Justia.com Opinion Summary: At issue before the Supreme Court was whether it was a violation of public policy to exclude from underinsured motorist coverage (UIM) a claim by an individual eligible for workers' compensation benefits. Appellant Frank Heller was severely injured from an automobile accident that happened during the course of his employment as a police officer for Sugarcreek Borough. Workers' Compensation covered his medical expenses and two-thirds of his salary. The Borough paid the remainder of Appellant's salary. Appellant's losses and damages far exceeded the policy limit from the tortfeasor's insurance carrier. Accordingly, Appellant notified his insurer of a potential UIM claim and sought UIM benefits from the Borough pursuant to a policy issued by the Pennsylvania League of Cities and Municipalities. Ultimately, Appellant's claim was denied. Upon review, the Supreme Court concluded that an exclusion in Appellant's workers' compensation policy violated public policy and was therefore unenforceable. The Court reversed the Commonwealth Court which held that the policy considerations favored the insurer: "Invalidating the workers' compensation exclusion would not force [the UIM insurer] to underwrite an unknown risk for which it did not receive compensation. The Borough voluntarily elected to purchase optional UIM coverage. .. [W]e find [Appellant's] assertion that the Borough purchased illusory coverage persuasive… the vast majority of all UIM claims likely will be made by Borough employees who are eligible for workers' compensation. The subject exclusion operates to deny UIM benefits to anyone who is eligible for workers' compensation."
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[J-19-2010]
IN THE SUPREME COURT OF PENNSYLVANIA
WESTERN DISTRICT
CASTILLE, C.J., SAYLOR, EAKIN, BAER, TODD, McCAFFERY, ORIE MELVIN JJ.
FRANK D. HELLER AND BEVERLY A.
HELLER, HUSBAND AND WIFE,
Appellants
v.
PENNSYLVANIA LEAGUE OF CITIES
AND MUNICIPALITIES T/D/B/A PENN
PRIME TRUST A/K/A PENNSYLVANIA
POOLED RISK INSURANCE FOR
MUNICIPAL ENTITIES,
Appellee
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No. 16 WAP 2009
Appeal from the Order of the
Commonwealth Court entered June 4,
2008 at No. 1853 CD 2007, reversing the
Order of the Court of Common Pleas of
Venango County entered September 7,
2007 at No. 17-2005.
950 A.2d 362 (Pa. Cmwlth. 2008)
ARGUED: April 13, 2010
OPINION
MADAME JUSTICE ORIE MELVIN
DECIDED: October 19, 2011
We granted review to determine whether it is a violation of public policy to exclude
from underinsured motorist (“UIM”) coverage a claim by an individual eligible for workers’
compensation benefits.
For the following reasons, we conclude that a workers’
compensation exclusion in an employer-sponsored insurance policy violates public policy
and is, therefore, unenforceable. Accordingly, we reverse the order of the Commonwealth
Court.
The facts pertinent to our review are undisputed. On October 31, 2002, Appellant,
Frank Heller (“Heller”)1, was severely injured in an automobile accident during the course of
his employment as a police officer for Sugarcreek Borough (“Borough”).
Workers’
compensation covered Heller’s medical expenses and two-thirds of his salary.2 The
Borough paid Heller the remainder of his salary.
Heller recovered the $25,000 policy limit from the tortfeasor’s insurance carrier,
Allstate Insurance Company. Heller’s losses and damages, however, far exceeded the
liability coverage.3 Accordingly, Heller notified his insurer of a potential UIM claim and
sought UIM benefits from the Borough pursuant to a policy issued by Appellee,
Pennsylvania League of Cities and Municipalities t/d/b/a Pennsylvania Pooled Risk
Insurance for Municipal Entities a/k/a Penn PRIME Trust (“Penn PRIME”).4 The Borough’s
policy provided UIM coverage up to $100,000 per person or per accident. Penn PRIME
denied Heller’s claim pursuant to a policy exclusion which states that UIM coverage does
not apply to “[a]ny claim by anyone eligible for workers[’] compensation benefits that are the
statutory obligation of the Member.” Liability Coverage Document, at 32.
1
Heller’s wife, Beverly Heller, is also named as a party in this case.
2
The Borough has workers’ compensation coverage through the State Workers’ Insurance
Fund (“SWIF”).
3
We note that the nature and severity of Heller’s injuries are not documented in the record.
The complaint for declaratory judgment states only that he sustained “severe and disabling
injuries.” Complaint for Declaratory Judgment, 3/8/05, at ¶ 4. Thus, we are unable to
discern the precise nature of the additional recovery Heller seeks under the Borough’s
policy.
4
Pursuant to 75 Pa.C.S. § 1733(a)(1), Penn PRIME’s policy is the UIM policy of first priority
because it is the “policy covering [the] motor vehicle occupied by the injured person at the
time of the accident.”
[J-19-2010] - 2
Following Penn PRIME’s denial of benefits, Heller filed a declaratory judgment action
in the Court of Common Pleas of Venango County. Heller sought an order voiding the
subject exclusion on the grounds that it is contrary to public policy. The parties stipulated
to the relevant facts and cross-motioned for summary judgment.
On September 7, 2007, the trial court granted Heller’s motion for summary judgment
and denied Penn PRIME’s motion for summary judgment. The court initially assessed the
ability of an injured employee to collect workers’ compensation and UIM benefits. The trial
court recognized that a repealed section of the Motor Vehicle Financial Responsibility Law
(“MVFRL”), 75 Pa.C.S. § 1735, prohibited an insurer from excluding UIM benefits based on
the receipt of workers’ compensation.5 The court observed that after the repeal of section
1735,6 an employee injured during the course and scope of his employment could still seek
workers’ compensation and UIM benefits. Gardner v. Erie Insurance Company, 722 A.2d
5
Section 1735 provided:
The coverage required by this subchapter [uninsured and
underinsured motorist coverage] shall not be made subject to
an exclusion or reduction in amount because of any workers’
compensation benefits payable as the result of the same injury.
