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July 18, 2008

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INSURER HELD ACCOUNTABLE FOR TERMINATING HEALTH INSURANCE COVERAGE

Thousands of Californians who lost their health coverage after filing claims with their insurance companies are about to get their policies restored.
Two of California’s biggest health insurers have agreed to collectively pay $13 million and reinstate more than 2,000 insurance policies to settle claims with the state that they illegally dropped policyholders from coverage.

Under an agreement announced Thursday, Anthem Blue Cross, a unit of Indianapolis-based WellPoint Inc., will pay $10 million and reinstate coverage for 1,770 enrollees while Blue Shield of California will pay $3 million and reinstate coverage for 450 enrollees. Both insurers will also reimburse policyholders for any outstanding medical debts that resulted from loss of insurance.

“This fine sends the message that if you come into California to sell health insurance, you must play by the rules,” said Cindy Ehnes, the director of the state’s Department of Managed Health Care.

Both companies denied any wrongdoing in rescission practices, the industry’s term for dropping patients from coverage when they try to make claims on their health insurance policies.

The settlements come two weeks after Ehnes told The Associated Press that the state failed to pursue a $1 million fine against Anthem Blue Cross because it was intimidated by the insurance company’s legal prowess.

Days later, the state vowed to seek penalties against Anthem Blue Cross that could have totaled $354 million.

Thursday’s announcements completed a two-year consumer protection push by the agency, said Ehnes.

In all, 3,770 dropped insurance policies have been restored through the effort to remediate rescission practices with the state’s five biggest insurers.
Anthem Blue Cross President Leslie Margolin issued a statement saying the state’s largest insurer was pleased to have reached agreement with the state.
“This resolution allows us to continue to build stronger working relationships with the DMHC and we look forward to coming together in a more collaborative way to address the health care needs of Californians,” said Margolin.
Last week, Ehnes warned that insurers who did not reach settlements would face stiffer penalties. The agency has already reached similar agreements with Health Net of California, PacifiCare and Kaiser Permanente.

Blue Shield’s vice president of public affairs, Tom Epstein, noted that its settlement was a voluntary decision.

“We did not acknowledge that any of our practices were inappropriate,” he said in an interview.

In a statement, Gov. Arnold Schwarzenegger applauded both agreements, adding that “patients should not live in fear of unfairly losing their health care coverage when they need it most.”

Epstein said Blue Shield came to agreement because it recognizes that there’s a lack of direction from the state on rescission practices, and wants to put it behind them.

“We recognize that rescission of a health coverage agreement is a serious matter that has significant consequences for the people involved,” he said in a statement. “We have treated these issues with the utmost care and have rescinded about one-tenth of 1 percent of our individual health plan contracts since 2004.”
Blue Shield could face another $2 million fine in 18 months if it does not simplify applications and be transparent with enrollees in the event that they are under investigation and risk losing their coverage, Ehnes said.

“We are certain to do those processes to avoid that fine,” Epstein said.
In 2007, Anthem Blue Cross had more than 4.1 million enrollees in full service health plans in California, and Blue Shield of California had more than 2.6 million enrollees.

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July 9, 2008

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ALLSTATE RANKS AS WORST INSURER FOR CONSUMERS
Insurance Industry Employs “Deny, Delay, Defend” Strategy, Puts Profits Over Policyholders

WASHINGTON, DC – Allstate ranks as the worst insurer for consumers, according to a comprehensive investigation of thousands of legal documents and financial filings.

The rankings show a distinct pattern of insurance industry greed amongst 10 companies that refuse to pay just claims, employ hardball tactics against policyholders, reward executives with extravagant salaries, and raise premiums while hoarding excessive profits.

“While Allstate publicly touts its ‘good hands’ approach, it has instead privately instructed its agents to employ a ‘boxing gloves’ strategy against its policyholders,” said American Association for Justice CEO Jon Haber. “Allstate ducks, bobs and weaves to avoid paying claims to increase its profits.”

Allstate (NYSE: ALL) set the standard for insurance company greed and placing profits over policyholders. Allstate contracted with consulting giant McKinsey & Co. in the mid-1990s to systematically force consumers to accept lowball claims or face its “boxing gloves,” an aggressive strategy designed to deny claims at any cost. One Allstate employee reported that supervisors told agents to lie and blame fires on arson, and in turn, were rewarded with portable fridges.

Thousands of court documents, materials uncovered from litigation and discovery, testimony, complaints filed with state insurance departments, SEC and FBI records, and news accounts were reviewed to compile the rankings and statistics.

