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

Case No. VEN 0120092
Regular
Apr 11, 2008

JOSE AVILA vs. SEMINIS VEGETABLE SEEDS, INC., REMEDYTEMP, INC., CALIFORNIA INSURANCE GUARANTEE ASSOCIATION by INTERCARE for RELIANCE INSURANCE COMPANY in liquidation, ZURICH NORTH AMERICA

The Workers' Compensation Appeals Board denied Zurich North America's petition for reconsideration, affirming the arbitrator's decision that Zurich's policy with Seminis Vegetable Seeds constituted "other insurance." This finding relieved the California Insurance Guarantee Association (CIGA) of liability, as the applicant's claim was not a "covered claim" under CIGA's statutory authority. The Board found that despite Seminis being a special employer, its policy with Zurich covered special employees, making it primary to CIGA's involvement following the insolvency of the general employer's insurer.

Workers' Compensation Appeals BoardSeminis Vegetable SeedsRemedyTempCalifornia Insurance Guarantee AssociationCIGAZurich North AmericaReliance Insurance Companyliquidationspecial employergeneral employer
References
8
Case No. 05-16-00875-CV
Regular Panel Decision
Jul 20, 2018

Peerless Indemnity Insurance Company, America First Insurance Company, the Netherlands Insurance Company, and America First Lloyds Insurance Company A.K.A. America First Insurance Company v. GLS Masonry, Inc.

The case involves an appeal by several insurance companies (Appellants) against GLS Masonry, Inc. (Appellee) after a take-nothing judgment in their suit to collect unpaid insurance premiums. The dispute centered on whether GLS's masonry workers were independent contractors or employees for premium calculation purposes, particularly for workers' compensation and general liability policies. The Appellants argued that GLS owed additional premiums due to audits reclassifying workers as employees and based on a lack of liability insurance for subcontractors. The trial court sided with GLS, finding that the insurance companies failed to establish the applicability of certain labor code provisions and did not sufficiently prove that GLS owed additional premiums, especially considering evidence that the workers were independent contractors and payments were made on policies. The Court of Appeals affirmed the trial court's judgment.

Insurance DisputeUnpaid PremiumsCommercial General LiabilityPremium AuditIndependent Contractor StatusEmployee ClassificationBreach of ContractTexas Appellate LawFactual Sufficiency ReviewSworn Account Claim
References
12
Case No. MISSING
Regular Panel Decision

Complete Auto Sales, Inc. v. Life Insurance Co. of North America

Plaintiff Complete Auto Sales, Inc. (Complete) filed a motion to remand its case against defendant Life Insurance Company of North America (LINA) back to state court. The case originated from Complete seeking contribution/indemnity from LINA, its insurer, for claims made against Complete by an injured employee. LINA had removed the case to federal court, arguing ERISA preemption. While some claims were partially remanded earlier, Complete now argues that LINA's insurance policy is exempt from ERISA jurisdiction, citing a prior ruling where a similar LINA policy was found to be state-governed. The court agreed, finding the current policy similar and not preempted by ERISA, thus lacking federal subject matter jurisdiction. Consequently, the motion to remand was granted, sending the case back to the 162nd Judicial District Court of Dallas County, Texas.

ERISA PreemptionRemoval JurisdictionState Law ClaimsInsurance Policy ExemptionFederal Question JurisdictionSubject Matter JurisdictionMotion to RemandTexas LawFifth CircuitDistrict Court
References
12
Case No. LAO 0762226, LAO 0762227
Regular
Sep 05, 2007

SHIRLEE DYERLY vs. LAWRY'S RESTAURANT, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for SUPERIOR NATIONAL INSURANCE COMPANY, INTERCARE INSURANCE SERVICES, ZURICH NORTH AMERICA INSURANCE COMPANY

This case involves a dispute over insurance coverage for an applicant's neck and back injuries sustained across specific and cumulative trauma incidents. The Workers' Compensation Appeals Board (WCAB) is reconsidering an arbitrator's decision that ordered Zurich North America Insurance Company to reimburse the California Insurance Guarantee Association (CIGA) for all benefits paid by the liquidated California Compensation Insurance Company (Cal Comp). The WCAB rescinds the arbitrator's order, ruling that CIGA can only recover the amount Cal Comp would have been entitled to collect had it not been liquidated, not the full amount paid.

CIGACal CompZurichliquidationcontributionreimbursementspecific injurycumulative traumastatute of limitationsjoint findings
References
7
Case No. 10-11-00142-CV
Regular Panel Decision
Jul 18, 2013

Dan Daniels v. Indemnity Insurance Co. of North America

Dan Daniels, an elevator installer for ThyssenKrupp Elevator Corporation, sued Indemnity Insurance Company of North America, his former employer's workers' compensation carrier, after an adverse administrative decision by the Texas Department of Insurance, Division of Workers’ Compensation (DWC). Daniels sought judicial review regarding the calculation of his Average Weekly Wage (AWW) and his post-injury earnings, specifically contesting the exclusion of certain payments made by ThyssenKrupp to his union for "health and other benefits" from his pre-injury AWW, and the valuation of a vehicle provided by the State of Missouri as part of his post-injury earnings. The trial court granted summary judgment for Indemnity and denied Daniels's motion for partial summary judgment. The appellate court affirmed the trial court's decision, concluding that the payments to the union were not includable in AWW and that Daniels's post-injury pecuniary and nonpecuniary wages were not less than 80% of his pre-injury AWW, thus disentitling him to Supplemental Income Benefits (SIBs).

