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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. MISSING
Regular Panel Decision

Certain Underwriters at Lloyd's v. KKM INC.

This appeal concerns an insurance claim for a building that collapsed due to corrosion. Appellee KKM, Inc. d/b/a Strand Surplus, the building owner, sought coverage from appellants, Certain Underwriters of Lloyd’s London, after its claim was denied. The trial court deemed the policy terms 'corrosion' and 'decay' ambiguous, submitting the coverage issue to a jury, which found for KKM, Inc. On appeal, the court upheld the trial court's finding of ambiguity and the interpretation that 'Additional Coverage' for hidden decay could override general exclusions. However, the judgment was reversed and remanded because the trial court erred in refusing to instruct the jury on the 'fortuity doctrine,' specifically regarding whether the insured knew or should have known of the ongoing corrosion before the policy was purchased.

Insurance claimBuilding collapsePolicy ambiguityContract interpretationCorrosionHidden decayFortuity doctrineKnown lossLoss in progressJury instructions
References
39
Case No. 07-14-00109-CV
Regular Panel Decision
Jul 06, 2015

Doe 1, Doe 2 and Doe 3 v. National Union Fire Insurance Company of Pittsburgh, PA.

This case involves an appeal from a trial court's summary judgment in favor of National Union Fire Insurance Company of Pittsburgh, PA, concerning a coverage dispute. The insureds, identified as Doe #1, Doe #2, and Doe #3, sought coverage under a commercial general liability (CGL) policy for claims of sexual misconduct. National Union argued that an endorsement (MS #2) replaced the policy's original exclusions with new ones, specifically excluding liability from conduct of a sexual nature. The insureds contended the endorsement's exclusions were ambiguous and only applied to clergy counseling professional liability coverage. The Court of Appeals found the language of the MS #2 endorsement ambiguous, thus reversing the trial court's judgment and remanding the case for further proceedings.

Insurance CoverageCommercial General LiabilityPolicy ExclusionsAmbiguitySummary JudgmentSexual MisconductClergy CounselingAppellate ReviewContract InterpretationTexas Law
References
7
Case No. MISSING
Regular Panel Decision

Elsner ex rel. Elsner v. Walker

This case involves an appeal by Grange Mutual Casualty Company regarding the denial of its Motion for Summary Judgment. Grange sought to reduce its uninsured/underinsured motorist policy liability by amounts paid by the plaintiffs' medical insurance carrier for severe injuries sustained by Stephen D. Eisner in an automobile accident. Grange argued that its policy's 'limit of liability' clause allowed for a setoff for medical payments. However, the court found no explicit policy language permitting such a reduction for medical insurance payments. Citing long-standing Tennessee precedent, the court affirmed the trial court's judgment, concluding that any ambiguity in insurance contracts must be construed strictly against the insurer and in favor of the insured. Therefore, no setoff was available for Grange for medical payments made by the Eisners’ medical insurance company.

Uninsured Motorist CoverageUnderinsured Motorist CoverageInsurance Policy InterpretationSetoff ProvisionMedical Insurance PaymentsContract AmbiguityStrict Construction Against InsurerLiberal Construction for InsuredAppellate ProcedureSummary Judgment Denial
References
8
Case No. MISSING
Regular Panel Decision

Vam Check Cashing Corp. v. Federal Insurance

Vam Check Cashing Corporation (VAM) sued Federal Insurance Company after experiencing a $120,000 loss due to an elaborate fraud scheme. Imposters tricked a cashier at VAM's Pine Check Cashing location into handing over the money. Federal denied VAM's claim, asserting the incident did not meet the policy's definition of 'Robbery,' specifically concerning the terms 'overt felonious act' and 'cognizance.' The court examined the insurance policy's ambiguous language, particularly the meanings of 'overt' and 'cognizance.' It ruled that the cashier did not need to recognize the act as criminal for coverage, only that the physical act of transferring money occurred in her presence and control. The court found Federal's interpretation would defeat the policy's purpose of protecting check cashing businesses from fraud. Consequently, VAM's motion for summary judgment was granted, and Federal's motion was denied.

Insurance Policy InterpretationRobbery DefinitionSummary JudgmentContract AmbiguityFraud SchemeCheck Cashing BusinessOn Premises ClauseOvert Felonious ActCognizance RequirementNew York Law
References
13
Case No. 2018 NY Slip Op 06963
Regular Panel Decision
Oct 18, 2018

International Union of Painters & Allied Trades, Dist. Council No. 4 v. New York State Dept. of Labor

This case addresses the interpretation of New York's prevailing wage law, Labor Law § 220 (3-e), concerning apprentice wages on public work projects. The International Union of Painters & Allied Trades and glazing contractors challenged the New York State Department of Labor's (DOL) policy which stipulates that apprentices must perform tasks within their registered trade classification to be paid apprentice rates. Plaintiffs argued this policy increased costs and limited on-the-job training for glazier apprentices whose curriculum included tasks classified as ironwork. The Court of Appeals reversed the Appellate Division, upholding the DOL's interpretation as rational. The Court reasoned that the statute's language was ambiguous, and the DOL's policy prevented employers from using apprentices as cheap labor outside their specific trade, thereby ensuring proper training and maintaining construction standards.