75 Pa.C.S. § 1735 (repealed). Section 1737 of the MVFRL also concerned the interrelation
of uninsured (“UM”) and UIM benefits to workers’ compensation, providing:
Nothwithstanding anything contained in the … Workmen’s
Compensation Act, no employee who is otherwise eligible shall
be precluded from recovery of uninsured and underinsured
motorist benefits from an employer’s motor vehicle policy under
this chapter….
75 Pa.C.S. § 1737 (repealed).
6
The General Assembly repealed sections 1735 and 1737 by the Act of July 2, 1993, P.L.
190, also known as Act 44. Hereinafter, we refer to Act 44 or the amendments to the
MVFRL.
[J-19-2010] - 3
1041, 1046-47 (Pa. 1999). Citing our decision in Selected Risks Insurance Company v.
Thompson, 552 A.2d 1382 (Pa. 1989), the trial court reasoned that prior to the adoption of
section 1735, an exclusion based on the receipt of workers’ compensation was void as
against public policy. The court noted that such an exclusion violated public policy by, inter
alia, creating a windfall for the insurer because it collected a separate premium for the UIM
coverage. The trial court further concluded that the exclusion frustrated the objectives of
the current MVFRL by denying the workers’ compensation carrier the right of subrogation.
Harper v. Providence Washington Insurance Co., 753 A.2d 282, 286 (Pa. Super. 2000).
Accordingly, the trial court found that the exclusion violated public policy.
On appeal to the Commonwealth Court, a divided panel reversed the decision of the
trial court. Heller v. Pennsylvania League of Cities and Municipalities, 950 A.2d 362 (Pa.
Cmwlth. 2008). The court began its analysis with a historical discussion of the interplay
between the MVFRL and the Pennsylvania Workers’ Compensation Act, 77 P.S. §§ 12626. The Commonwealth Court explained that 75 Pa.C.S. § 1735 prohibited insurance
companies from excluding UIM benefits based on the receipt of workers’ compensation.
The court derived this premise from our decision in Selected Risks, supra, where we voided
an exclusionary provision in an insurance policy that permitted a reduction in UIM benefits
in an amount equivalent to workers’ compensation benefits.
The Commonwealth Court reviewed our case law regarding the interrelation of UIM
and workers’ compensation after the repeal of section 1735. The court observed that in
Gardner, supra, we held that Act 44’s repeal of section 1735 was not a revocation of the
right to dual recovery. The Commonwealth Court explained that under the post-repeal law,
[J-19-2010] - 4
workers’ compensation benefits are no longer deducted from UIM benefits, but a workers’
compensation carrier is allowed to seek subrogation.7
The court also discussed our decision in Pennsylvania National Mutual Casualty Co.
v. Black, 916 A.2d 569 (Pa. 2007), where we reviewed a set-off provision allowing for a
reduced recovery under the UIM portion of an insurance policy when the insured recovered
under the liability portion of the same policy. We concluded that the set-off did not violate
public policy because it did not conflict with the MVFRL and was simply a cap on total
coverage, consistent with the premiums paid by the insureds.8 Id. at 580-81.
Within this framework, the Commonwealth Court evaluated the public policy at issue.
Consistent with our precedent, the court stated that it must consider whether the MVFRL or
the Workers’ Compensation Act contains provisions that “specifically prohibit the inclusion
7
Act 44 concurrently repealed sections 1722 and 1720, as they pertain to workers’
compensation. Section 1722 provided, in pertinent part:
In any action for damages against a tortfeasor, or in any
uninsured or underinsured motorist proceeding, arising out of
the maintenance or use of a motor vehicle, a person who is
eligible to receive benefits under the coverages set forth in this
subchapter, or workers' compensation ... shall be precluded
from recovering the amount of benefits paid or payable under
this subchapter, or workers' compensation....
75 Pa.C.S. § 1722 (repealed in part).
Section 1720 provided, as relevant herein, “[i]n actions arising out of the
maintenance or use of a motor vehicle, there shall be no right of subrogation or
reimbursement from a claimant's tort recovery with respect to workers' compensation
benefits....” 75 Pa.C.S. § 1720 (repealed in part). Section 25(b) of Act 44 repealed sections
1722 and 1720 as they relate to workers’ compensation payments or other benefits under
the Workers’ Compensation Act.
8
The Commonwealth Court also observed that the Third Circuit Court of Appeals has held
that not all provisions prohibiting dual recovery are invalid. Heller, 950 A.2d at 368-69
(discussing Nationwide Mutual Insurance Co. v. Cosenza, 258 F.3d 197 (3rd Cir. 2001)).
[J-19-2010] - 5
of an exclusion to UIM coverage based upon the receipt of workers’ compensation benefits,
and if not, whether legal precedent warrants a conclusion that the exclusion violates public
policy.” Heller, 950 A.2d at 370. The Commonwealth Court found that the exclusion is not
prohibited by any specific statutory provisions and determined that there is no case law
directly on point.9 Concluding that the courts should not act as a “super-legislature” and redraft contract documents, the Commonwealth Court held that the conflicting policy
considerations favored the insurer. Accordingly, the court found that the subject exclusion
did not violate public policy.
Judge Friedman authored a dissenting opinion wherein she explained that the
compensatory scheme established by Act 44 shifts the ultimate burden for benefits from the
employer and the workers’ compensation carrier to the tortfeasor and the insurance carrier.
She opined that the employee is entitled to seek UIM benefits because workers’
compensation does not cover damages for, inter alia, pain and suffering. Selected Risks,
552 A.2d at 1388. Judge Friedman stated, “[I]f a UIM carrier excludes from its UIM
coverage anyone who is eligible for [workers’ compensation] benefits, a [workers’
compensation] carrier cannot assert a subrogation interest against UIM payments and an
employee cannot recover all applicable damages.” Heller, 950 A.2d at 373. Thus, she
reasoned that Penn PRIME’s exclusion defeats the two-pronged public policy of: (1) shifting
the burden to UIM carriers where a third-party tortfeasor causes a work-related injury; and
(2) enabling the injured employee to recover for losses and damages not covered by
workers’ compensation.
