Seguro-Suarez by and Through Connette v. Key Risk Ins. Co.
Seguro-Suarez by and Through Connette v. Key Risk Ins. Co.
Opinion
*202 When a North Carolina worker is hurt on the job, his injury is within the exclusive scope of the Workers' Compensation Act and he can obtain relief only by pursuing a claim before the North Carolina Industrial Commission (the "Commission"). But when, after the Commission awards the injured worker benefits, an employer's insurance company knowingly provides false information to police to frame him for insurance fraud, resulting in his arrest, incarceration, and indictment on felony charges, the worker's claims for malicious prosecution, abuse of process, and unfair and deceptive trade practices ("UDTP") exceed the scope of the Workers' Compensation Act and are properly before the General Court of Justice.
Plaintiff Mario Seguro-Suarez ("Plaintiff") brought suit against Defendants Key Risk Insurance Company ("Key Risk"), Joseph J. Abriola, Sharon Sosebee, Suzanne McAuliffe, and Cheryl Gless (collectively the "Individual Defendants" together with Key Risk as "Defendants") 1 for malicious prosecution, abuse of process, UDTP, bad faith, willful and wanton conduct, conspiracy, and punitive damages. Defendants appeal the denial of their motions to dismiss all of Plaintiff's claims *745 pursuant to Rules 12(b)(1) and 12(b)(6) of the North Carolina Rules of Civil Procedure. After careful review of the record and applicable law, we hold that the trial court did not err in denying the motions to dismiss pursuant to Rule 12(b)(1), but that it did err in failing to dismiss Plaintiff's *203 bad faith and civil conspiracy claims under Rule 12(b)(6). We therefore affirm the trial court's order in part, reverse in part, and remand for further proceedings.
I. FACTUAL AND PROCEDURAL HISTORY
The record below, consisting primarily of the allegations in Plaintiff's complaint, indicates the following:
In 2003, Plaintiff was working for his employer, Southern Fiber, when he fell from a height of approximately 18 feet onto concrete, striking his head. As a result of the fall, Plaintiff suffered several broken bones and severe traumatic brain injury. He was rendered comatose, required intubation and ventilation support to breathe, and underwent emergency neurosurgery at Carolinas Medical Center in Charlotte, North Carolina, to relieve pressure on his brain. He eventually emerged from his coma but the brain injury changed his personality, required physical, speech, and occupational therapy, and Plaintiff currently suffers from significant behavioral and memory deficits, including deficits in executive functioning, problem solving, planning, and balance. Plaintiff's injuries have rendered him dependent on others for: (1) dressing ; (2) feeding; (3) toileting; (4) assistance in daily activities; (5) grooming; (6) bathing; and (7) home management. Southern Fiber and Key Risk, as Southern Fiber's insurance carrier, admitted that Plaintiff's injuries were compensable.
While Plaintiff was in inpatient care, Key Risk was informed multiple times that Plaintiff would require 24-hour care upon discharge. Rather than provide for care at an assisted living center or by an at-home professional caregiver, Key Risk and its employees arranged for Plaintiff's 18-year-old daughter, who had immigrated to the United States only two months prior, to assume all home care for Plaintiff. After approximately 11 weeks, Plaintiff's daughter moved him into the home of a family friend, who assumed caregiving duties. Key Risk did not pay Plaintiff's daughter or friend for assuming the 24-hour care of Plaintiff.
Plaintiff saw an authorized treating physician, Dr. Flora Hammond, throughout 2003, 2004, and 2005. Dr. Hammond performed multiple tests on Plaintiff to discern the nature and extent of his condition, with each test showing symptoms consistent with traumatic brain injury. Dr. Hammond also requested an occupational home therapy evaluation, as she recognized that Plaintiff continued to suffer injuries as a result of several falls stemming from his balance issues. Key Risk denied the request and refused to provide the evaluation. Dr. Hammond later requested an evaluation by a neurologist, which Key Risk again declined to provide; instead, Plaintiff was evaluated by Dr. Thomas Gaultieri, a *204 neuropsychologist. Key Risk refused to authorize continued treatment by Dr. Hammond after Plaintiff was referred to Dr. Gaultieri.
