St. Paul Fire & Marine Insurance v. Ellis & Ellis

262 F.3d 53, 2001 U.S. App. LEXIS 19238, 2001 WL 968051
CourtCourt of Appeals for the First Circuit
DecidedAugust 29, 2001
Docket00-1318
StatusPublished
Cited by21 cases

This text of 262 F.3d 53 (St. Paul Fire & Marine Insurance v. Ellis & Ellis) is published on Counsel Stack Legal Research, covering Court of Appeals for the First Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
St. Paul Fire & Marine Insurance v. Ellis & Ellis, 262 F.3d 53, 2001 U.S. App. LEXIS 19238, 2001 WL 968051 (1st Cir. 2001).

Opinion

LIPEZ, Circuit Judge.

St. Paul Fire & Marine Insurance Company appeals from the entry of judgment as a matter of law on its claims that defendants James Ellis and Ellis & Ellis engaged in common law fraud, unfair trade practices as proscribed by Mass. Gen. Laws ch. 93A, and statutory fraud in violation of § 14 of the Massachusetts workers’ compensation statute during Ellis’s representation of David Formoso in pursuing a claim for Workers’ Compensation benefits from St. Paul. Although the issue of St. Paul’s burden of. proving the element of damages in its fraud claim presents some complexity because of the workers’ compensation context, we nonetheless agree with St. Paul that the trial court erred in granting defendants’ motions for judgment as a matter of law. Consequently, we vacate the judgment of the district court.

I.

We recite the evidence presented at the trial in some detail because the outcome of this appeal turns, in part, upon the proper construction of that evidence. Since 1981, James Ellis has been an attorney specializing in workers’ compensation law. At the time of the events underlying this case, he was a partner with his brother in the firm of Ellis & Ellis, where he managed the workers’ compensation department. The present case arises from Ellis’s representation of one person who was employed at two different jobs under two different names: Denis Milan and David Formoso. During 1989, this individual, while maintaining his separate identities, had two work-related injuries, one at each place of employment. To reduce some of the inevitable confusion regarding these dual identities, we will refer to Denis Milan only when discussing his claim for the first accident at the Victory Button Company. Because it appears uncontradicted that David Formoso is the correct name of this individual, we will use that name in all other instances.

The first accident occurred on March 25, 1989 at the Victory Button Company. Denis Milan, a worker at the factory, claimed an injury to his lower back after he reached up to pull some hangers. Doctors placed that injury at the L5-S1 location. Milan sought workers’ compensation benefits for this injury and filed a claim with Victory Button’s insurer, Cigna Insurance Company. The second accident occurred approximately eight months after the first, on November 17, 1989, at the *57 Westford Regency Hotel. David Formoso, who worked as a dishwasher at the hotel, claimed to have injured his back during a fall. Doctors examining Formoso determined that this injury was also at the L5-S1 location in his lower back. Formoso also sought benefits for this alleged injury, submitting a workers’ compensation claim to the Massachusetts Department of Industrial Accidents on December 22, 1989. This claim was referred to St. Paul, West-ford Regency’s insurer. Ellis represented Formoso in both claims.

Although Formoso was claiming a causal relationship between his back injury and the fall at the Westford Regency Hotel, the prior accident at the Victory Button Company — with its injury to the same part of the back — was never disclosed to St. Paul. Not surprisingly, the parties dispute the significance of this nondisclosure. Ellis, who testified as a hostile witness during St. Paul’s case-in-chief, claimed ignorance of the concealed identity until five months after the Westford Regency Hotel accident. He did not disclose this dual identity because of his belief that Formoso was still entitled to benefits and his concern that disclosure would jeopardize For-moso’s ability to remain in this country. 1 St. Paul took a darker view of Ellis’s conduct, describing a fraudulent scheme to obtain workers’ compensation benefits. We, of course, must view the evidence in the light most favorable to St. Paul because of the standard of review applicable to this appeal. So viewed, the evidence discloses a fraudulent scheme to obtain workers’ compensation benefits.

A. Formoso’s deceit

Three months after the Victory Button Company accident, Milan began a course of treatment for his injury. His prognosis at that time was poor, with at least one of his doctors indicating that Milan would suffer a total disability unless and until surgery was performed. That surgery never occurred. Indeed, Milan’s doctors were unanimous in concluding that he had suffered a disabling injury that prevented him, at least temporarily, from returning to work. These doctors, however, were apparently never told that during the same period that they concluded he could not work, Milan was working, as Formoso, at the Westford Regency Hotel as a dishwasher. 2 Moreover, Formoso took another job at Malu Construction in the fall of 1989, again while still under a diagnosis of disability from his doctors. Thus, during the time when Milan was diagnosed as totally disabled, Formoso was in fact performing two other jobs. In other words, the injury to Milan, though serious enough to keep Milan from working, had no corresponding effect on Formoso’s ability to work.

Indeed, Formoso apparently only lost his ability to work when he suffered an accident as Formoso at the Westford Regency Hotel. Nonetheless, there was a basis in the evidence for questioning whether that accident actually resulted in any injury. Dr. Robert Bates, a chiropractor, treated Milan from August 10, 1989, to April 6, 1990, three times a week. Though this time period included the Westford Regency Hotel accident on November 17, 1989 — and therefore should have included some loss of function corresponding to that *58 injury — Dr. Bates testified that Milan showed a “fairly consistent” improvement in condition. “There were ... waxes and waning of symptoms, in other words, be a little better, a little worse; but overall he got a little bit better through the treatment.”

Moreover, Dr. Bates put Milan through a series of circuit training exercises designed to improve muscle strength in his back. Dr. Bates kept logs of these exercises. These logs showed that between November 17 and December 4, 1989, and again between December 4, 1989 and February 2, 1990, Milan increased the weights he used on these machines as well as the number of repetitions he performed. In contrast, during the same period, Formoso was seen by Dr. Param Singh (on November 28, 1989), Dr. Roland Caron (on December 29, 1989) and Dr. Bernard Stone (on February 28, 1990). Dr. Singh reported that Formoso was experiencing low back pain that was “moderate to severe in intensity, constant in nature, aggravated by movements of the spine, by prolonged ambulation, prolonged standing, or any physical exertion.” Dr. Caron saw surgery as an option and opined that Formoso “is totally disabled at the present time” with a “guarded” prognosis. Dr. Stone confirmed the reports of low back pain and recommended surgery as a realistic option because Formoso’s symptoms were “not improving.” Dr. Bates, however, considered Milan’s progress on the circuit training exercises from November 17, 1989 to February 2, 1990, as indicative of a “positive result.”

This evidence reveals a striking disjunction during the same time frame between Milan’s improving conditions and Formo-so’s supposedly severe back problem. Indeed, the medical histories of Milan and Formoso are like those of two different people.

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Bluebook (online)
262 F.3d 53, 2001 U.S. App. LEXIS 19238, 2001 WL 968051, Counsel Stack Legal Research, https://law.counselstack.com/opinion/st-paul-fire-marine-insurance-v-ellis-ellis-ca1-2001.