The rest of the rankings are as follows:
2. Unum (NYSE: UNM) – Unum’s actions are even more shameful considering the type of insurance it sells: disability. Unum’s behavior was epitomized when it denied the claim of a woman with multiple sclerosis for three years, stating her conditions were “self-reported,” contrary to doctors’ evaluations. In 2005, Unum agreed to a settlement with insurance commissioners from 48 states over their practices.
3. AIG (NYSE: AIG) – The world’s biggest insurer, AIG’s slogan was “we know money.” AIG, described by commentators as “the new Enron,” has engaged in massive corporate fraud and claims abuses. In 2006, the company paid $1.6 billion to settle a host of charges.
4. State Farm – State Farm is notorious for its deny and delay tactics, and like Allstate, hired McKinsey consultants. State Farm’s true motives became apparent during Hurricane Katrina; for example, it employed multiple engineering firms until they could deny the claims of the Nguyen family of Mississippi. In April 2007, State Farm agreed to re-evaluate more than 3,000 Hurricane Katrina claims.
5. Conseco (NYSE: CNO) – Conseco sells long-term care policies, typically to the elderly. Amongst its egregious behavior, the insurer “made it so hard to make a claim that people either died or gave up,” said a former Conseco-subsidiary agent. Former Conseco executives were fined when they admitted to filing misleading financial statements with regulators.
6. WellPoint (NYSE: WLP) – Health insurer WellPoint has a long history of putting profits ahead of policyholders. For instance, California fined a WellPoint subsidiary in March 2007 after an investigation revealed that the insurer routinely canceled policies of pregnant women and chronically ill patients.
7. Farmers – Swiss-owned Farmers Insurance Group consistently ranks at or near the bottom of homeowner satisfaction surveys, and for good reason. For example, Farmers had an incentive program called “Quest for Gold” that offered pizza parties to its adjusters that met low claims payments goals. Like Allstate, it also hired the McKinsey consultants.
8. UnitedHealth (NYSE: UNH) – The SEC opened an investigation into former UnitedHealth CEO William McGuire for stock backdating, which ultimately led to his ouster in 2006 and returning $620 million in stock gains and retirement compensation. Physicians have also reported that their reimbursements are so low and delayed by the company that patient health is being compromised.
9. Torchmark (NYSE: TMK) – According to Hoover’s In-Depth Company Records, Torchmark’s very origins were little more than a scam devised to enrich its founder, Frank Samford. Torchmark has preyed on low-income Southern residents and charged minority policyholders more than whites on burial policies.
10. Liberty Mutual – Like Allstate and State Farm, Liberty Mutual hired consulting giant McKinsey to adopt aggressive tactics. Liberty’s tactics were highlighted when a New York couple’s insurance was “nonrenewed” by Liberty, even though they lived 12 miles from the coast and never experienced weather-related flooding.

Financial documents also revealed extravagant profits and executive compensation while policyholders’ claims were routinely delayed and denied:
· Over the last 10 years, the property / casualty and life / health insurance industries have each enjoyed annual profits exceeding $30 billion.
· The insurance industry takes in over $1 trillion in premiums every year. It has $3.8 trillion in assets, more than the GDPs of all but two countries.
· The CEOs of the top 10 property / casualty firms earned an average of $8.9 million in 2007. The CEOs of the top 10 life / health insurance earned an average of $9.1 million.
· The median insurance CEO’s cash compensation is $1.6 million per year, leading all industries.

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July 8, 2008

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Indiana has one of the worst records in the country for processing the disability claims of people unable to work because of medical or psychiatric reasons. Once they’re approved, recipients get an average of $1,000 a month in financial assistance.

For a determination at the Indianapolis offices for Social Security disability or Supplemental Security Income, the average applicant waits 749 days from the time of filing until a hearing before an administrative judge, the step necessary if claims are denied — and most are.

Most Americans wait 505 days, the Social Security Administration estimates.
Without a job or any source of income while they wait, some applicants lose their homes and cars. Some must live with relatives or friends or in shelters. Some go on welfare. Some die before a final decision.

“I was very appalled at how long it took,” said Smith, a Southside resident who watched with envy as a friend in Tennessee completed the process in a year. “I kept thinking: any time now, any time now.”

Government officials blame the national backlog of disability claims on years of agency underfunding and understaffing combined with a growing number of applications from baby boomers.

A recent Government Accountability Office report also identified mismanagement as an issue. The report did not cite specific incidents of mismanagement in the three Indianapolis offices.

NOT ENOUGH JUDGES

Nationwide, the Social Security Administration has 10 percent fewer judges to hear case appeals than it did a decade ago, while the number of cases has increased by more than 176 percent, said Carmen Moreno, regional communications director for the Social Security Administration’s Chicago region, which includes Indiana.

“We’re sympathetic over the fact that the waiting times are long, but keeping in mind that we are receiving so much less money than we need, these are the consequences,” Moreno said.

In Indianapolis, no one filled the chief administrative law judge position for seven or eight months, said Phillip Price, an Indianapolis attorney who has specialized in disability cases for about three decades.

“If you don’t have a boss for that period of time, you’ll change the way you do things,” Price said.

Judges have been slow to move on cases, said Price and Steven Jacobs, another attorney who has worked on such cases since 1974. Most cases used to be heard within six months, Price said.

Data compiled by Allsup Co., a disability claims service, show the average applicant for disability at the Indianapolis offices in February waited 816 days, the longest waiting period in the country.

“We need more judges, more staff. We need a more efficient staff,” Jacobs said.

For the first time in a decade, the Social Security Administration this year received more rather than less funding. Congress allocated an additional $148 million to address the backlog, allowing the agency to hire 175 more judges and other staff nationwide. Indiana hired one additional judge, bringing the total to 12.

Buoyed by the infusion of money and staff, the agency processed all cases nationwide older than 1,000 days. Now it’s targeting the 135,000 cases across the country that are more than 900 days old, Moreno said.

But even with more judges, the wait remains too long, Jacobs said:
“It’s like saying: ‘I’m a lot taller now. I’ve grown from 3-foot-6 to 3-foot-7.’ You’re still a shrimp.”

LOOKING FOR SOLUTIONS

To help troubled offices like the ones in Indianapolis, a new hearing center in Virginia will allow judges there to assist staff here by conducting hearings by video.