Dr. Gaultieri treated Plaintiff from 2005 to mid-2007. Though he first believed Plaintiff was legitimately suffering from the conditions described above, Key Risk eventually provided Dr. Gaultieri with video footage that convinced him otherwise. The video, cut from 9 hours of surveillance footage taken by Key Risk over a six-month period and edited down to 45 minutes, led Dr. Gaultieri to opine that Plaintiff was willfully exaggerating his symptoms and that he needed no further treatment.
The above conduct by Key Risk in administering Plaintiff's care for an admittedly compensable injury led to considerable litigation. In 2008, a deputy commissioner of the Commission ordered Key Risk to authorize further treatment by Dr. Hammond, and Plaintiff returned to her care. In 2010, after Key Risk argued that Plaintiff's benefits should be cut off for fraud and misrepresentation, a deputy commissioner entered an opinion and award requiring Key Risk to pay continued compensation for Plaintiff's care. On 29 April 2011, the Full Commission entered its own opinion and award in Plaintiff's favor (the "Opinion and Award"). Not only
*746
did the Full Commission award Plaintiff continued benefits, but it concluded as a matter of law that "[Key Risk and Southern Fiber] brought and defended this claim without reasonable grounds. ... [Key Risk's and Southern Fiber's] position is not based upon reason." As a result, the Full Commission awarded Plaintiff attorney's fees, continued Key Risk's payment obligations in the amount of $345.35 per week "until further Order of the [Commission,]" and ordered that Plaintiff's daughter and family friend be reimbursed for their caregiving services, finding that Key Risk's refusal to pay prior to the entry of the Opinion and Award "was unreasonable and ... constituted stubborn, unfounded litigiousness." Key Risk filed an untimely appeal of the Full Commission's decision to this Court, which was dismissed by order. Order,
Seguro-Suarez v. Southern Fiber
, COA12-238-1 (N.C. Ct. App. May 15, 2012). Key Risk next petitioned the North Carolina Supreme Court for writ of certiorari, but its petition was denied.
Seguro-Suarez v. Southern Fiber
,
Following its losses before the Commission, and after exhausting its appeal efforts, Key Risk, by and through its employees Individual Defendants, hired Carolina Investigative Services and Robert E. Hill (the "Investigator") to surreptitiously surveil and record Plaintiff for several weeks. Key Risk also arranged for an independent medical exam of Plaintiff on 10 June 2013 in order to determine whether his symptoms were legitimate and if Plaintiff actually required ongoing care.
*205 The forensic psychiatrist who examined Plaintiff observed Plaintiff's "childlike" demeanor and concluded he was suffering from dementia, traumatic brain injury, chronic dizziness, and chronic headaches-all stemming from his workplace injury. Key Risk's chosen examiner further opined that Plaintiff's "symptoms appeared to be valid. There was no apparent malingering, in [her] opinion."
The mounting medical evidence and full-throated rebuke from the Commission left Key Risk undeterred in its efforts to undermine Plaintiff's medical diagnosis and continued care. After the independent medical exam, Key Risk directed its Investigator to convince the Lincolnton Police Department (the "LPD") to bring criminal charges against Plaintiff under the theory that he was obtaining his workers' compensation benefits by false pretenses, i.e. , by faking his diagnosed symptoms from his traumatic brain injury. The Investigator provided the LPD with an extensively edited videotape similar to that shown to Dr. Gaultieri in the proceeding before the Commission; as a result, the LPD arrested and jailed Plaintiff on 24 October 2013. On 10 March 2014, Plaintiff was indicted on 25 counts of obtaining property by false pretenses and one count of insurance fraud, all for accepting the checks ordered paid to him by the Commission.