9
The court reasoned that the instant matter is distinguishable from Gardner, supra,
because it concerns a specific provision in an insurance policy whereas Gardner concerned
the exclusivity provisions of the Workers’ Compensation Act. See 77 P.S. § 481(a). The
Commonwealth Court further stated that Selected Risks, supra, is of limited precedential
value because the case was decided prior to the amendments to the MVFRL.
[J-19-2010] - 6
Heller filed a petition for allowance of appeal with this Court, which we granted
limited to the following issue:
Whether or not this Court should strike down an exclusion in
Appellee’s policy providing that any person receiving workers’
compensation benefits was ineligible for UM/UIM benefits?
Heller argues that the policy exclusion in question violates the MVFRL. Since the
MVFRL requires that an insurer provide UM/UIM coverage unless rejected, Heller avers
that a workers’ compensation exclusion is an impermissible way of denying coverage that is
statutorily required. Kmonk-Sullivan v. State Farm Mutual Auto. Insurance Co., 788 A.2d
955 (Pa. 2001); Prudential Property and Casualty Insurance Co. v. Colbert, 813 A.2d 747
(Pa. 2002). Accordingly, Heller maintains that allowing the exclusion to stand frustrates the
legislative scheme underlying the MVFRL.
Heller also posits that while we have often discussed public policy concerns, the
term remains undefined. Nonetheless, he claims that there is a clear violation of public
policy where a policyholder pays a premium for illusory coverage. Heller contends that
“virtually all” UIM claims will be made by Borough employees eligible for workers’
compensation, leaving a “shallow pool” of individuals to whom coverage will apply.10 Thus,
Heller maintains that Penn PRIME received a windfall by charging a premium for illusory
coverage.11
10
Heller asserts that the only individuals covered under Penn PRIME’s policy are alleged or
convicted criminals being transported in police vehicles.
11
Heller notes that the Borough could have achieved an identical result by rejecting Penn
PRIME’s UIM coverage, thereby saving the Borough the premium payments.
[J-19-2010] - 7
Heller also argues that the Commonwealth Court failed to consider the “made whole”
doctrine.12
Heller observes that the Workers’ Compensation Act limits the benefits
available to an injured worker, covering medical expenses and two-thirds of the worker’s
average weekly wage. Since workers’ compensation provides only a partial benefit, Heller
maintains that the recovery of UIM benefits is essential for him to be made whole.13
According to Heller, it is the insurer’s burden to pay the benefits necessary to compensate
him for his injuries. In support of this position, Heller broadly reiterates the concerns
expressed in Judge Friedman’s dissent, asserting that Act 44 shifts the burden to pay from
the workers’ compensation carrier to the insurer. Heller contends that allowing the
exclusion to stand defeats the purpose of the amendments to the MVFRL.
The Pennsylvania Association for Justice14 (“PAJ”) filed an amicus curiae brief in
support of Heller’s position. PAJ argues that it is a violation of public policy to exclude from
UIM coverage a claim by anyone eligible for workers’ compensation benefits arising out of
the same injury.
PAJ asserts that the exclusion is an impermissible method of
circumventing that which the law requires. PAJ draws on the statutory evolution of the
MVFRL, noting that it reflects a clear legislative intent to allow subrogation and to shift the
burden away from workers’ compensation carriers.
PAJ echoes Heller’s argument
regarding illusory coverage, claiming that Penn PRIME sold the Borough coverage “with
little or no chance of any of the intended users, the employees, being able to access the
12
Under the “made whole” doctrine, an insured must recover the full amount of his losses
before his insurer may demand reimbursement for any payments previously made to the
insured under an insurance policy. Jones v. Nationwide Property and Casualty Insurance
Co., 995 A.2d 1233, 1238 n.6 (Pa. Super. 2010).
13
Heller further claims that the exclusion prevents the workers’ compensation carrier from
being made whole. He hypothesizes numerous ripple effects from this scenario, including
an increase in workers’ compensation premiums.
14
Formerly known as the Pennsylvania Trial Lawyers Association.
[J-19-2010] - 8
coverage by virtue of an exclusion….” Brief of Amicus at 6. PAJ observes that if the
Borough did not wish for its employees to have coverage, it could have rejected the
coverage outright and avoided paying the premiums. PAJ maintains that any suggestion
that Borough employees are still covered by the policy is “divorced from reality.” Brief of
Amicus at 11.
By contrast, Penn PRIME contends that the Commonwealth Court correctly found
that the subject exclusion is valid and enforceable. Initially, Penn PRIME avers that when
this Court has declared policy language void as against public policy, the relevant provision
has conflicted with specific language in the MVFRL. Penn PRIME argues that the workers’
compensation exclusion does not conflict with any language in the MVFRL. Instead, it
maintains that the exclusion supports the “dominant” policy underlying the MVFRL — cost
containment. Penn PRIME asserts that the purpose of UIM coverage, to protect innocent
victims, has not been elevated to a “dominant” public policy. In this vein, Penn PRIME
observes that the MVFRL obligates the offer of UM/UIM coverage in every policy but allows
insureds to reject the coverage. 75 Pa.C.S. § 1731(a).15 Penn PRIME argues, “In light of
the express public policy allowing an insured not to provide UIM coverage, a provision for
15
Specifically, 75 Pa.C.S. § 1731(a), provides:
(a) Mandatory offering.--No motor vehicle liability insurance
policy shall be delivered or issued for delivery in this
Commonwealth, with respect to any motor vehicle registered or
principally garaged in this Commonwealth, unless uninsured
motorist and underinsured motorist coverages are offered
therein or supplemental thereto in amounts as provided in
section 1734 (relating to request for lower limits of coverage).
Purchase of uninsured motorist and underinsured motorist
coverages is optional.
