commission’s and the AJ’s valid orders to replace the septic and HVAC systems in a case that became moot on appeal due to circumstances beyond the control of the parties. Additionally, did the court err by following federal vacatur law instead of existing Mississippi law?" These were issues of first impression. the Supreme Court found that the Court of Appeals did not err and that the federal vacatur rule was appropriate. The Commission’s orders were vacated properly. Furthermore, the Supreme Court affirmed the Court of Appeals’ reversing and rendering of the Commission’s sanctions award. View "Gamma Healthcare Inc., et al. v. Estate of Sharon Burrell Grantham" on Justia Law

Dorothy Wright and her grandchildren (collectively, the “Decedents”) were killed when their vehicle was struck by a stolen vehicle that was being chased by College Park Police Department officers. At the time of the accident, the City of College Park had an insurance policy provided by Atlantic Specialty Insurance Company (“Atlantic”), which provided coverage for negligent acts involving the City’s motor vehicles up to $5,000,000 but also included immunity endorsements which said that Atlantic had no duty to pay damages “unless the defenses of sovereign and governmental immunity are inapplicable.” Plaintiffs filed suit against the City, raising claims of negligence and recklessness resulting in the wrongful deaths of the three Decedents, to which the City raised sovereign immunity as a defense. Plaintiffs claimed the insurance policy limit was $5,000,000 for the three deaths, while Atlantic contended the policy limit was capped at $700,000 under the relevant statutory scheme and the terms of the City’s policy. As the parties agreed, pursuant to OCGA 36-92-2 (a)(3), the sovereign immunity of local government entities was automatically waived up to $700,000 in this instance, regardless of whether the City had a liability insurance policy. Atlantic intervened in the case to litigate the limit of the insurance policy. The trial court ruled that the policy limit is $5,000,000, and the Court of Appeals affirmed. The Georgia Supreme Court then granted Atlantic’s petition for certiorari to decide whether the City’s insurance policy waived the City’s sovereign immunity under OCGA 36-92-2 (d)(3). The Supreme Court concluded the Court of Appeals incorrectly ruled that the City’s insurance policy increased the sovereign immunity waiver notwithstanding the immunity endorsements, which expressly precluded coverage when a sovereign immunity defense applies. Judgment was therefore reversed. View "Atlantic Specialty Insurance Co. v. City of College Park, et al." on Justia Law

The Court of Appeals held that only the amount that a workers' compensation insurer actually pays for medical expenses is part of the statutory offset against underinsured motorist benefits.Michael Gilliam was injured in an automobile accident during the course of his employment and received payments from his employer's workers' compensation insurer and the other driver's liability insurer. Gilliam later sought to recover the amounts by which the other driver was underinsured from an insurance policy covering the vehicle he was driving. As required by Maryland law, the healthcare providers who treated Gilliam had generated bills in amounts greater than the amounts set by the Workers' Compensation Commission but accepted payments at those lower amounts in full satisfaction for their services. At issue was whether the difference between the bills' amounts and the workers' compensation insurer's payments constituted a "benefit" that Gilliam had "recovered" under the Workers' Compensation Act that was to be offset against any recovery Gilliam would obtain from the underinsured motorist coverage of the auto policy. The Supreme Court held that a difference between a higher face amount billed by a healthcare provider and the amount actually paid by the workers' compensation insurer was not part of that offset. View "Westfield Insurance Co. v. Gilliam" on Justia Law