After his first appearance in criminal court, Plaintiff was ordered to undergo a psychological examination at Central Regional Hospital in Butner, North Carolina to determine his competency to stand trial. The examining psychologist noted that Plaintiff "exhibited cognitive deficit consistent with his documented history, including memory impairment [,]" and concluded that Plaintiff was mentally incapable of both proceeding to trial and effectively assisting counsel. The State ultimately dismissed all charges against Plaintiff after a hearing in which the trial court asked the State if it "really want[ed] to assist in the establishment of a malicious prosecution claim[,]" and expressed "some real concerns when a man is drawing a check pursuant to an order, in effect, pursuant to a court order, and one side doesn't like the court order and decides to take out criminal charges because they disagree with what the ruling was."
After his release from custody, Plaintiff filed suit against Defendants and the Investigator in Mecklenburg County Superior Court, asserting causes of action for: (1) malicious prosecution; (2) abuse of process; (3) UDTP; (4) bad faith; (5) willful and wanton conduct; (6) civil conspiracy; and (7) punitive damages. Plaintiff's complaint asserts that Defendants undertook the above actions with the aim of terminating Plaintiff's workers' compensation benefits and relieving Key Risk of its financial burden. Defendants filed a motion to dismiss pursuant to *747 *206 Rules of Civil Procedure 12(b)(1) and 12(b)(6), asserting that the trial court lacked subject matter jurisdiction and that the complaint failed to state a claim upon which relief could be granted. The trial court denied Defendants' motion by order entered 30 January 2017, and Defendants timely filed their notice of appeal on 13 February 2017.
II. ANALYSIS
A. Appellate Jurisdiction
The denial of a motion to dismiss brought pursuant to Rules 12(b)(1) and 12(b)(6) is an interlocutory order and typically not subject to immediate appellate review unless it affects a substantial right.
See, e.g.,
Murray v. Univ. of N.C. at Chapel Hill
,
As for the denial of Defendants' motion to dismiss pursuant to Rule 12(b)(6), Defendants request that we exercise our discretion to consider their appeal thereof "to expedite the administration of justice," as allowed in
Flaherty v. Hunt
,
B. Standards of Review
We consider the denial of a motion to dismiss under Rule 12(b)(1) for lack of subject matter jurisdiction
de novo
, in which we "consider[ ] the matter anew and freely substitute[ ] [our] judgment for that of the
*207
[trial court]."
Blow v. DSM Pharms., Inc.
,
Similarly, we apply the
de novo
standard to review a trial court's ruling on a motion to dismiss pursuant to Rule 12(b)(6).
Green v. Kearney
,
C. Subject Matter Jurisdiction
Defendants argue that three prior decisions by this Court compel a conclusion that the Commission exercises exclusive jurisdiction over the tort claims alleged in *748 Plaintiff's complaint. We reject this argument, because each of the prior decisions is inapposite to this matter. We address each in turn.
In
Johnson v. First Union Corp.
,
*208
Id. at 143,
In
Deem v. Treadaway & Sons Painting & Wallcovering, Inc.
,
Bowden v. Young
,
We further recognized in
Bowden
that the " 'the Industrial Commission, charged with administration of the Workers' Compensation Act, is better suited than the Court to identify and regulate alleged abuses, if any, by insurance carriers and health care providers in matters under the
*209
Workers' Compensation Act.' "
Id.
at 290,
To apply the "straightforward rule" recognized in
Johnson
,
Deem
,
and
Bowden
to Plaintiff's action, as Defendants request, would stretch it beyond its factual and legal underpinnings. Plaintiff's complaint does not allege that he has been denied any workers' compensation benefits; to the contrary, he acknowledged at the final hearing in the criminal matter that Key Risk was still making the workers' compensation payments. Plaintiff's action, therefore, is markedly different from those brought in
Johnson
and
Deem
, which involved "allegation[s] that defendants did not appropriately handle his workers' compensation claim, and thus he was injured
because he did not receive his entitled benefit
."