The agency also may send traveling judges to the busiest offices, Moreno said.

But many who deal with the system are skeptical.

“It’s a step in the right direction, but nowhere near enough help,” said Dan Allsup, spokesman for Allsup Co.

People should wait no longer than 95 days from application to hearing, said Ethel Zelenske, director of government affairs for the National Organization of Social Security Claimants’ Representatives, which also advocates for increased staffing.

Social Security Commissioner Michael Astrue has said he would like to see the wait reduced to 250 to 275 days, about half the time applicants face today.

Allsup thinks the backlog can be eliminated by Social Security agencies partnering with private companies to help people through the application process.

Applicants need help from professionals who know the system, he said.

The system requires a claimant to file an application. If that’s turned down, the claimant must file a second application. If that application is turned down, the claimant can ask an administrative law judge to decide whether the applicant will receive benefits.

Only about one-third of initial applications are approved. Even fewer applications — less than 15 percent — are approved during reconsideration. More than half who go before an administrative law judge receive the benefit, according to Allsup’s statistics.

Despite the efforts of the Social Security Administration, the situation may grow worse, experts say. In a poor economy, it becomes harder for disabled people to find work, and more may look to the government for support.

HOPING FOR IMPROVEMENTS

Dana Smith’s inability to work stems from a severe car accident at age 14. She now suffers from osteoarthritis in her right hip, bursitis in her right shoulder, migraine headaches and fibromyalgia, which she says causes horrific pain.

Smith, 43, said she’s tried to work. She’s held jobs in offices, in fast-food restaurants, in department and convenience stores, and on a chicken farm. But each time, the pain came back, and Smith had to quit.

In December 2003, the man she was seeing (now her husband, James Smith) offered to let her live with him while she applied for disability. She concentrated on her quest for benefits.

“Every time I would try to deal with them (Social Security officials), I was told: ‘You need to call this number. No, you need to call this number.’ You never get a straight answer from anybody,” she said.

Eventually, Smith turned to Allsup for help. In March 2007, she had a hearing and soon was granted benefits.

But she realizes her husband’s generosity gave her security many others do not enjoy.

“I just hope that something can be done so others don’t have to wait this long,” she said. “There are other people that are worse off than I am.”

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Falls from elevation hazards are present at most every jobsite, and many workers are exposed to these hazards daily. Any walking/working surface could be a potential fall hazard.

An unprotected side or edge which is 6 feet or more above a lower level should be protected from falling by the use of a guardrail system, safety net system, or personal fall arrest system. These hazardous exposures exist in many forms, and can be as seemingly innocuous as changing a light bulb from a step ladder to something as high-risk as connecting bolts on high steel at 200 feet in the air.

Based on data from the NIOSH National Traumatic Occupational Fatalities (NTOF) Surveillance System, falls from elevations were the fourth leading cause of workplace death from 1980 through 1994. The 8,102 deaths due to falls from elevations accounted for 10% of all occupational fatalities during this period and an average of 540 deaths per year.

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Each day, U.S. workers suffer injury, disability, and death from workplace incidents. On average, nearly 16 workers die each day from traumatic injuries. Overall, 5,734 workers died in 2005 from an occupational injury and more than 4 million workers had a nonfatal injury or illness. Private-sector workers, daily, experience 11,500 nonfatal work-related injuries/illnesses; more than half of these injuries/illnesses require job transfer, work restrictions, or time away from their jobs as a result. Among all workers, not just the private sector, 9,000 workers are treated in emergency departments each day, and approximately 200 of these workers are hospitalized. In 2004, this resulted in an estimated 3.4 million nonfatal injuries and illnesses among civilian workers that were serious enough to be treated in hospital emergency departments.

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June 26, 2008

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By MIKE STOBBE, The Associated Press
Tuesday, June 24, 2008; 7:32 AM

ATLANTA — The elderly fear breaking a hip when they fall, but a government study indicates that hitting their head can also have deadly consequences: Brain injuries account for half of all deaths from falls. The study by the Centers for Disease Control and Prevention is the first comprehensive national look at the role brain injuries play in fatal elderly falls. It examined 16,000 deaths in 2005 that listed unintentional falls as an underlying cause of death.CDC researchers found that slightly more than half of the deaths were attributed to brain injuries. The other deaths were due to a variety of causes including heart failure, strokes, infections and existing chronic conditions worsened by a broken hip or other injuries sustained in a fall.

“A lot of people don’t think a fall is serious unless they broke a bone, they don’t think it’s serious unless they break a hip. They don’t worry about their head,” said Pat Flemming, a senior physical therapist and researcher at Vanderbilt University

Each year, one in three Americans age 65 and older fall. About 30 percent of such falls require medical treatment.

Previous CDC research showed that the U.S. death rate from falling has risen dramatically _ about 55 percent _ for the elderly since the 1990s. The new study highlights the role that brain injuries play in such deaths.

As people age, veins and arteries can be more easily torn during a sudden blow or jolt to the head, said Marlena Wald, a CDC epidemiologist who co-authored the study.

That can cause a fatal brain bleed. Other factors can contribute, such as the use of blood-thinners, said Judy Stevens, another CDC researcher and co-author.

The severity of brain injuries isn’t always immediately apparent, and some people may not lose consciousness. Wald noted a scenario seen in hospitals in which an elderly fall victim comes in alert and talking, but dies an hour or two later.

