Case Law Update September 2020
Federal District Court Case
Employers Insurance Company v. Redlands Christian Migrant Association, ___F. Supp. ____ (M.D. FL 9/2/20)
Retroactive Ins. Contracts/Motions to Dismiss
The District Court denied Wassau/Employers’ Motion to Dismiss, based upon SOL. Wassau/Employers sued Redlands for failing to pay premiums under a retrospective insurance contract. In such a policy, the insured pays small premiums during the policy term, but after the term, the insurer examines the loss activity and charges a retrospective premium. Here Employers assessed a 500k premium, which Redlands failed to pay. Wassau sued, and Redlands countersued, alleging that Employers accepted a claim 16 years earlier (1) without investigating it properly (citing two prior WC claims of the individual) (2) still paying benefits to the claimant, and (3) failing to settle, all causing them to incur additional premium. Employers moved to dismiss alleging the counterclaims fell outside of the five year SOL for breach of contract. The District Court, although not determining the ultimate facts, denied Employers’ Motion, as the fact finder must determine, at least at the summary judgment phase the date on which the cause of action accrues. Employers argued it accrued in 2005, while Redlands argues the accrual is ongoing, as is the WC claim. The court also rejected Employers’ alternative grounds for dismissal based on a more definite statement. Click here to view Opinion
DCA Cases
Sanchez v. Yellow Transportation/Gallagher Bassett, ___ So.3d ___ (Fla. 1st DCA 9/21/20)
MCC/Burden of Proof
Scott Miller/Bill Rogner
The DCA reversed the JCC’s finding that the claimant failed to prove his 2004 workplace accident was the MCC of lumbar spine treatment recommended in 2018. Claimant began working with the employer in 1991. In 2004, the E/C authorized orthopedist Dr. Cohen to evaluate the lumbar spine. Later that year, the lumbar spine injury was consolidated with two other injuries with the employer. By 2014, a new servicing agent took over, but many of the old records apparently were not transferred. The DCA noted that the E/C entered into a stipulation in 2016 that agreed Dr. Cohen remained authorized to treat the cervical and lumbar spine, and attempted to reserve the right to challenge causation. Dr. Cohen’s records (the only admissible medical evidence) showed complaints of lumbar pain in 2014 without treatment or diagnosis, and a 2018 visit where the claimant alluded to the 2004 claim, where the doctor diagnosed L5-S1 DDD. The E/C subsequently paid for a lumbar MRI, and further visits where Dr. Cohen recommended a referral to pain management and ESIs. At the trial on those requested recommendations, the E/C argued per the Pre-Trial that the lumbar spine was no longer accepted, and that the claimant had suffered an intervening event. The claimant argued proof of MCC was unnecessary, as there was no intervening or competing cause. The JCC found Dr. Cohen’s records unreliable and that the claimant failed to prove MCC. The DCA noted the key was the identity of the accepted medical condition. They rejected the E/C’s position as unsupported by evidence that they accepted only a “lumbar sprain”, and noted they specifically accepted the lumbar spine. The DCA similarly dismissed arguments that a body part is not a specific injury diagnosis, and that they could not have accepted a degenerative condition that was unknown until the June 2018 MRI. The court found instructive similar broad language in Meehan (accepting “building related illnesses….”) and Jackson (“back injuries”) as binding upon a party, which thus removes the need for further proof by the claimant of MCC. In such cases, the burden then shifts back to the E/C to show a break in the causal chain/intervening event, which did not exist here. Click here to view Opinion
Please note that the DCA Opinions and Merit Orders contained in this newsletter are non-final until 30 days after their rendition. Until that time, they are subject to amendment, vacation, or other action which may remove or alter some or all of the decision. Please contact any HR LAW attorney if you have a question as to the finality and applicability of an Opinion or Order. We endeavor to include any amendments or alterations to Opinions or Orders that may occur at a later date