Prior to July 1, 1990, such coverage was mandatory. Id., Historical and Statutory Notes.
[J-19-2010] - 9
such coverage subject to an exception for employees who receive workers’ compensation
comports with public policy.”16 Brief of Appellee at 8. Thus, it is Penn PRIME’s position
that it is logically impossible to convert the legislature’s decision to make UIM benefits
optional into a public policy mandate.
In rejecting Heller’s argument that the Borough paid for illusory coverage, Penn
PRIME observes that the Borough voluntarily entered into a coverage agreement
containing a workers’ compensation exclusion. Penn PRIME argues that the Borough
bought coverage only for employees who are not receiving workers’ compensation benefits.
As such, Penn PRIME contends that there is no merit to the allegation that the Borough did
not receive the benefit of the contractually agreed upon coverage. According to Penn
PRIME, to require it to provide benefits to Heller would force it to pay for a risk for which it
received no compensation.
Penn PRIME also rejects Heller’s contention that the denial of benefits prevents him
from being made whole. Penn PRIME notes that Heller continues to receive his full salary
from the Borough, has received payment under the tortfeasor’s liability policy, and can
recover benefits from his personal automobile insurance policy.17 Penn PRIME further
observes that any UIM benefits recovered by Heller would be subsumed by the subrogation
interest of the Borough’s workers’ compensation carrier, SWIF. Thus, Penn PRIME
maintains that Heller cannot legitimately assert that he will not be made whole.
16
We note that the subject exclusion is based on eligibility for workers’ compensation, not
the actual receipt of benefits.
17
In addition to granting review in the instant case, we also granted allowance of appeal in
Williams v. Geico, --- A.3d --- (Pa. 2011), to determine whether the “regular use” exclusion
in a police officer’s personal automobile insurance policy violates public policy where the
officer is injured during the course and scope of his employment. Our decision in Williams,
also issued contemporaneously and discussed infra, guides our holding in the instant case.
[J-19-2010] - 10
In the instant case, we must determine whether the workers’ compensation
exclusion violates public policy. Accordingly, we are presented with a question of law for
which our scope of review is plenary and our standard of review is de novo. Generette v.
Donegal Mutual Insurance Co., 957 A.2d 1180, 1189 (Pa. 2008).
“Generally, courts must give plain meaning to a clear and unambiguous contract
provision unless to do so would be contrary to a clearly expressed public policy.”
Prudential Property and Casualty Insurance Co. v. Colbert, 813 A.2d 747, 750 (Pa. 2002).
In several recent cases, this Court has examined claims that unambiguous provisions in
automobile insurance policies are unenforceable because they violate public policies
expressed in or underlying the MVFRL. In response, we have affirmed our reticence to
throw aside clear contractual language based on “the often formless face of public policy.”
Colbert, 813 A.2d at 752. With regard to the concept of public policy, we have stated:
Public policy is to be ascertained by reference to the laws and
legal precedents and not from general considerations of
supposed public interest. As the term “public policy” is vague,
there must be found definite indications in the law of the
sovereignty to justify the invalidation of a contract as contrary
to that policy.... Only dominant public policy would justify such
action. In the absence of a plain indication of that policy
through long governmental practice or statutory enactments, or
of violations of obvious ethical or moral standards, the Court
should not assume to declare contracts ... contrary to public
policy. The courts must be content to await legislative action.
Burstein v. Prudential Property and Casualty Insurance Co., 809 A.2d 204, 207 (Pa. 2002)
(quoting Eichelman v. Nationwide Insurance Co., 711 A.2d 1006, 1008 (Pa. 1998)). This
Court has further elaborated:
It is only when a given policy is so obviously for or against the
public health, safety, morals or welfare that there is a virtual
unanimity of opinion in regard to it, that a court may constitute
[J-19-2010] - 11
itself the voice of the community in so declaring [that the
contract is against public policy].
Mamlin v. Genoe, 17 A.2d 407, 409 (Pa. 1941).
Heller does not argue that the workers’ compensation exclusion in Penn PRIME’s
policy is ambiguous, and he does not dispute that the exclusion bars his recovery of UIM
benefits. Instead, he argues that the exclusion is contrary to public policy. In resolving this
issue, we first consider whether the exclusion expressly violates the MVFRL or the
Workers’ Compensation Act. The parties do not cite any statutory provisions that expressly
conflict with the subject exclusion, and we find no clear violations. Accordingly, we
conclude that the workers’ compensation exclusion does not expressly contradict the
statutory language of the MVFRL or the Workers’ Compensation Act.
We next consider the amorphous question of whether the exclusion violates the
public policy underlying the MVFRL, both generally and with regard to the specific
provisions governing UIM coverage and workers’ compensation.
This Court has
consistently acknowledged that the “dominant and overarching public policy” of the MVFRL
is one of cost containment. Paylor v. Hartford Insurance Co., 640 A.2d 1234, 1235 (Pa.
1994). “The repeal of the No-Fault Act and the enactment of the MVFRL reflected a
legislative concern for the spiraling consumer cost of automobile insurance and the
resultant increase in the number of uninsured motorists driving on public highways.” Id.
We have repeatedly recognized:
[W]hile cost containment is not the only objective of the statute,
it has become an increasingly significant one, and it is
apparent that the General Assembly has been employing the
vehicle of free consumer choice with greater latitude and
frequency in furtherance of this objective….
Lewis v. Erie Insurance Exchange, 793 A.2d 143, 154 (Pa. 2002). While it is undisputed
that the purpose of underinsured motorist provisions is to provide coverage to those injured
[J-19-2010] - 12
by a tortfeasor lacking adequate coverage, this is not a public policy “overriding every other
consideration in contract construction.” Eichelman, 711 A.2d at 1010.