The study also found that deaths and hospitalization rates for fall-related brain injuries increased with age. Brain injuries accounted for about 8 percent of hospital stays for non-fatal falls.

There are several steps older Americans can take to try to prevent falls. Exercise can increase leg strength and balance. Glasses or other vision correction measures can help people avoid obstacles. And being careful with the use of drugs that can affect thinking and coordination _ such as tranquilizers and sleeping pills _ can also make a difference.

“Falls are not an inevitable consequence of aging. These head injuries are not inevitable, either,” Wald said.

The research is being published in the June issue of a scientific publication, the Journal of Safety Research.

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June 17, 2008

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By Arnold Wax, MD

Negligence and malpractice can injure patients, but so can juries, as this specialist discovered.

I’m a medical oncologist who was one of the original forces behind the tort reform movement in Nevada. Overall, I’m happy with the changes in our state, which I believe were necessary to keep good physicians practicing here. Nevertheless, one particular case showed me how the system can backfire.

In 2002, a delightful woman I’ll call Mary was referred to me. Two years earlier, she had developed a skin lesion on her pubic area, which her family physician removed and a pathologist diagnosed as a dysplastic nevus. The margins were cleared, and Mary went on her way.

In 2004, the lesion recurred and her FP again removed it. This time it was malignant. Mary was then referred to a general surgeon for a wide excision and primary closure. Because of the lesion’s proximity to lymphatics, I requested a lymphoscintigram and a sentinel lymph node biopsy. The surgery was completed and, much to my surprise and chagrin, the lymph node biopsy was positive for melanoma.

Mary was an active person who needed to be fully ambulatory to keep her job and help care for her grandchildren. With this in mind, we discussed the possibility of an inguinal lymph node dissection. But because the surgical complications would interfere with her ability to make a living, she declined.

After a negative staging workup, we discussed her other options: observation, clinical trial, or interferon therapy. Mary wanted to treat her disease, so she passed on watchful waiting. Likewise, participating in a clinical trial was out of the question, because she’d have to leave town to be treated. That left interferon therapy, which she agreed to.

Earlier evidence of malignancy

In the interim, a second pathologist reviewed Mary’s original report from 2002 and found the results were consistent with a diagnosis of malignant melanoma, not a dysplastic nevus. Shortly thereafter, the original pathologist admitted that he’d misread the slides.

Then came the interferon therapy, complete with the expected side effects-fever, chills, sweats, fatigue, and depression. Mary’s health declined to the point where she had to take a leave from work. She also developed an unexpected side effect: marked liver function abnormalities, which led to profound weight loss. The interferon was stopped, but the abnormalities persisted. A liver biopsy was performed, and Mary was found to have an autoimmune hepatitis, unmasked but not caused by the interferon. Plans for further therapy were abandoned and, in time, her liver problems resolved.

As I’d expected, Mary sued the pathologist who had misread the original biopsy. Soon after, one of her attorneys asked me to serve as an expert witness in the case. As her treating physician, I felt a moral obligation to support Mary’s claim. Her lawyer said she was asking only for damages to help provide for her grandchildren-which ultimately became more important when her husband died unexpectedly from a post-surgical pulmonary embolus.

It appeared that the case would be resolved quickly, considering that the defendant freely admitted his error. However, this turned out to be far from true.

Juries can be fickle and misinformed

Affidavits were submitted and depositions taken, including mine. With the comments and bare facts now available, the case went to trial. While this easily could have been a $1 million-plus case, tort reform in Nevada meant Mary couldn’t receive more than $350,000 in noneconomic damages (pain and suffering) or any collateral source payments. The value of Mary’s medical costs, which exceeded $100,000 and were covered by insurance, wouldn’t be included in any award.

The trial lasted six days. I was on the witness stand for two hours for direct and cross examination. I described the statistical decrease in Mary’s five-year survival, as well as all treatment variations between the different stages of melanoma. I also stated that I thought the pathologist’s admission of his mistake was “honorable.”

As I’d expected, the jury found the original pathologist negligent. But, to my surprise, Mary wasn’t awarded any damages. One of her attorneys later told me that the jury wanted to pin an award on the pathologist’s professional corporation, but it hadn’t been named in the suit. The jurors reasoned that the pathologist had not acted maliciously, and that if he were found liable for a monetary award, he might leave the state. They were likely influenced by political ads that ran during the state’s tort reform ballot campaign, describing physicians who were leaving Nevada because of its malpractice crisis.

The trial judge was incensed by the verdict, because the jury didn’t follow the legal standard that should have been applied in the case. I was later informed that the defense attorneys planned to go after Mary for court costs, something that the judge vowed he’d never let happen.

Today, Mary is a widowed grandmother, caring for her grandchildren with few resources-injured, admittedly, by a physician’s error. She’s been off of all therapies since the interferon, which proved successful. But if her melanoma recurs, it will likely be fatal.

When I helped spearhead the tort reform movement in Nevada, I didn’t foresee the unintended consequences of innocent, truly injured individuals not receiving their rightful awards due to jurors’ misguided emotions. Had I been aware of that possibility, what would I have done?

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WASHINGTON, June 5 (Reuters) - Hispanic workers in the United States are killed at work at a 25 percent higher rate than other U.S. workers with many deaths coming in construction, federal health officials said on Thursday.