Prevailing Wage LawApprentice WagesPublic Work ProjectsGlazier ApprenticesIronworker TasksStatutory InterpretationAdministrative DeferenceLabor Law § 220Trade ClassificationWorkforce Development
References
17
Case No. MISSING
Regular Panel Decision

Fagnani v. American Home Assurance Co.

This case involves an appeal concerning an insurance policy's exclusionary clause. Plaintiffs' decedents, Stephen Fagnani and Brandon Young, were killed in a helicopter crash while working for ODECO. The defendant insurance carrier disclaimed liability, citing a policy exclusion for 'Flying in any Rotocraft being used for transportation of Oil Rig Crews to and from such rigs.' Special Term granted summary judgment for the plaintiffs, interpreting ambiguities against the insurer. Justice Titone, however, dissents, arguing that both sides presented extrinsic evidence, which creates a question of fact regarding the meaning of 'oil rig' that necessitates a trial. He recommends reversing the judgment, vacating the order, and remitting the matter for trial.

Insurance PolicyExclusionary ClauseSummary JudgmentContract InterpretationExtrinsic EvidenceAmbiguityHelicopter CrashAccidental DeathOil Rig CrewsAppellate Dissent
References
10
Case No. MISSING
Regular Panel Decision

Ramirez v. United States Fidelity & Guarantee Co.

Anthony Ramirez was killed in an accident while working for Leisure Pool Service, leading his estate and property owner Samuel Hillman to sue his employers for wrongful death. Hillman subsequently cross-claimed against the employers for indemnification and contribution. USF&G, the employers' insurer, disclaimed coverage for Hillman's cross-claim based on an employee bodily injury exclusion in their general liability policy. The Supreme Court granted summary judgment for USF&G, upholding the exclusion. On appeal, the court dismissed Ramirez's appeal, modified Hillman's appeal by explicitly declaring the exclusion applied, and affirmed the judgment, finding the policy's exclusionary language clear and unambiguous regarding employee injuries and related contribution claims.

Insurance policyDeclaratory judgmentSummary judgmentEmployee exclusionBodily injuryContributionIndemnificationAppellate reviewPolicy interpretationAmbiguity
References
10
Case No. 08-0073
Regular Panel Decision
Mar 27, 2009

Progressive County Mutual Insurance Company v. Regan Kelley

This case addresses whether two documents from an insurance company constitute one or two separate insurance policies. Regan Kelley, injured in a car accident, sought underinsured benefits from Progressive County Mutual Insurance Company after exhausting the motorist's insurer's limits. Progressive paid benefits under one policy but denied a claim under an alleged second policy, arguing the documents formed a single policy. The trial court granted summary judgment for Progressive, which the court of appeals reversed. The Supreme Court of Texas held that the documents are ambiguous as to whether one or two policies were issued, creating a fact question. Consequently, the Supreme Court reversed the court of appeals' judgment and remanded the case to the trial court for further proceedings to resolve this ambiguity.

Insurance Policy InterpretationMulti-Car PolicyContract AmbiguitySummary JudgmentAnti-Stacking ProvisionExtrinsic EvidenceLatent AmbiguityFact QuestionTexas Supreme CourtAuto Insurance
References
10
Case No. MISSING
Regular Panel Decision

Tozzi v. Long Island Railroad

Fred Tozzi, an employee of L & L Painting Company, Inc., was injured on the job in 1989, leading to a primary action against Long Island Railroad Company and a third-party action by the Railroad against L & L. Subsequently, L & L commenced a fourth-party action against its insurer, Commerce and Indemnity Insurance Company (C & I), seeking defense and indemnification under its commercial general liability policy. L & L moved for summary judgment, arguing the policy was ambiguous and regulatory estoppel applied, while C & I cross-moved to dismiss, citing an employee bodily injury exclusion. The court declined to apply regulatory estoppel due to the limited nature of New York's regulatory approval process for the insurance endorsement. However, the court found an ambiguity in the policy when considering the "Notice of Occurrence" endorsement alongside the exclusion. Construing this ambiguity in favor of the insured, the court granted L & L's motion for summary judgment, mandating C & I to defend and indemnify L & L, but also declared that L & L owed common-law and contractual indemnification to the Long Island Railroad Company.

Insurance policy interpretationCommercial General Liability (CGL)Employee bodily injury exclusionContractual indemnificationDuty to defendDuty to indemnifyRegulatory estoppelJudicial estoppelSummary judgmentAmbiguity in contract
References
45
Case No. MISSING
Regular Panel Decision

Perth Amboy Drydock Co. v. New Jersey Manufacturers Insurance

This case concerns the interpretation of an insurance policy issued to Perth Amboy Drydock Co. by New Jersey Manufacturers Insurance. The policy provided workmen's compensation and employer's liability coverage, primarily for 'shipwright work' employees. The core dispute revolved around an endorsement that expanded liability limits. While the endorsement's heading mentioned 'Masters or Members of the Crews of Vessels', a typewritten addendum at its foot broadened its application to 'Shipwright Work and operation of Tugboats'. The court affirmed the order and judgment, holding that the typewritten statement should prevail, resolving any ambiguity in favor of the insured. A dissenting opinion argued against this interpretation, asserting that the language was clear and restricted to maritime employees.

Insurance PolicyWorkmen's CompensationEmployer's LiabilityPolicy EndorsementContract InterpretationAmbiguityShipwright WorkMaritime LawAppellate ReviewDissenting Opinion
References
2
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