Ramirez v. Transcontinental Insurance Co.

881 S.W.2d 818, 1994 Tex. App. LEXIS 1799, 1994 WL 377745
CourtCourt of Appeals of Texas
DecidedJuly 21, 1994
DocketA-14-93-00961-CV
StatusPublished
Cited by32 cases

This text of 881 S.W.2d 818 (Ramirez v. Transcontinental Insurance Co.) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Ramirez v. Transcontinental Insurance Co., 881 S.W.2d 818, 1994 Tex. App. LEXIS 1799, 1994 WL 377745 (Tex. Ct. App. 1994).

Opinions

MAJORITY OPINION

J. CURTISS BROWN, Chief Justice.

This is a summary judgment case. Angelo Loiza Ramirez (Ramirez), appellant, sued Transcontinental Insurance Company (TIC), appellee, for breach of the duty of good faith and fair dealing in handling his workers’ compensation claim. TIC filed a motion for summary judgment and it was granted by the trial court. Ramirez brings one point of error asserting that the trial court erred in granting TIC’s motion for summary judgment. We affirm.

On or about July 12, 1989, Ramirez, a landscape laborer for Magnolia Gardens Nursery (Magnolia), was unloading a truck when he allegedly fell, striking and injuring the right side of his face. Ramirez claims that the accident aggravated a condition of the jaw known as temporomandibular joint (TMJ) syndrome. Ramirez filed a claim for workers’ compensation benefits with TIC, Magnolia’s workers’ compensation carrier. Although it did not issue a formal denial, TIC declined to pay workers’ compensation benefits to Ramirez.

The claim was brought before the Texas Workers’ Compensation Commission (TWCC).1 On February 23,1990, the TWCC found that Ramirez suffered an injury in the course and scope of his employment and awarded $15,590.23 to Ramirez. The award was appealed to the district court and suit was filed. In July 1990, Ramirez and TIC settled the workers’ compensation claim; however, Ramirez filed suit a month later against TIC for breach of the duty of good faith and fair dealing. On January 13, 1993, TIC filed a motion for summary judgment, asserting that it was entitled to judgment as a matter of law because it had a reasonable basis to deny Ramirez’s claim based on the information available to it at the time. Ramirez filed a response and supplemental response to TIC’s motion. The trial court granted TIC’s summary judgment motion on July 1, 1993, and Ramirez appealed.

In his sole point of error, Ramirez contends that the trial court erred in granting summary judgment in favor of TIC “because genuine issues of material fact existed as to whether [TIC] had a reasonable basis for denying benefits and [TIC] failed to establish it is entitled to judgment as a matter of law.”

The standard of review for summary judgments is well-established. A mov-ant for summary judgment has the burden of showing that there is no genuine issue of material fact and that it is entitled to judgment as a matter of law. Nixon v. Mr. Property Management Co., 690 S.W.2d 546, 548-49 (Tex.1985); Montgomery v. Kennedy, 669 S.W.2d 309, 310-11 (Tex.1984). In deciding whether there is a disputed material fact issue precluding summary judgment, proof favorable to the non-movant is taken as true, the court indulging every reasonable inference and resolving any doubts in favor of the [822]*822non-movant. Nixon, 690 S.W.2d at 548-49; Montgomery, 669 S.W.2d at 310. In other words, the issue on appeal is not whether the non-movant raised a material issue of fact precluding summary judgment; rather, the issue is whether the movant proved it was entitled to judgment as a matter of law. See TexR.Civ.P. 166a(c); Gibbs v. General Motors Corp., 450 S.W.2d 827, 828-29 (Tex.1970). If the appellate court finds the mov-ant has not met its burden, it must reverse and remand the case for further proceedings. Gibbs, 450 S.W.2d at 828-29. To prevail on summary judgment, a defendant, as the mov-ant, must establish as a matter of law that there is no genuine issue of fact as to one or more of the essential elements of the plaintiffs cause of action. Id. at 828.

In Arnold v. National County Mut Fire Ins. Co., 725 S.W.2d 165, 167 (Tex.1987), the Texas Supreme Court recognized a duty on the part of insurers to deal fairly and in good faith with their insureds. In Aranda v. Insurance Co. of North Am., 748 S.W.2d 210, 212-13 (Tex.1988), this duty was recognized in the context of a claim by an employee for benefits arising under a workers’ compensation insurance contract. The court held that “there is a duty on the part of workers’ compensation carriers to deal fairly and in good faith with injured employees in the processing of compensation claims.” Id.

A claimant who asserts that a workers’ compensation carrier has breached its duty of good faith fair dealing by refusing to pay or delaying payment of a claim must show that:

(1) the workers’ compensation carrier had no reasonable basis to deny or delay payment of benefits of the policy; and
(2) the carrier knew or should have known that there was no reasonable basis for denying or delaying payment of the claim.

Id. at 213. [emphasis in original]

The first part of the test requires an objective determination of whether a reasonable workers’ compensation carrier under similar circumstances, would have denied or delayed payment. Id. The second part of the test balances the right of the insurer to reject invalid claims against its duty to investigate and pay compensable claims. Id. The second part of the test is met by establishing that the carrier actually knew there was no reasonable basis to deny the claim or deny payment, or that the carrier, based on its duty to investigate, should have known that there was no reasonable basis for denial or delay. Id.2

Under the test, insurance carriers maintain the right to deny invalid or questionable claims and will not be subject to liability for an erroneous denial of a claim. Id. “In other words, if the insurer has denied what is later determined to be a valid claim under the contract of insurance, the insurer must respond in actual damages up to the policy limits.” Lyons v. Millers Casualty Ins. Co., 866 S.W.2d 597, 600 (Tex.1993). “But as long as the insurer has a reasonable basis to deny or delay payment of the claim, even if that basis is eventually determined by the factfinder to be erroneous, the insurer is not liable for the tort of bad faith.” Id. Whether there is no reasonable basis for denial must be judged by the facts before the insurer at the time it handled the claim. Viles v. Security Nat’l Ins. Co., 788 S.W.2d 566, 567 (Tex.1990); State Farm Lloyds Ins. v. Polasek, 847 S.W.2d 279, 287 (Tex,App.—San Antonio 1992, writ denied).

In the instant case, TIC denied benefits to Ramirez because there were questions not only about whether Ramirez’s TMJ syndrome was aggravated by the accident, but also about whether the accident actually occurred. In other words, there were questions about coverage under the insurance contract. The Texas Supreme Court has recently clarified the distinction between a claim for breach of the insurance contract and a claim for breach of the duty of good faith and fair dealing. In Transportation Ins. Co. v. Moriel,

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Bluebook (online)
881 S.W.2d 818, 1994 Tex. App. LEXIS 1799, 1994 WL 377745, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ramirez-v-transcontinental-insurance-co-texapp-1994.