Hispanics disproportionately take dangerous jobs like construction. Some may hesitate to speak up about safety hazards and may accept risky tasks for fear of being fired, the U.S. Centers for Disease Control and Prevention said.

The most common causes of death were falls at construction sites and roadway incidents including crashes or being hit by a car while working on a road crew, the CDC said. Deaths from workplace falls increased about 370 percent from 1992 to 2006.

The report tracked Hispanic workplace fatalities of U.S. citizens, legal immigrants or illegal immigrants.

Immigration has become a potent political issue in the United States where about 12 million illegal immigrants live, many from Mexico, Central America and South America.

In 2006, the death rate for Hispanics was 5 per 100,000 workers, compared with 4 per 100,000 for all workers, 4 per 100,000 for non-Hispanic whites and 3.7 per 100,000 for non-Hispanic blacks, the CDC said.

Hispanics are the nation’s fastest-growing minority. There were 19.6 million Hispanic workers in the United States in 2006, 56 percent of them foreign born.

They have become an increasingly important source of labor in U.S. construction.

An analysis of construction deaths found that Hispanic workers had higher rates than non-Hispanics in the same occupations such as laborers or roofers, the CDC said.

Dr. Sherry Baron of the CDC’s National Institute for Occupational Safety and Health said inadequate training and supervision of workers, often made worse by language barriers or literacy problems, were factors behind this trend.

From 1992 to 2006, 11,303 Hispanic workers — 95 percent of them men — died due to workplace injuries, accounting for about 13 percent of overall such deaths in the United States.

The CDC said 67 percent of Hispanics killed in job injuries were foreign born, almost three quarters from Mexico. It said the work-related injury death rate for foreign-born Hispanic workers is about 70 percent higher than U.S.-born Hispanics.

The highest job fatality rates for Hispanics were in South Carolina (22.8 per 100,000 Hispanic workers), Oklahoma, Georgia and Tennessee, the CDC said. (Editing by Alan Elsner and Maggie Fox)

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June 4, 2008

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This case presents two issues of first impression. We hold that under some circumstances a minor’s invitation to enter the premises may bind the landowner for purposes of premises liability, and that a trampoline may constitute an attractive nuisance. In this case both issues turn on facts not appropriately resolved on summary judgment.

Facts and Procedural History
On January 30, 2002, twelve-year-old Alisha Palmer was at home after school with her brothers, Dylan, nine, and Michael, ten. Her mother, Beth Palmer Kopczynski, was still at work. Next door, six-year-old Bryan Barger was jumping on the Bargers’ trampoline in an unenclosed area behind the Bargers’ house. Bryan was jumping without supervision, which was not unusual.

At some point that afternoon, Bryan asked Dylan to jump with him, and Michael Spears, another neighbor, aged thirteen or fourteen, also joined them. Alisha testified that she also started using the trampoline a short time later, after Bryan “asked me if I wanted to jump with him.” The parties agree that Bryan’s invitations to Alisha and her brother were the first communications between the Palmers and the Bargers.

Alisha had previously watched Bryan jump, but she had never been on a trampoline before. As she was jumping, someone “stole” her jump, i.e., landed and changed the tension and height of the surface just before she landed. As a result, she injured her knee.

Alisha and her mother filed a complaint for damages against the Bargers, alleging both premises liability and liability for an attractive nuisance. The Bargers moved for summary judgment, claiming that Alisha was a trespasser and that the attractive nuisance doctrine did not apply. The trial court granted summary judgment in favor of the Bargers.

The Court of Appeals affirmed, finding no premises liability because Alisha was a trespasser and there was no evidence of willful or wanton conduct on the part of the Bargers. Kopczynski v. Barger, 870 N.E.2d 1, 9 (Ind. Ct. App. 2007). The Court of Appeals also found that the attractive nuisance doctrine did not apply because the plaintiffs failed to establish either that the trampoline was particularly dangerous or attractive to children or that the Bargers knew that children would trespass and be injured on the trampoline. Id. at 10. Judge Crone dissented, concluding that material issues of fact remained as to both Alisha’s status on the premises and also whether the trampoline was an attractive nuisance. Id. at 11. We granted transfer. 878 N.E.2d 215 (Ind. 2007) (table).

Standard of Review
In reviewing summary judgment rulings, we apply the same standard as the trial court. Row v. Holt, 864 N.E.2d 1011, 1013 (Ind. 2007). We affirm summary judgment unless there is a genuine issue as to a material fact or the moving party is not entitled to a judgment as a matter of law. Id. All facts and reasonable inferences from them are to be construed in favor of the nonmoving party. Naugle v. Beech Grove City Sch., 864 N.E.2d 1058, 1062 (Ind. 2007).

I. Count I―Premises Liability
The amended complaint describes Count I as a claim for negligence. The plaintiffs’ brief on appeal asserts that discovery had “more clearly defined” that count as a claim for premises liability and a claim for negligent supervision. However, the plaintiffs’ argument focuses entirely on premises liability, and cites the alleged lack of supervision as evidence of breach under premises liability rather than as a separate tort, so we will treat it as such.

A landowner’s liability to persons on the premises depends on the person’s status as a trespasser, licensee, or invitee. Burrell v. Meads, 569 N.E.2d 637, 639 (Ind. 1991). The Bargers argue that Alisha was a trespasser, and therefore their only duty was to refrain from willful or wanton behavior. The plaintiffs contend Alisha was a social guest and therefore an invitee to whom the Bargers owed a duty to exercise reasonable care for her protection while on the premises.