Cost containment is inextricably linked to UM/UIM coverage. The purpose behind
UIM coverage is, as noted, to protect the insured from the risk of injury caused by a
negligent driver who lacks adequate insurance. Paylor, 640 A.2d at 1235-36 (quoting
Wolgemuth v. Harleysville Mutual Insurance Co., 535 A.2d 1145, 1150 (Pa. Super. 1988),
appeal denied, 551 A.2d 216 (Pa. 1988)). By purchasing UIM coverage, the insured shifts
that risk to his insurer. By limiting coverage, the insurer lowers its risk and the cost of the
policy is lessened. The outcome does not violate public policy; it favors it.
Our inquiry, however, does not end here. Despite our repeated affirmance of the
cost containment policy underlying the MVFRL, we have cautioned that it has limits. While
the enactment of the MVFRL grew out of a legislative concern for the “spiraling” costs of
automobile insurance, the cost containment objective cannot be mechanically invoked as a
justification for every contractual provision that restricts coverage and purportedly lessens
the cost of insurance. Burstein, 809 A.2d at 208.
The cost containment goal protects insurers from the forced underwriting of unknown
risks that insureds have not disclosed or paid to insure. Id. This concern lies at the heart
of numerous decisions by this Court, including the seminal decisions of Eichelman and
Burstein. In his Concurring and Dissenting Opinion in Colbert, then-Justice, now Chief
Justice Castille observed that this Court, when reviewing exclusions in reference to the
concept of public policy, should “ensure that both insurer and insured receive the benefit of
what is statutorily required and contractually agreed upon … and nothing more.” Colbert,
813 A.2d at 759 (Castille, J., concurring and dissenting).
Consistent with this
pronouncement, we have recognized that there is a direct correlation between the
premiums paid by the insured and the coverage an individual can reasonably expect to
receive. Hall v. Amica Mutual Insurance Co., 648 A.2d 755, 761 (Pa. 1994) (quoting
[J-19-2010] - 13
Jeffrey v. Erie Insurance Exchange, 621 A.2d 635, 645 (Pa. Super. 1993)). Thus, the
broad goal of cost containment cannot alter the fact that an insured is entitled to the
coverage for which he contracted and paid.
Reflected in our goal to ensure that an insured receives the benefit of the
contractually agreed upon coverage is our unwavering affirmation of policy exclusions
where an insured is merely seeking “gratis coverage.” Generette, 957 A.2d at 1188. Our
case law is replete with examples where we have upheld contractual provisions to prevent
an insured from obtaining coverage greater than that for which he paid. For example, in
Paylor, we upheld a family car exclusion because the plaintiff was attempting to convert
inexpensive UIM coverage into additional, more costly, liability coverage. Paylor, 640 A.2d
at 1241. Similarly, this Court has declined to invalidate policy exclusions that would provide
a disincentive to purchase insurance by allowing an insured to expand coverage at the
expense of the insurer. See Windrim v. Nationwide Insurance Co., 641 A.2d 1154 (Pa.
1994); Eichelman, 711 A.2d at 1010.
Thus, where coverage was not elected and
premiums were not paid, our precedent precludes an insured from demanding coverage.
It is within this framework that we evaluate the exclusion at issue. Invalidating the
workers’ compensation exclusion would not force Penn PRIME to underwrite an unknown
risk for which it did not receive compensation. The Borough voluntarily elected to purchase
optional UIM coverage. It paid a premium to Penn PRIME for this coverage, which
provided protection up to $100,000 per person or per accident.18 Thus, the Borough
purchased UIM coverage that insurers are required to offer, and it paid an unallocated
18
The declarations page of the insurance policy indicates that the Borough paid a premium
of $8,646.00 to Penn PRIME for automobile liability coverage. Included in this coverage
were first party benefits, UM/UIM coverage, and “garagekeepers coverage.” Complaint for
Declaratory Judgment, 3/8/05, at 7-9.
[J-19-2010] - 14
premium to Penn PRIME for this optional coverage. Accordingly, the instant case is
distinguishable from those where a party is merely seeking “gratis coverage.”
The application of public policy concerns in determining the validity of an insurance
exclusion depends upon the factual circumstances present in each case. Paylor, 640 A.2d
at 1240. Herein, we find Heller’s assertion that the Borough purchased illusory coverage
persuasive. Instantly, we are presented with the situation where a mandatory offering
under the MVFRL was accepted by the Borough, who paid a premium for UIM coverage to
provide additional protection to its employees who operate or occupy its vehicles.19 The
vehicles in question are used by Borough employees during the course and scope of their
employment.20 Thus, the vast majority of all UIM claims likely will be made by Borough
employees who are eligible for workers’ compensation. The subject exclusion, however,
operates to deny UIM benefits to anyone who is eligible for workers’ compensation.
Therefore, we find that Penn PRIME sold the Borough additional coverage that, in effect,
will not attach by virtue of an exclusion. Under the facts of this case and as applied to
19
The dissent disagrees with this conclusion, arguing that we have discounted the fact that
the policy applies to non-employee passengers. Dissenting Opinion, slip op. at 3. While it
is theoretically possible for this coverage to apply to non-employees, we are unable to
conclude that the Borough intended to purchase $100,000 in coverage for a class of
transient, and potentially unauthorized, vehicle occupants that are the exception rather than
the norm. Indeed, both parties acknowledge that the Borough’s employees are intended
beneficiaries of the UIM coverage. Heller suggests that the coverage was intended to
apply to all employees injured in a work-related motor vehicle accident, whereas Penn
PRIME asserts that the covered class of employees is limited to those who are not disabled
under the Workers’ Compensation Act. See Brief for Appellant at 10-11; Brief for Appellees
at 16.
20
We recognize, as Penn PRIME asserts, that the applicable policy is a fleet policy and is
not limited to the Borough’s police cruisers. The fact that other Borough vehicles are
covered under the policy does not change our analysis. Penn PRIME’s provision still
excludes those who have the authority to operate the vehicles.
