Employers Mutual Liability Insurance v. Insurance Division

620 P.2d 497, 49 Or. App. 515, 1980 Ore. App. LEXIS 3856
CourtCourt of Appeals of Oregon
DecidedDecember 1, 1980
DocketNo. 76-3-4, CA 15070
StatusPublished

This text of 620 P.2d 497 (Employers Mutual Liability Insurance v. Insurance Division) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Employers Mutual Liability Insurance v. Insurance Division, 620 P.2d 497, 49 Or. App. 515, 1980 Ore. App. LEXIS 3856 (Or. Ct. App. 1980).

Opinion

GILLETTE, P. J.

Employers Mutual Liability Insurance Company (Employers) seeks review of the order of the Insurance Division (Division) finding that it violated two provisions of the Insurance Code, one prohibiting unfair discrimination between risks of essentially the same degree of hazard, and one prohibiting misrepresentation in the offer or sale of insurance. The alleged violations arose from the use of an assumed loss ratio in the calculation of dividends in participating workers’ compensation insurance policies sold to two different insureds. We affirm in part, reverse in part and remand.

Employers is an insurance company which sells workers’ compensation coverage in this state. One type of workers’ compensation policy, known as a participating policy, provides for dividends payable to the insured after the policy period expires. Such dividends may be "flat”, where the policy sets a maximum flat dividend, or "par”, where dividends are determined according to a sliding scale based in part upon the ratio between the losses suffered by the insured and the premiums paid. The policies which gave rise to the alleged violations here were both "par” policies in which dividends were to be determined in part by the insured’s loss ratio. Aside from that similarity, the two violations at issue here involve different insureds and different fact situations and will, therefore, be discussed separately.

UNFAIR DISCRIMINATION

The charge of unfair discrimination arises from a policy issued to Leonetti Manufacturing Company (Leonet-ti) on August 1, 1973. Employers had previously insured Leonetti under two different workers’ compensation policies which provided for a flat dividend percentage. The policy issued on August 1, 1973, however, was a "par”, or sliding scale participating policy.

Regarding dividends, the policy provided:

"The policyholder is a member of the company and shall participate, to the extent and upon the conditions fixed and determined by the Board of Directors in accordance with the provisions of law, in distribution of dividends so fixed and determined.”

[518]*518The Premium Refund Endorsement - Sliding Scale incorporated into the policy provided:

"It is agreed that, with respect to premium earned in Oregon, the insured shall be entitled to such premium refund (dividends) from divisible surplus as shall be determined by the Board of Directors under the sliding scale refund schedule Plan D in effect and applicable to the policy at the time of expiration, provided no premium shall remain unpaid after written demand therefor.’’(emphasis supplied)

The par policy was issued for a one year period, but Leonetti became dissatisfied with Employers’ claim service and cancelled the policy effective November 1, 1973, after being assured in writing that cancellation would not result in a penalty.

On February 26, 1974, Employers’ Board of Directors declared dividends to policyholders participating under a sliding scale plan. In July, 1974, the Board purported to amend the sliding scale refund plan D, to be effective as to policies expiring in September, 1973, and thereafter, as follows:

"If any policy written under these plans is canceled or not renewed, at the option of the company, minimum losses may be reestablished as losses incurred in an amount up to 50% of the premium on such policies.”

In May, 1975, dividends were declared for sliding scale participating policies which expired in July, 1974. This was apparently the resolution which was considered applicable to the Leonetti policy because that policy, had it not been cancelled, would have expired on July 31, 1974.1

Leonetti’s losses during the period in which the par policy was in force were low, its actual loss ratio being 27.7 percent. When dividends were distributed, however, the assumed 50 percent loss ratio was applied; instead of receiving the $1039.99 which would have been its dividend under its actual 27.7 percent loss ratio, Leonetti received $407.06.

[519]*519Leonetti objected and eventually received the full amount of its refund based on its 27.7 percent loss ratio, rather than the assumed loss ratio, but only after seeking help from the Workers’ Compensation Board, the Insurance Commissioner’s office and the Anti-Trust Divisions of the California and Oregon Departments of Justice.

The Division filed a notice of hearing to determine whether Employers had engaged in enumerated unfair trade practices, including the one under consideration here. A hearing was held in May, 1976, written arguments were submitted by March, 1977, and the Commissioner issued his opinion and order on May 31, 1979.2 Employers petitioned for reconsideration and that petition was granted. A revised order was issued on February 13,1980. The revised order amended the original conclusions of law and order only; the findings of fact, findings of ultimate fact and opinion were not changed.

The facts related above are essentially those found by the Commissioner. He found as an ultimate fact that Employers assessed the assumed loss ratio penalty against Leonetti because Leonetti cancelled its workers’ compensation policy and that policyholders who did not cancel were not assigned an assumed loss ratio.3 The revised order determined that Employers had unfairly discriminated against Leonetti by giving unequal dividends.

In his opinion the Commissioner explained Employers’ use of the assumed loss ratio as follows:

"Viewed in its best light [Employers’] ostensible purpose in assessing the assumed loss ratio is to avoid the losses occurring after the policy has ended. While most employee injuries are treated and compensated before the policy expires and before dividends are paid, some injuries do not manifest themselves until later. * * * The number of these post-dividend losses is few, but their occurrence is [520]*520always a possibility. * * * An example might be the discovery of an unforeseen back injury arising as a complication of an injury originally thought to be relatively minor. Since the policyholder has been paid dividends before the employee discovers his injury, the injury is not reflected in his 'experience’ for that period; hence, it might be argued, the policyholder’s dividends were too high. By substituting an 'assumed loss ratio’ of 50%, however, Employers of Wausau could attempt to shift the possibility of a loss development tail’ from itself to the policyholder.
'This is apparently the justification here. Instead of recognizing Leonetti’s low loss of 27.7%, Employers of Wausau arbitrarily 'assumed’ their loss to be 50% because of cancellation.” (Citations to transcript omitted).

The statute under which Employers is charged with respect to the Leonetti policy is ORS 746.015(1), which provides in pertinent part:

"No person shall make or permit any unfair discrimination between * * * risks of essentially the same degree of hazard, in availability of insurance, in the application of rates for insurance, in the dividends or other benefits payable under insurance policies, or in any other terms of conditions of insurance policies.”

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Bluebook (online)
620 P.2d 497, 49 Or. App. 515, 1980 Ore. App. LEXIS 3856, Counsel Stack Legal Research, https://law.counselstack.com/opinion/employers-mutual-liability-insurance-v-insurance-division-orctapp-1980.