The Court of Appeals held that the determination of Alisha’s status—and therefore the duty owed to Alisha by the Bargers—is a matter of law for the trial court. Kopczynski v. Barger, 870 N.E.2d 1, 5 (Ind. Ct. App. 2007) (citing Taylor v. Duke, 713 N.E.2d 877, 881 (Ind. Ct. App. 1999)). We have observed that the existence of a duty is ordinarily a question of law for the court to decide, but it may turn on factual issues that must be resolved by the trier of fact. Rhodes v. Wright, 805 N.E.2d 382, 386 (Ind. 2004) (citing Douglass v. Irvin, 549 N.E.2d 368, 369 n.1 (Ind. 1990) (“While it is clear that the trial court must determine if an existing relationship gives rise to a duty, it must also be noted that a factual question may be interwoven with the determination of the existence of a relationship, thus making the ultimate existence of a duty a mixed question of law and fact.”)); see Restatement (Second) of Torts § 332 cmt. l (1965) (“Since the status of the visitor as an invitee may depend upon whether the possessor should have known that the visitor would be led to believe that a particular part of the premises is held open to him, the question is often one of fact for the jury, subject to the normal control which the court exercises over the jury’s function in such matters.”). For the reasons explained below, we conclude that factual issues preclude summary judgment in this case.

If Alicia entered the Bargers’ property without authority, she was a trespasser. See Burrell, 569 N.E.2d at 640. If her entry was authorized, she was either a licensee or an invitee. See id. In some contexts the distinction between licensees and invitees is murky, but Burrell makes it clear that a social guest is an invitee. Id. at 643. Because her visit was solely social, Alisha was not a licensee, and was either a trespasser or an invitee. Alisha’s status as trespasser or invitee, therefore, depends on whether she was authorized to be on the Bargers’ property.

Bryan’s invitation to join the group on the trampoline is the only evidence suggesting Alisha had permission to enter the Bargers’ property and use the trampoline. “[A]n invitation is conduct which justifies others in believing that the possessor desires them to enter the land.” Restatement (Second) of Torts § 332 cmt. b. An invitation does not have to come directly from the landowner. Whether a landowner’s consent can be based on the action of another turns on standard agency principles. See Botka v. Estate of Hoerr, 21 P.3d 723, 727-28 (Wash. Ct. App. 2001) (“Permission sufficient to establish invitee or licensee status can be implied from the prior conduct and statements of the property possessors or their agents.”); Kern v. Ray, 724 N.Y.S.2d 457, 458 (N.Y. App. Div. 2001) (holding that children were acting as parents’ agents in inviting people to their house); cf. St. Mary’s Med. Ctr. of Evansville, Inc. v. Loomis, 783 N.E.2d 274, 279 (Ind. Ct. App. 2002) (holding that employee’s knowledge of unsafe condition on premises is imputed to employer). In the absence of actual authority to invite third parties to the house, the issue is whether the landowner’s conduct gave the third party reason to believe that the landowner was willing to allow the third party to enter the land. See 62 Am. Jur. 2d Premises Liability § 112 (2005) (“The word ‘consent’ or ‘permission’ indicates that the possessor of the land is in fact willing that the visitor, or entrant, enter and remain thereon, or that the possessor’s conduct gives the entrant reason to believe that the possessor is willing to allow him or her to enter if he or she desires to do so.” (citing Restatement (Second) of Torts § 330 cmt. c)); cf. Holman v. State, 816 N.E.2d 78, 82 (Ind. Ct. App. 2004) (applying a totality of the circumstances test to determine the validity of a minor’s invitation in a criminal residential entry case).

The plaintiffs concede that the Bargers issued no express invitation because Bryan was not a landowner and did not have actual authority to invite Alisha onto the premises. Thus, the question becomes whether the Bargers gave Alisha reason to believe that they were willing to allow her on their land. The Bargers testified that they had once run off some children who were jumping on the trampoline, one of whom was Michael Spears. But Alisha had never met the Bargers, and was not among the group the Bargers had “run off.” Whether she had reason to know that Bryan did not have actual authority is a factual question. Although Bryan was only six years old, his parents left him alone in the unfenced backyard. Bryan’s age might suggest to an adult that he lacked authority. But Alisha is also a minor. A landowner’s greater duties to children may arise “taking into account the abilities, age, experience, and maturity of the child . . . .” Johnson v. Pettigrew, 595 N.E.2d 747, 750-51 (Ind. Ct. App. 1992) (citing Restatement (Second) of Torts §§ 339, 343). Accordingly, we agree with Judge Crone that “the reasonableness of twelve-year-old Alisha’s belief that she had permission to jump on the Barger’s trampoline by virtue of six-year-old Bryan’s invitation . . . presents a genuine issue of material fact that precludes a determination of her status as a matter of law.” Kopczynski, 870 N.E.2d at 11 (Crone, J., dissenting). Summary judgment as to Count I must be reversed.