[J-19-2010] - 15
Borough employees, the exclusion renders the coverage illusory.21 Further, the exclusion
operates to convert Penn PRIME’s statutory obligation into a sham offering. Penn PRIME
received a windfall by charging the Borough a premium for the coverage.22
Penn PRIME attempts to refute Heller’s argument by claiming that the Borough
voluntarily elected to purchase UIM coverage that is limited in scope.23 According to Penn
21
The dissent posits that the facts of this case, specifically Penn PRIME’s status as a
municipal liability pool, weighs against invalidating the exclusion. Dissenting Opinion, slip
op. at 4. Beyond bald assertions, Penn PRIME does not advance this argument. See
McLaughlin v. Gastrointestinal Specialists, Inc., 750 A.2d 283, 286 n. 6 (Pa. 2000)
(cautioning against addressing arguments not raised by the parties).
22
The dissent complains of the lack of record evidence “concerning the amount of the
premium allocated to UIM coverage,” Dissenting Opinion, slip op. at 2, and attributes this
failure to Heller. Due to this asserted lack of evidence, the dissent speculates that the
premium could have been “negligible” and, as such, “the workers’ compensation operat[ed]
as the primary protection, and the UIM coverage serv[ed] as a failsafe.” Id. at 3.
It is undisputed that the premium paid was in an unallocated amount. Complaint for
Declaratory Judgment, 3/8/05, at 7-9. Penn PRIME, however, does not argue that the
premium attributable to the UIM coverage is "negligible," and it is not this Court's duty to
address an undeveloped argument on Penn PRIME’s behalf. See McLaughlin, supra.
Furthermore, the dissent's suggestion that the premium could have been "negligible" is
speculative and unsupported by the record. A review of the record indicates that the
Borough rejected Penn PRIME’s initial offer of the minimum UIM coverage limit, which
would have provided coverage of $35,000. Appellants’ Supplemental Brief in Support of
Motion for Summary Judgment, 7/3/07, Exhibit D. Instead, the Borough elected to
purchase a higher UIM limit of $100,000, for which it paid “an additional contribution.” Id.
23
Penn PRIME also highlights the optional nature of UM/UIM coverage to justify its
workers’ compensation exclusion, claiming that optional coverage cannot be converted into
a public policy mandate. Penn PRIME’s argument is misplaced. The optional nature of
UM/UIM coverage is limited to its offer. Once an insured elects to purchase the coverage,
it is no longer “optional” and must satisfy statutory requirements and comport with public
policy. An insurer cannot invoke the optional nature of the coverage to justify numerous
coverage exclusions. To do so would permit an insurer to construct an unlimited number of
exclusions such that they swallow the coverage and render it illusory.
[J-19-2010] - 16
PRIME, the Borough only contracted and paid for coverage for employees who are not
eligible for workers’ compensation benefits. While Penn PRIME does not elaborate on this
assertion, one implication is that the coverage applies when the Borough’s employees are
using the vehicles outside the course and scope of their employment. There is, however,
no evidence in the record indicating that Borough employees may access the vehicles for
personal use. We decline to speculate as to the possible additional uses of the vehicles.
Our analysis is limited to the factual circumstances under which Heller was injured while
driving his work vehicle in the course and scope of his employment.
In its argument to this Court, Penn PRIME adopts the Commonwealth Court’s finding
that the coverage is not illusory because it applies to “[e]mployees who may be injured but
are not disabled under the Act.” Heller, 950 A.2d at 371 n.5 (emphasis in original). This
argument is specious.
Penn PRIME and the Commonwealth Court have drawn a
distinction without consequence, and we fail to see how it demonstrates that the coverage
is not illusory.
Workers’ compensation covers injury, illness, or disease sustained during or arising
out of employment.24 Workers’ compensation pays for an injured individual’s medical
expenses and, in the event that the individual is unable to work, provides wage-loss
compensation. Workers’ compensation is not restricted to disabling injuries. It is possible
to recover under the Workers’ Compensation Act exclusively for medical expenses in “no
lost time/medical only” claims. See Orenich v. W.C.A.B. (Geisinger Wyoming Valley
Medical Center), 863 A.2d 165 (Pa. Cmwlth. 2004), appeal denied, 880 A.2d 1242 (Pa.
2005). Thus, to the extent that an individual suffers an injury during the course and scope
24
Injury is defined as “an injury to an employe, regardless of his previous physical
condition, arising in the course of his employment and related thereto, and such disease or
infection as naturally results from the injury or is aggravated, reactivated or accelerated by
the injury.” 77 P.S. § 411(1).
[J-19-2010] - 17
of his employment, but is not disabled or caused to miss work, he may still recover medical
benefits under the Workers’ Compensation Act. As such, he is eligible for workers’
compensation and precluded from any UIM recovery he may attempt to obtain as a result of
Penn PRIME’s exclusion.
Moreover, Penn PRIME’s argument ignores the practicalities of the situation. We
cannot envision an instance where an injury sustained by a Borough employee during the
course and scope of employment would render him ineligible for workers’ compensation,
yet give rise to a UIM claim. Any work-related injury that is of sufficient severity to warrant
or necessitate a claim for UIM benefits will fall within the parameters of workers’
compensation. In this vein, it is especially important to recognize the difference between
UIM and UM coverage. UIM coverage applies where a tortfeasor has some insurance
coverage, but the amount is insufficient to compensate the victim.25 Stated differently, UIM
coverage is triggered where an insured sustains injuries that are severe enough to warrant
recovery beyond what the victim receives from the tortfeasor's insurer. See Generette, 957
A.2d at 1189. If an employee is injured while operating his employer's vehicle in the course
of employment, but that injury is insufficient to implicate workers' compensation, we fail to
appreciate why the employee would file a UIM claim. Such injuries should be covered by
the tortfeasor’s liability policy.26 Thus, we find no merit to the allegation that Penn PRIME’s
policy covers Borough employees who are injured during the course of their employment
but not disabled.
25
75 Pa.C.S. § 1702 defines “underinsured motor vehicle” as a motor vehicle for which the
limits of available liability insurance and self-insurance are insufficient to pay losses and
damages. By contrast, an uninsured motor vehicle is one for which there is no liability
insurance or self-insurance applicable at the time of the accident.