Deem
,
Plaintiff's tort claims, though tangentially associated with his ongoing workers' compensation payments, concern the initiation and continued pursuit of
a
criminal prosecution
, not a workers' compensation claim. "General jurisdiction for the trial of criminal actions is vested in the superior court and the district court divisions of the General Court of Justice." N.C. Gen. Stat. § 7A-270 (2017). By contrast, "the North Carolina
*210
Industrial Commission is not a court of general jurisdiction; the Commission is a quasi-judicial administrative board created by the legislature to administer the Workers' Compensation Act and has no authority beyond that provided by statute."
Cornell v. W. and S. Life Ins. Co.
,
Law enforcement officers and prosecutors employed by the State and its subdivisions are not tasked with "processing and handling" workers' compensation claims, and neither are the district and superior court divisions of the General Court of Justice. Malicious use and abuse thereof, therefore, does not "aris[e] from ... [the] processing and handling of a workers' compensation claim ... within the exclusive jurisdiction of the Industrial Commission[.]"
Bowden
,
Although Plaintiff's complaint alleges that Defendants committed tortious acts in order to avoid liability to pay his workers' compensation, motivational concerns are irrelevant to our analysis. Taken to its logical end, this argument would allow a workers' compensation carrier to hire an assassin to kill an injured employee in order to terminate ongoing workers' compensation but avoid tort liability for wrongful death in civil court. Our Supreme Court has expressly held that:
When an employer intentionally engages in misconduct knowing it is substantially certain to cause serious injury or death to employees and an employee is injured or killed by that misconduct, that employee, or the personal representative of the estate in the case of death, may pursue a civil action against the employer. Such misconduct is tantamount to an intentional tort, and civil actions based thereon are not barred by the exclusivity provisions of the [Workers' Compensation] Act .
Woodson
,
Because the acts complained of in Plaintiff's complaint do not "aris[e] from an employer's or insurer's processing and handling of a workers' compensation claim[,]"
id.
at 291,
D. Rule 12(b)(6)
In the alternative to their argument under Rule 12(b)(1), Defendants posit that Plaintiff's complaint entirely fails to state a claim upon which relief can be granted under Rule 12(b)(6). We therefore address each of Plaintiff's individual claims in turn.
1. Malicious Prosecution
Plaintiff's first claim seeks redress for malicious prosecution. "To establish malicious prosecution, a plaintiff must show that the defendant (1) initiated or participated in the earlier proceeding, (2) did so maliciously, (3) without probable cause, and (4) the earlier proceeding ended in favor of the plaintiff."
Turner v. Thomas
,
In
Farm Bureau
, an investigator for the insurance company conducted an in-depth investigation of a house fire following a claim by an insured. 366 N.C. at 508-509,
Influencing a public prosecutor. A private person who gives to a public official information of another's supposed criminal misconduct, of which the official is ignorant, obviously causes the institution of such subsequent proceedings as the official may begin on his own initiative, but giving the information or even making an accusation of criminal misconduct does not constitute a procurement of the proceedings initiated by the officer if it is left entirely to his discretion to initiate the proceedings or not. When a private person gives to a prosecuting officer information that he believes to be true , and the officer in exercise of his uncontrolled discretion initiates criminal proceedings based upon that information, the informer is not liable under the rule stated in this Section even though the information proves to be false and his belief was one that a reasonable man would not entertain. The exercise of the officer's discretion makes the initiation of the prosecution his own and protects from liability the person whose information or accusation has led the officer to initiate the proceedings.