II. Count II―Attractive Nuisance

The plaintiffs argue that even if Alisha was a trespasser, they may recover under the attractive nuisance doctrine, which imposes on a landowner a duty of care for a child trespasser if the following elements are met: 1) the structure or condition complained of is maintained or permitted on the property by the owner or renter; 2) the structure or condition is particularly dangerous to children and unlikely to be comprehended by children; 3) the structure or condition is especially attractive to children; 4) the owner or renter has actual or constructive knowledge of both the structure or condition and the likelihood that children will trespass and be injured; and 5) the injury is a natural, probable, and foreseeable result of the wrong. Pier v. Schultz, 243 Ind. 200, 205, 182 N.E.2d 255, 258 (Ind. 1962); Morningstar v. Maynard, 798 N.E.2d 920, 922-23 (Ind. Ct. App. 2003). An unenclosed junkyard is an example of a condition that may constitute an attractive nuisance. See Borinstein v. Hansbrough, 119 Ind. App. 134, 82 N.E.2d 266 (1948). The purpose of the attractive nuisance doctrine “is to protect children from dangers which they do not appreciate.” Restatement (Second) of Torts § 339 cmt. m (1965). However, because the attractive nuisance doctrine imposes a substantial burden on the property owner, it is narrowly construed and does not, for example, generally apply to “common or ordinary objects or conditions” such as walls, fences, or gates. 62 Am. Jur. 2d Premises Liability §§ 290, 366, 368 (2005).

The Bargers argue that Count II of the plaintiffs’ complaint is deficient for several reasons. They contend that a moving landing surface is a danger that can be comprehended by a twelve year old; trampolines pose no particular attraction to children; the Bargers had no reason to suspect that Alisha would trespass; and Alisha’s injury was not the natural, probable, and foreseeable result of Alisha’s use and trespass. The Court of Appeals held that the attractive nuisance doctrine does not apply because in general the dangers of jumping on a trampoline should be as obvious to children as “the dangers of falling from heights.” The Court of Appeals also found that the plaintiffs failed to designate evidence establishing the latent danger of jumping on a trampoline. Kopczynski v. Barger, 870 N.E.2d 1, 10 (Ind. Ct. App. 2007).

We agree with the Court of Appeals that the risks associated with trampolines may be obvious, particularly to an adult. See Liccione v. Gearing, 675 N.Y.S.2d 728, 729 (N.Y. App. Div. 1998) (holding that the defendant established as a matter of law that nineteen year old was of sufficient age, education and experience to assume the risks of jumping on a trampoline). But the particular risks associated with jumping on a trampoline are not necessarily open and obvious to children, particularly those who have never jumped before. Cf. Bryant v. Adams, 448 S.E.2d 832, 841-42 (N.C. App. Ct. 1994) (holding that whether or not jumping on a trampoline was an open and obvious danger to a fourteen year old in a products liability case was a disputed fact question for the jury). We agree with the Court of Appeals majority that the harm from falling down is obvious to most. But the dangers of falling onto the ground are very different from the dangers of falling onto a trampoline, particularly one with other jumpers whose presence may unexpectedly change the tension of the trampoline’s surface. See Lykins v. Fun Spot Trampolines, 874 N.E.2d 811, 818-19 (Ohio Ct. App. 2007) (holding that while “jumping on a trampoline involves the obvious risks of losing balance, falling down, falling off the apparatus altogether, and colliding with other individuals if more than one is present on the trampoline,” the court could not find as a matter of law that the particular risks associated with multiple jumpers were open and obvious). And a child may be lulled into thinking a trampoline is safe by watching others jump without incident or injury. See Am. Jur. 2d Premises Liability § 342 (“[A] child may not realize the danger of his or her action where he or she has seen other children engaging in the act without injury.”).

In this case the designated evidence conflicts regarding whether Alisha could have appreciated the dangers of jumping on a trampoline, particularly with multiple jumpers. The plaintiffs designated the affidavit of Alan R. Caskey, Ph.D, who testified: “It is my experience that children under the age of sixteen do not appreciate or understand the dangers of using a trampoline without adult supervision and with multiple jumpers and that the dangers of trampolines are not readily apparent to such children.

Further, the designated evidence reveals that in 1998 about 75 percent of the roughly 95,000 emergency room treatments for trampoline-related injuries involved patients under fifteen. Although Alisha admits she had watched Bryan jump prior to her accident, there is no evidence that Alisha witnessed any injuries or had seen multiple jumpers on the trampoline. Further, Alisha testified that she had never been on a trampoline, was unsupervised, and was not warned of the dangers of jumping in general or multiple jumpers in particular. Accordingly, the Bargers have not established a lack of disputed material facts with regard to the open and obvious nature to Alisha of the dangers of trampolines.

The Bargers next argue that they had no reason to know that Alisha might trespass. Specifically, the Bargers point to designated evidence that the Bargers and Palmers did not know each other, Alisha’s mother told her not to leave the house, and the Bargers allowed children to jump only with their permission. However, the plaintiffs have to show only the likelihood that some child would trespass and be injured, not a particular child. Dr. Caskey testified that “research indicates that trampolines left unattended are particularly attractive to children” and that “injuries are more likely to occur” when the trampoline is left unsupervised. The Bargers have not shown that it is unreasonable to assume that children would be attracted to a large trampoline that sits in the middle of an open yard, particularly when there is an unsupervised child regularly jumping on it. Indeed, the Bargers admit that other children have trespassed and used their trampoline without permission. Moreover, as explained in Part I, it is an issue for the trier of fact whether another child might reasonably regard Bryan as an authorized host. If so, by leaving Bryan alone in the yard, the Bargers increased the risk of unauthorized use of the trampoline by another child.