26
We note that the outcome might vary if UM, as opposed to UIM, provisions were
implicated. That situation, however, is not presently before the Court.
[J-19-2010] - 18
Despite its claim that the coverage is not illusory, Penn PRIME has not presented
this Court with an instance under which coverage will attach such that it would be required
to pay UIM benefits. Our own analysis fails to reveal a scenario where the coverage will
meaningfully apply to the intended beneficiaries — the Borough’s employees. Under the
facts of the case, the exclusion renders the coverage illusory. The Borough has been
denied the benefit of the bargain, while Penn PRIME has received a windfall by collecting a
premium for illusory coverage. To uphold the exclusion would thwart the purpose of the
MVFRL by allowing an insurer to deny benefits for which their insured paid a premium.
Thus, permitting the exclusion to stand provides a disincentive for insureds to pay
premiums for coverage that is not statutorily required and relieves the insurer of its
obligation to provide benefits for which the insured paid. While the Borough may have
received a reduced premium in exchange for what Penn PRIME deems “limited” coverage,
an insured cannot contract for illusory coverage.
In addition to finding the coverage illusory as it applies to Borough employees, we
conclude that the workers’ compensation exclusion violates the statutory scheme for
coordination of benefits evident in the MVFRL. A review of the evolution of the MVFRL
reflects a clear legislative intent to place the burden for the payment of benefits on the
tortfeasor or the UM/UIM carrier where a third-party causes a work-related injury. Penn
PRIME’s exclusion reverses this legislative priority by impeding the workers’ compensation
carrier’s right of subrogation. The result of the exclusionary provision is to ensure that the
burden for the payment of benefits remains on the Borough and its workers’ compensation
carrier. Since the exclusion frustrates the compensatory scheme established by the
General Assembly, we find that it violates public policy.
Our analysis of this issue begins with a brief historical review of the MVFRL,
recognizing that the amendments occasioned by Act 44 exchanged one comprehensive
scheme for another. The pre-amendment MVFRL permitted the dual recovery of workers’
[J-19-2010] - 19
compensation and UM/UIM benefits. Section 1735 provided that UM/UIM coverage could
not be made subject to an exclusion, or benefits subject to a reduction, because of workers’
compensation benefits payable.
Section 1737 stated that nothing in the Workers’
Compensation Act could prevent an employee from recovering UM/UIM benefits from an
employer-sponsored policy. Thus, the pre-amendment version of the MVFRL expressly
sanctioned recovery from employer-purchased plans and precluded insurers from
constructing exclusions or benefit reductions based on the recovery of workers’
compensation. See Ducjai v. Dennis, 656 A.2d 102, 106 (Pa. 1995); Hackenberg v.
Southeastern Pa. Transportation Authority, 586 A.2d 879, 882 n.8 (Pa. 1991).
Sections 1722 and 1720, as they pertain to workers’ compensation, are also relevant
herein. Section 1722 barred claimants in tort actions and UM/UIM proceedings from
recovering benefits and expenses already paid by workers’ compensation. Section 1720
prevented a workers’ compensation carrier from seeking subrogation. Thus, workers’
compensation carriers had no right of subrogation against an employee’s third-party claim,
and an employee was unable to recover any amounts payable under workers’
compensation. Warner v. Continental/CNA Insurance Cos., 688 A.2d 177 (Pa. Super.
1996), appeal denied, 698 A.2d 68 (Pa. 1997).
As the aforementioned demonstrates, the statutory framework placed the ultimate
burden for the payment of benefits on the workers’ compensation carrier. Gardner, 722
A.2d at 1045; Hannigan v. W.C.A.B. (O’Brien Ultra Service Station), 860 A.2d 632, 636 (Pa.
Cmwlth. 2004), appeal denied, 872 A.2d 174 (Pa. 2005). While it was clear that an
employee could potentially obtain a dual recovery, section 1722 prohibited an employee
from recovering expenses already paid through workers’ compensation.27 Thus, the
27
Stated differently, section 1722 prevented an employee from lumping into uninsured
damages a claim for all lost earnings or medical expenses. Accordingly, the effect of
section 1737, which expressly sanctioned recovery of UM/UIM benefits from employer(continued…)
[J-19-2010] - 20
employee was denied a double recovery for medical expenses and wage loss, while the
workers’ compensation carrier was precluded from being reimbursed from the UM/UIM
recovery of the amounts already paid in compensation. The effect, and obvious legislative
intent of this scheme, “was to mandate that the ultimate burden for payment of
compensation benefits remain with the [w]orkers’ [c]ompensation insurance and not be
passed on [to] the automobile insurance [carrier] (and the premiums by which auto
insurance is funded).” City of Meadville v. W.C.A.B. (Kightlinger), 810 A.2d 703, 705 (Pa.
Cmwlth. 2002), appeal denied, 852 A.2d 1182 (Pa. 2002) (quoting Updike v. W.C.A.B.
(Yeager Supply Inc.), 740 A.2d 1193, 1195 (Pa. Cmwlth. 1999)).
Act 44 represented a legislative attempt to alter the scheme of benefits available to
an employee injured in an automobile accident. Gardner, 722 A.2d at 1045. Under Act 44,
an injured employee can still recover both workers’ compensation and UM/UIM benefits,
including a possible recovery from each source for the same injury.28 With Act 44,
however, the General Assembly concurrently repealed sections 1720 and 1722 as they
related to workers’ compensation. Consequently, there is no reduction of a claimant’s
recovery in UM/UIM proceedings by the amount of workers’ compensation benefits
received. Act 44 also granted workers’ compensation carriers the right to subrogate
against any benefits received in connection with the third-party action.29 Accordingly, the
(…continued)
sponsored plans, was to allow recovery for pain and suffering and for any shortfall in wageloss reimbursement.