Id. at 513,
Here, Plaintiff's complaint alleges that Defendants "decided to falsely and maliciously accuse [Plaintiff] of committing insurance fraud and taking property by false pretenses," that they "caused criminal proceedings to be initiated against [him,]" and that they "acted with malice in providing false and misleading information to the [LPD] ...." It further alleges that Defendants "intentionally and maliciously caused incomplete, false and misleading information [to] be given to the [LPD] ...." 3 Employing a liberal construction of Plaintiff's complaint, we hold that these allegations are sufficient to survive Defendants' motion to dismiss pursuant to Rule 12(b)(6), and affirm the trial court's denial thereof on this claim. 4
2. Abuse of Process
Plaintiff's second claim for relief is for abuse of process. "Two elements must be proved to find abuse of process: (1) that the defendant had an ulterior motive to achieve a collateral purpose not within the normal scope of the process used, and (2) that the defendant committed some act that is a 'malicious misuse or misapplication of that process
after issuance
to accomplish some purpose not warranted or commanded by the writ.' "
Pinewood Homes, Inc. v. Harris
,
3. Unfair and Deceptive Trade Practices
Plaintiff's third cause of action asserts a UDTP claim against Key Risk based on Section 75-1.1 of the North Carolina General Statutes. Defendants argue that Plaintiff's claim is barred for lack of privity, relying on our holding in
Wilson v. Wilson
,
The same year that
Wilson
was decided, this Court held it was inapposite to a third party's UDTP claim against an insured driver's carrier.
Murray v. Nationwide Mut. Ins. Co.
,
Most recently, this Court has summarized the rule of
Murray
and its progeny as follows: "In the automobile accident context, an injured party is recognized as a third-party beneficiary to the liability insurance policy, because, under the statute, '[t]he primary purpose of th[e] compulsory motor vehicle liability insurance is to compensate innocent victims who have been injured by financially irresponsible motorists.' "
USA Trouser, S.A. de C.V. v. Williams
, --- N.C. App. ----, ----,
In
Nash Hospitals
, after providing medical treatment to a person injured in an automobile accident, Nash Hospitals sent notice of a medical lien to State Farm, the injuring party's insurer.
Like compulsory automobile insurance, "[t]he General Assembly has mandated that every employer subject to the Workers' Compensation Act maintain the ability to pay compensation benefits, either by purchasing workers' compensation insurance ... or by self-insuring."
N.C. Ins. Guar. Ass'n v. Board of Trs. of Guilford Tech. Cmty. College
,
*216
Roberts v. City Ice & Fuel Co.
,
Given the marked similarities between the compulsory automobile and workers' compensation insurance statutes, the reasoning in
Murray
that an "injured party in an automobile accident is an intended third-party beneficiary to the insurance contract between insurer and the tortfeasor/insured party,"
Defendants urge this Court to reach a contrary result on the basis that they continue to litigate Plaintiff's compensation pursuant to
Unlike the insurer in
Wilson
, Defendants have an ongoing legal obligation to pay Plaintiff as required by the Opinion and Award and Key Risk's own insurance policy with Southern Fiber. "[W]here the policy of
*217
insurance is against liability ... and the liability of the insured has been established by judgment, the injured person may maintain an action on the policy of insurance,
that
*754
is, coverage attaches when liability attaches
...."
Hall v. Harleysville Mut. Cas. Co.
,
Also, Section 97-18.1 includes no provision allowing or authorizing an employer's carrier to maliciously seek the arrest, incarceration, and felony prosecution of an employee for accepting workers' compensation payments awarded to him by the Commission, and no such action is permitted by Key Risk's insurance policy with Southern Fiber.
Wilson
concerned a pre-trial UDTP complaint against both the insurer and the insured.
4. Bad Faith and Civil Conspiracy
Although we affirm the portion of the trial court's order denying the dismissal of Plaintiff's malicious prosecution, abuse of process, and UDTP claims, we are persuaded by Defendants' challenges to Plaintiff's bad faith and civil conspiracy claims. We address each claim in turn.
*218
A necessary element of a bad faith claim against an insurer is a refusal by the insurer to pay a valid claim.
Lovell v. Nationwide Mut. Ins. Co.