Finally, the Bargers claim that Alisha’s knee injury was not a natural, probable, or foreseeable consequence of her trespass and jumping. The designated evidence reveals, however, that the trampoline’s warning labels cautioned that multiple jumpers on a trampoline “increase[] the chance of serious injury” and “can result in broken head, neck, back or legs.” Dr. Caskey testified that “research and databases also indicate that the type of knee injury sustained by Alisha Palmer is a type of injury that is seen from multiple jumpers on a trampoline.” Thus, the Bargers have failed to establish a lack of disputed material facts as to the foreseeability of Alisha’s injury.

Conclusion

The trial court’s grant of summary judgment is reversed. This case is remanded to the trial court for further proceedings consistent with this opinion. Shepard, C.J., and Dickson, Sullivan, and Rucker, JJ., concur.

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May 23, 2008

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Helpful Information from NeurologyChannel.comPatients suffering TBI are typically brought to a hospital emergency room for initial diagnosis and treatment. Once vital signs are assessed and stabilized, and other life-threatening injuries are identified and treated, the process of diagnosing the extent of brain injury begins.

A complete neurological evaluation is performed to rule out conditions requiring neurosurgical attention, such as hematomas, depressed skull fractures, and elevated intracrantial pressure (ICP). X-rays, CT scans, and/or MRI scans may be performed to determine if the bones of the skull are fractured and if bone fragments have penetrated the brain tissues.

The patient may be presented with a series of questions (What is your name? Where are you? What day is it?) and given simple commands (Wiggle your toes. Hold up two fingers.) to determine if he or she can open their eyes, move, speak, and understand what is happening around them. If possible, a detailed medical history is performed to identify any previous injuries, existing seizure disorders, learning disabilities, prior psychiatric or psychological treatment, and/or substance abuse.

The patient’s degree of consciousness is assessed to determine the severity of brain injury and predict his or her chances for recovery. To do this, physicians typically use the Glasgow Coma Scale (GCS), which measures the patient’s ability to open their eyes, move, and speak. The more severe the injury, the lower the total score suggesting little chance for complete recovery.

Glasgow Coma Scale

Eye Opening
4 = Responds spontaneously
3 = Responds to voice
2 = Responds to pain
1 = No response

Best Motor Response
6 = Follows commands
5 = Localizes to pain
4 = Withdraws to pain
3 = Decorticate (produces an exaggerated posture of upper extremity flexion and lower extremity extension in response to pain)
2 = Decerebrate (produces an exaggerated posture of extension in response to pain) 1 = No Response

Best Verbal Response
5 = Oriented and converses
4 = Disoriented and converses
3 = Inappropriate words
2 = Incomprehensible sounds
1 = No response

Total scores of 8 or below indicate a true coma and severe brain injury. Scores of 9 to 12 suggest moderate brain injury; scores of 13 and above indicate mild brain injury. However, the severity of the brain injury is not determined by GCS alone, as treatable conditions such as infection and dehydration may lower the GCS score.

When the patient is unconscious, the duration or length of coma (LOC) may be used to assess the severity of TBI and predict outcome. The longer the length of coma, the more severe the injury is. An LOC of less than about 20 minutes reflects a mild brain injury; longer than about 6 hours after admission reflects severe injury; between 20 minutes and 6 hours suggests moderate injury.

The neurological examination may show signs indicating the severity of injury such as increased reflexes and muscle tone (spasticity), abnormal movements (tremors), difficulty swallowing, or slurring of speech, all of which may indicate a moderate to severe head injury.

Imaging
Neuroradiological tests using computer-assisted brain scans help visualize damage to the brain. The most common of these is computerized axial tomography (CAT or CT scan), an x-ray technique that produces a cross-sectional image of the brain. CT scans can detect physical changes in the brain such as hematomas and swelling, which may require immediate treatment. The procedure is painless and takes 15 to 45 minutes, during which the patient must lie completely still.Another useful diagnostic test is magnetic resonance imaging (MRI scan), which uses a large magnet and radio waves to generate computerized images of the brain without exposing the patient to x-ray radiation. MRIs produce high resolution images of brain structures and are painless, but noisy. The patient must lie on a flat table in the machine, typically shaped like a long tube. An MRI can take up to 60 minutes.Depending on individual circumstances, a variety of other diagnostic tools and techniques may be employed. These include the following:

Angiogram–A test to examine blood vessels in the brain. It involves injecting dye into an artery supplying blood to the brain, usually by means of a catheter inserted in the groin. The test takes 1 to 3 hours.

ICP Monitor–A device used to measure intracranial pressure (pressure within the brain). It consists of a small tube, placed into or on top of the brain through a small hole in the skull, connected to a transducer that registers the pressure.

EEG (electroencephalograph)–A test to measure electrical activity in the brain. It uses electrodes, in the form of patches, applied to the head. This painless procedure can be done at bedside or in a hospital’s EEG department. The duration of the test varies. X-rays, MRIs, and CT scans can detect fractures, hemorrhages, swelling, and certain kinds of tissue damage, but they do not always detect traumatic brain injury. This is because TBI, especially in its milder forms, often involves subtle traumas scattered among neurons and supportive tissues, stretched or damaged axon membranes (diffuse axonal injury), chemical injury caused by the biochemical cascade of toxic substances in the brain tissues, and cellular dysfunction. These changes often cannot be found with standard imaging procedures. More sophisticated imaging techniques that measure brain cell metabolism, such as single-photon emission computed tomography (SPECT) or positron emission tomography (PET), can help diagnose such injuries.

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