28
We have consistently held that section 1735 was not the source of the right to dual
recovery. Ducjai, 656 A.2d at 106; Hackenberg, 586 A.2d at 882 n.8; Gardner, 722 A.2d at
1044. As such, its repeal did not eviscerate the ability of an injured individual to collect
workers’ compensation and UM/UIM benefits.
29
Subrogation is governed by section 319 of the Workers’ Compensation Act, which
provides:
(continued…)
[J-19-2010] - 21
collection of UM/UIM benefits by an employee creates a fund against which the workers’
compensation carrier can exert a lien for the amounts it paid the employee for the already
recompensed injury. Thus, under the amendments, the injured worker recovers more, but
the ultimate beneficiary is the workers’ compensation carrier since it can exert a
subrogation lien against any double recovery. Gardner, 722 A.2d at 1046 (discussing
Travelers Indemnity Company of Illinois v. DiBartolo, 131 F.3d 343, 348-49 (3d Cir. 1997)).
The statutory evolution of the MVFRL demonstrates that Act 44 shifted the burden
for the payment of benefits from innocent employers and their workers’ compensation
carriers to the tortfeasor or the insurer. Under this scheme, it is Penn PRIME who must
bear the burden of paying for Heller’s work-related injury, which was caused by an
underinsured third-party tortfeasor. Penn PRIME’s exclusion, however, prevents this
outcome and defeats the policy underlying Act 44.30 As Judge Friedman recognized in her
dissent, precluding from UIM coverage individuals who are eligible for workers’
compensation hinders the workers’ compensation carrier’s subrogation interest. The result
is that the employer, innocent of any wrongdoing, and its workers’ compensation carrier
remain responsible for the payment of benefits, contrary to the legislative hierarchy for
(…continued)
Where the compensable injury is caused in whole or in part by
the act or omission of a third party, the employer shall be
subrogated to the right of the employe, his personal
representative, his estate or his dependents, against such third
party to the extent of the compensation payable under this
article by the employer….
77 P.S. § 671.
30
Penn PRIME’s exclusion obstructs the purpose of the Pennsylvania Workers’
Compensation Act in the same manner that it interferes with the MVFRL. See Warner, 688
A.2d at 185.
[J-19-2010] - 22
coordinating benefits under Act 44.
Since Penn PRIME’s exclusion frustrates the
compensation scheme established by the General Assembly, it violates public policy and is
unenforceable.
The policy argument based on Act 44 is not one of “supposed” public interest; the
subrogation right reflects a clear statutory enactment. “[A]n enactment by the legislature —
such as the MVFRL — is indeed the embodiment of public policy.” Erie Insurance
Exchange v. Baker, 972 A.2d 507, 511 n.7 (Pa. 2009). We recognize, as Penn PRIME
argues, that allowing workers’ compensation carriers to subrogate against third-party
recovery is not a core policy of the MVFRL; it is limited by an insured’s decision to reject
UM/UIM benefits. Stated differently, the optional nature of UM/UIM coverage does not
guarantee a workers’ compensation carrier a right of subrogation. Where, however, an
insured elects to purchase UIM coverage, this policy is undeniably implicated and must be
given due consideration. Our conclusion is not altered by the mere fact that the Borough’s
decision to reject UIM coverage would have foreclosed the instant litigation. In instances
where an employer opts to purchase UIM coverage, the General Assembly has indicated
that it is the insurer, not the workers’ compensation carrier, who is ultimately responsible for
the payment of benefits.
Our decision in the instant case is also guided by our holding in Williams v. Geico, --A.3d --- (Pa. 2011). In Williams, we addressed whether a police officer injured in the
course and scope of his employment is entitled to collect UIM benefits from his personal
automobile insurance policy. The insurer in Williams denied coverage based on the
“regular use exclusion,” which precludes an insured from obtaining UIM benefits while
operating a vehicle that he does not own but regularly uses. The trial court granted the
insurer’s motion for summary judgment, and the Superior Court affirmed. The officer
appealed, arguing that application of the regular-use exclusion to police officers and other
first responders violates public policy. We affirmed the exclusion, finding that it is a valid
[J-19-2010] - 23
limitation on coverage consistent with the premiums paid by the insured. In accordance
with our precedent, we declined to force the insurer to underwrite an unknown risk for
which it did not receive compensation.
Williams is relevant to our analysis herein because Penn PRIME suggests that
recovery of UIM benefits is unnecessary under its policy since Heller can collect UIM
benefits from his personal automobile policy. Penn PRIME’s argument is disingenuous.
Our holding in Williams demonstrates that a police officer injured in the course and scope
of his employment while operating his employer’s vehicle cannot simply turn to his personal
policy to recover additional benefits. Where the applicable policy contains a regular use
exclusion, recovery is precluded. In light of our decision in Williams, to uphold the workers’
compensation exclusion could effectively foreclose Heller’s ability to recover beyond the
tortfeasor’s policy and the benefits available to him under workers’ compensation.
In summation, we find that while the exclusionary provision does not facially violate
the cost containment policy of the MVFRL, its inclusion in an employer-sponsored policy
operates to foreclose the majority of expected claims. Thus, the exclusion renders the
coverage illusory, and the insurer receives a windfall by charging a premium for the
coverage. Moreover, where a third-party tortfeasor causes a work-related injury, Act 44
dictates that the ultimate burden for the payment of benefits must rest upon the tortfeasor
or the UM/UIM carrier. Penn PRIME’s exclusion reverses this legislative priority by
frustrating the right of subrogation, thereby ensuring that the burden for the payment of
benefits remains on the employer and its workers’ compensation carrier. Since the
workers’ compensation exclusion operates to render the instant UIM coverage illusory and
runs counter to the intended compensatory scheme established by the General Assembly,
we find it void as against public policy.
The order of the Commonwealth Court is reversed.
[J-19-2010] - 24
Messrs. Justice Eakin and Baer, Madame Justice Todd and Mr. Justice McCaffery join the
opinion.
Mr. Justice Saylor files a dissenting opinion in which Mr. Chief Justice Castille joins.
[J-19-2010] - 25
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