Simi Corporation v. Garamendi

1 Cal. Rptr. 3d 207, 109 Cal. App. 4th 1496, 68 Cal. Comp. Cases 909, 2003 Daily Journal DAR 7085, 2003 Cal. App. LEXIS 959
CourtCalifornia Court of Appeal
DecidedJune 26, 2003
DocketB149374
StatusPublished
Cited by51 cases

This text of 1 Cal. Rptr. 3d 207 (Simi Corporation v. Garamendi) is published on Counsel Stack Legal Research, covering California Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Simi Corporation v. Garamendi, 1 Cal. Rptr. 3d 207, 109 Cal. App. 4th 1496, 68 Cal. Comp. Cases 909, 2003 Daily Journal DAR 7085, 2003 Cal. App. LEXIS 959 (Cal. Ct. App. 2003).

Opinion

*1500 Opinion

SPENCER, P. J.

Introduction

The Insurance Commissioner of the State of California and the Workers’ Compensation Insurance Rating Bureau (WCIRB) appeal from a judgment granting a petition for writ of mandate. The judgment requires the Insurance Commissioner to set aside and vacate his decision interpreting certain regulations governing the reporting status of workers’ compensation claims, as applied to three specific claims made against Simi Corporation.

Appellants contend the trial court erred in failing to dismiss the case as moot, in setting aside the Insurance Commissioner’s interpretation of his own regulations and in admitting into evidence documents not presented to the Insurance Commissioner in the underlying administrative proceeding. We agree with the second of appellant’s contentions, that the Insurance Commissioner’s interpretation of the regulations at issue was entitled to deference and must be upheld. We therefore reverse the judgment.

Statutory and Regulatory Framework

Workers’ compensation laws are to be “liberally construed by the courts with the purpose of extending their benefits for the protection of persons injured in the course of their employment.” (Lab. Code, § 3202.) Toward that end, Labor Code section 5402, subdivision (b), provides that “[i]f liability is not rejected [by the employer] within 90 days after the date the claim form is filed under Section 5401, the injury shall be presumed compensable under this division.” The presumption thus created can be rebutted only by evidence discovered after the 90-day period. (Cal. Code Regs., tit. 8, § 9812, subd. (j).) Neither Simi Corporation, the employer, nor its insurer rejected liability for the claims at issue within 90 days of the claims’ filing. The presumption consequently applies in this case.

All workers’ compensation insurers must report workers’ compensation claim data to a central repository, a rating organization that the Insurance Commissioner has designated. (Ins. Code, §§ 11734, subd. (b), 11751.5.) The WCIRB serves as the rating organization to which all workers’ compensation insurers must report data.

To achieve a uniform system for accurately recording and analyzing data, Insurance Code section 11751.5 authorizes the Insurance Commissioner to *1501 adopt “reasonable rules and statistical plans” for reporting loss and expense information. To achieve this end, the Insurance Commissioner adopted the California Workers’ Compensation Unit Statistical Plan (Unit Statistical Plan). (Cal. Code Regs., tit. 10, § 2318.5.)

The Unit Statistical Plan applicable to these proceedings was adopted January 1, 1983, amended January 1988 and reprinted in 1993. It requires each insurer to report detailed information about incurred losses in connection with claims made against its insured. (Unit Statistical Plan, § II(G)(12) & (13).) 1 The data reported provide the raw material with which to develop an “experience modification factor” for each qualified employer. That factor plays a part in calculating the employer’s workers’ compensation insurance premium.

An experience rating plan, “in which the California workers’ compensation insurance experience of the particular insured is ... a factor in” determining whether to raise or lower the premium (former Ins. Code, § 11730), determines the experience modification factor. Since January 1, 1995, the rating plan must “contain reasonable eligibility standards, provide adequate incentives for loss prevention, and . . . provide for sufficient premium differentials so as to encourage safety.” (Ins. Code, § 11736.)

The experience rating plan in effect when Simi Corporation’s employees made the three claims at issue here sets out the rules governing experience rating. Some of these rules describe how WCIRB calculates an employer’s experience modification factor based on data the employer reports to WCIRB. (Cal. Code Regs., tit. 10, § 2353.)

Section III, part B, paragraph 1(b) of the 1983 Unit Statistical Plan sets out three ways that a claim initially reported as compensable may be declared noncompensable. “A correction or revision of losses must be filed if . . . [o]ne or more claims are declared noncompensable. A claim is declared non-compensable if: j^f] (1) There is an official ruling specifically holding that a claimant is not entitled to benefits under the Workers’ Compensation Laws of California, even though the claimant may have been awarded reimbursement for expenses incurred by the claimant in presenting his case. [f] (2) No claim was filed during the period of limitation provided by the Workers’ Compensation Laws of California for the filing of such claim, and the carrier therefore closes the claim. [H] (3) Where the carrier contends, prior to the valuation date, that a claimant is not entitled to benefits under the Workers’ Compensation Laws and the claim is officially *1502 closed because of the claimant’s failure to prosecute his claim.” 2 It is the Insurance Commissioner’s interpretation of the third contingency that is at issue in the instant case. 3

Factual and Procedural Background

Simi Corporation purchased workers’ compensation insurance from Superior Pacific Casualty Company, then known as Pacific Rim Assurance Company, for two years commencing December 31, 1989. The three employee claims at issue in this proceeding developed during the coverage period. The insurer paid out sums for medical-legal expenses, i.e., expenses incurred in connection with a medical evaluation of the claimant to determine compensability, for each of these claimants. (Lab. Code, § 4060.) The sums paid vary from $3,685.14 for claim No. 02-39165 to $4,443 for claim No. 02-57512 and $5,208.75 for claim No. 02-37713.

The insurer denied each of these claims in 1992, which the claimants did not pursue further through the insurer. The insurer thereupon closed its internal claim files. It closed one file sometime after April 12, 1993 and closed the other two files in 1994.

Simi Corporation sued Superior Pacific Casualty Company at some point before 1998, alleging that the insurer’s erroneous report of data regarding the three claims referenced above had damaged Simi Corporation. While that civil suit was pending, Simi Corporation requested that WCIRB determine whether the insurer had reported losses properly for these three claims. Simi Corporation argued that the insurer should have filed revised loss reports for the three claims, in that they satisfied the “declared non-compensable” definition set forth in the 1983 Unit Statistical Plan at section III, part B, paragraph 1(b). The insurer filed opposition, arguing that it had reported the claims in conformity with the Unit Statistical Plan.

The WCIRB subsequently issued a letter decision in which it concluded that the insurer had reported the loss information correctly with respect to the three claims in question. Simi Corporation then appealed that decision to the Insurance Commissioner pursuant to Insurance Code section 11753.1, subdivision (a).

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1 Cal. Rptr. 3d 207, 109 Cal. App. 4th 1496, 68 Cal. Comp. Cases 909, 2003 Daily Journal DAR 7085, 2003 Cal. App. LEXIS 959, Counsel Stack Legal Research, https://law.counselstack.com/opinion/simi-corporation-v-garamendi-calctapp-2003.