Workers' CompensationSupplemental Income BenefitsAverage Weekly WageNonpecuniary WagesSummary JudgmentAppellate ReviewTexas Labor CodeAdministrative DecisionEmployer PaymentsPost-Injury Earnings
References
14
Case No. 03-21-00242-CV
Regular Panel Decision
Dec 28, 2022

Vista Medical Center Hospital, Surgery Specialty Hospital of America, Southeast Houston and Vista Hospital of Dallas v. Texas Mutual Insurance Company

This appeal stems from a dispute over workers' compensation medical benefits reimbursement between multiple hospitals (Vista Parties) and numerous insurance carriers (Carriers) in Texas. The core issue revolves around the application of a "stop-loss exception" under Former Rule 134.401, designed for unusually costly or lengthy hospital stays, which the Vista Parties sought for 542 injured workers. After the State Office of Administrative Hearings (SOAH) largely denied additional reimbursement, the district court affirmed SOAH's order. The Court of Appeals, Third District, affirmed the district court's judgment, rejecting the Vista Parties' arguments that the SOAH order was arbitrary and capricious or lacked substantial evidence. The court found that SOAH properly conducted a case-by-case inquiry into whether services were "unusually costly and unusually extensive" and did not err in its application of the rule or in its findings.

Workers' CompensationMedical ReimbursementStop-Loss ExceptionAdministrative LawAppellate CourtTexas Court of AppealsSubstantial Evidence ReviewArbitrary and CapriciousFee GuidelinesHospital Reimbursement
References
51
Case No. ADJ 4359672 (VNO 0478019)
Regular
Apr 08, 2016

JORGE OROZCO vs. MARRIOTT DOWNTOWN LOS ANGELES/INTERSTATE HOTELS AND RESORTS, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for AMERICAN PROTECTION INSURANCE COMPANY, ZURICH NORTH AMERICA, CENTURY PLAZA HOTEL

This case concerns the California Insurance Guarantee Association's (CIGA) liability for an insolvent insurer's obligations under a workers' compensation settlement. The applicant settled a cumulative trauma injury claim, and the settlement agreement apportioned liability for remaining lien claims among insurers, including American Protection Company. After American Protection Company became insolvent, CIGA stepped in, but sought dismissal, arguing its liability was not joint and several and no "other insurance" existed. The Board affirmed the dismissal of CIGA, holding that the original joint and several nature of the insurers' liability, as established by case law and the settlement, means Zurich North America's remaining liability constitutes "other insurance" relieving CIGA.

CIGAAmerican Protection Insurance CompanyMarriott Downtown Los AngelesInterstate Hotels and ResortsZurich North AmericaCentury Plaza HotelBroadspireSedgwick Claims Management ServicesCompromise and Release Agreementcumulative trauma
References
4
Case No. MISSING
Regular Panel Decision
Feb 28, 1991

North River Insurance v. United National Insurance

This appellate decision addresses the apportionment of liability between North River Insurance Co. and United National Insurance Company arising from a settlement for an injured employee. The court clarified that North River, as the workers' compensation carrier, is solely responsible for its waived lien, reversing a lower court's finding. It further determined that both insurers' "other insurance" clauses called for pro rata contribution, not equal shares, for the $588,245 settlement payment and defense costs. The court calculated specific shares for each insurer and ruled that North River is entitled to interest from the original payment date in 1982. The Supreme Court's order was thus modified to reflect these findings.

Insurance disputePro rata contributionEquitable apportionmentWorkers' compensation lienDefense costsOther insurance clausesSettlement apportionmentInterest calculationAppellate decisionInsurer liability
References
10
Case No. MISSING
Regular Panel Decision

Bishop v. Insurance Co. of North America

Roland Dean Bishop sought workers' compensation benefits for total and permanent incapacity after sustaining an injury on August 11, 1972. The Insurance Company of North America, the workers' compensation carrier, had paid benefits for 125 weeks. Bishop pleaded a general injury, while the carrier contended the injury was confined to his left foot below the knee. A jury found temporary total incapacity for 125 weeks and permanent partial incapacity thereafter, and crucially, determined the injury was confined to his left leg below the knee. The court rendered a take-nothing judgment, which Bishop appealed. The appellate court affirmed the judgment, finding no reversible error in the jury's findings or the court's evidentiary rulings, and upheld the specific injury finding.

Workers' Compensation BenefitsSpecific InjuryGeneral InjuryJury FindingsAppellate ReviewMedical TestimonyBack InjuryAnkle FusionIncapacity BenefitsEvidentiary Dispute
References
7
Case No. MISSING
Regular Panel Decision

Maida v. Life Insurance Co. of North America

Plaintiff Anthony Maida sued Life Insurance Company of North America (LINA) after his long-term disability benefits were terminated. Maida initially claimed physical disability due to a fall and later asserted mental disability from post-traumatic stress disorder. The court granted LINA's motion for summary judgment on the physical disability claim, finding LINA's denial was not arbitrary and capricious based on multiple medical reports. Additionally, LINA was awarded $10,155 on its counterclaim for overpaid benefits. However, the court vacated LINA's rejection of the mental disability claim, deeming it arbitrary and capricious due to the lack of proper medical review, and remanded the matter to LINA for reconsideration, while retaining jurisdiction.

Disability BenefitsERISA LitigationSummary JudgmentArbitrary and Capricious ReviewRemand to AdministratorPost-Traumatic Stress DisorderPhysical Injury ClaimMental Health ClaimInsurance Policy DisputeOverpayment Reimbursement
References
19
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