Ingham, Jackson, and Calhoun County, Michigan (collectively, the Counties) filed an action alleging that they had a right to receive a decade’s worth of surplus contributions (surplus equity) made to the Michigan County Road Commission Self-Insurance Pool (the Pool). The Counties believed they were the successors in interest to their dissolved road commissions and, as such, were entitled to the surplus equity that the commissions might have received had they not been dissolved and withdrawn from the Pool. Jackson County made one other argument: because its road commission never formally withdrew from the Pool, the county said it had a right to receive surplus equity on the same terms as any current member. The Pool disagreed, contending the Counties had no right to surplus equity because the documents governing the Pool’s operations and its contracts with its various members provided the Pool with discretion in distributing surplus equity. This included, the Pool contended, the power to exclude former members should a distribution be made. The Court of Appeals sided with the Counties, holding that the Counties were the successors in interest to their dissolved road commissions and, as a matter of public policy, the Counties had a right to receive surplus equity for fiscal years in which their road commissions were members of the Pool. The Court of Appeals also determined that the dissolution of the Jackson County Road Commission did not disqualify Jackson County from membership in the Pool, and therefore, the county could receive surplus equity regardless of any public-policy considerations. The Michigan Supreme Court reversed. The Court agreed with the Pool that the Counties did not have a contractual right to receive surplus equity and that such an arrangement was not contrary to public policy. For Jackson County, the Court held that the dissolution of its county road commission did not transfer membership in the Pool from the road commission to the county itself, so the Pool could exclude Jackson County from post-dissolution distributions. View "County Of Ingham v. Michigan County Road Commission Self-Insurance Pool" on Justia Law

The Supreme Judicial Court affirmed the decision of the appellate division of the Workers' Compensation Board affirming the decision of an administrative law judge (ALJ) granting Plaintiff's petition for award of compensation, holding that an employee is not required to give notice of his occupational disease claim to his former employer's insurer when the employer no longer exists.Nearly twenty years after retiring from his employment Plaintiff underwent surgery for lung cancer and was later diagnosed with asbestosis. Plaintiff filed five petitions for award of compensation, each alleging a different date of injury and naming and different employer and insurer pairing. The ALJ (1) found that Plaintiff's last injurious exposure to asbestos occurred when he was working for Auburn Sheet Metal, which was insured by Maine Employers' Mutual Insurance Company (MEMIC) but no longer existed, and (2) granted Plaintiff's petition for an award of compensation. The appellate division concluded that Plaintiff was not required to provide notice to MEMIC. The Supreme Court affirmed, holding that the appellate division did not err in concluding that the workers' compensation statute does not impose on an injured employee whose employer no longer exists the duty to give notice to the insurer. View "Desgrosseilliers v. Auburn Sheet Metal" on Justia Law

The primary issue in this case was whether imposing sales tax on in-state lessors of business equipment to a title insurer violated Article XIII, section 28(f) of the California Constitution. The California Department of Tax and Fee Administration (Department) contended it did not because the lessor, not the title insurer/lessee, was the taxpayer. In the Department’s view, whether the lessee reimburses the lessor for its sales tax obligation was strictly a matter of contract and did not implicate the constitutional limit on taxing insurers. Conversely, First American Title Insurance Company (First American) pointed out that in equipment leases not involving an insurer, the state assesses a use tax, not a sales tax. But where, as here, the lessee is constitutionally exempt from paying use tax, Regulation 1660(c)(1) solved that problem by providing that the sales tax applied instead. First American argued that as a result, Regulation 1660(c)(1) imposed a de facto use tax on title insurers in violation of Article XIII, section 28(f). The trial court agreed with First American and ordered the Department to “remove, strike out and otherwise give no force or effect to that portion of Regulation 1660(c)” providing that when the lessee is not subject to use tax, the sales tax applies. The Court of Appeal reversed: “Article XIII, section 28(f) does not prohibit a sales tax whose legal incidence is on a lessor, even though the economic burden of the tax is ultimately borne by the title insurer/lessee.” View "First American Title Insurance Co. v. Cal. Dept. of Tax and Fee Admin." on Justia Law

State Farm General Insurance Company (SFG) appealed an order awarding attorney fees to intervenor Consumer Watchdog (CW), in a dispute over documents SFG designated as confidential in a rate hearing under Proposition 103. After the administrative law judge (ALJ) denied SFG’s motion to seal, SFG sought writ relief from the superior court, which CW and the Insurance Commissioner successfully opposed. CW then moved for fees under section 1861.10, which provided for reasonable advocacy fees to a consumer representative that makes a substantial contribution to the adoption of an order. The court awarded CW’s requested fees, and SFG appealed, contending the fee motion was untimely, and the fee award was inconsistent with the statutory requirements and an abuse of discretion. Rejecting these arguments, the Court of Appeal affirmed. View "State Farm General Insurance Company v. Lara" on Justia Law