,
Like the bad faith claim, we also reverse the portion of the trial court's order denying dismissal of Plaintiff's civil conspiracy claim based on the intra-corporate immunity rule. The doctrine provides that, "because 'at least two persons must be present to form a conspiracy, a corporation cannot conspire with itself, just as an individual cannot conspire with himself.' "
Conleys Creek Ltd. P'ship. v. Smoky Mountain Country Club Prop. Owners Ass'n, Inc.
, --- N.C. App. ----, ----,
5. Punitive Damages
Finally, Defendants argue that we should reverse the trial court's order as to Plaintiff's punitive damages claim because his complaint should have been dismissed in its entirety. As set forth
supra
, however, we hold that Plaintiff has stated tort claims for malicious prosecution, abuse of process, and UDTP sufficient to survive Defendants' motion to dismiss. His allegations of fraudulent, malicious, and willful and wanton conduct on the part of Defendants in perpetrating those acts are sufficient to allege punitive damages within the meaning of Section 1D-15 of our General Statutes. N.C. Gen. Stat. § 1D-15 (2017) ;
see also, e.g.,
Horne v. Cumberland Cty. Hosp. Sys., Inc.,
III. CONCLUSION
Plaintiff's tort claims, although they pertain to a workers' compensation award, do not, as a matter of fact or law, "arise[ ] from an ... insurer's processing and handling of a workers' compensation claim." Rather, Plaintiff's complaint arises out of a fraudulently and maliciously instituted criminal prosecution over which the Commission has no jurisdiction. Further, Plaintiff, as an injured employee who has obtained an award requiring payments to him under his employer's workers' compensation insurance policy is an intended third-party beneficiary of the policy in privity to bring a UDTP claim against the insurer. Plaintiff has sufficiently alleged claims for malicious prosecution, abuse of process, UDTP, and punitive damages; he has failed, however, to sufficiently allege claims for bad faith and civil conspiracy. For these reasons, we: (1) affirm the denial of Defendants' motion to dismiss all claims pursuant to Rule 12(b)(1) ; (2) affirm the denial of Defendants' motion pursuant to Rule 12(b)(6) as it pertains to Plaintiff's malicious prosecution, abuse of process, UDTP, and punitive damages claims; and (3) reverse the denial of Defendants' motion to dismiss pursuant to Rule 12(b)(6) as it pertains to Plaintiff's bad faith and civil conspiracy claims.
AFFIRMED IN PART; REVERSED IN PART.
Judges STROUD and DILLON concur.
The other defendants named in the action, Robert E. Hill and Carolina Investigative Services, Inc., did not appeal. We therefore limit our use of "Defendants" in this opinion to Key Risk and the Individual Defendants.
Defendants contend that an allegation in Plaintiff's complaint that Defendants' tortious acts "relate[d] to the defense of the worker's compensation claim" necessitates a holding that Plaintiff's action "arise[s] from" said workers' compensation claim. As explained
supra
, this is not so-that Defendants' motivation was to terminate the obligation to pay Plaintiff compensation does not render the tortious acts themselves "arising from ... [Key Risk's] processing and handling of [Plaintiff's] workers' compensation claim[,]"
Bowden
,
Although this allegation is made under a different cause of action, dismissal under Rule 12(b)(6) is not proper where "the allegations of the complaint ... are sufficient to state a claim ... under some legal theory,
whether properly labeled or not
."
Chapel H.O.M. Assocs., LLC v. RME Mgmt., LLC
, --- N.C. App. ----, ----,
Whether these allegations ultimately are supported by evidence is yet to be determined.
"By virtue of [
We note that some jurisdictions provide for exceptions to intra-corporate immunity where: (1) the employees or agents possess an independent motive from their employer or principal; or (2) the alleged conspiratorial acts were taken outside the scope of the employment or agency.
See, e.g.,
Painter's Mill Grille, LLC v. Brown
,
Case-law data current through December 31, 2025. Source: CourtListener bulk data.