Justia Insurance Law Opinion Summaries

Employee was injured at work and underwent surgery. Employee’s health insurer covered the surgery’s costs at a discounted rate. After the Department of Labor found Employer liable for Employee’s condition Employer accepted Employee’s claim and reimbursed Employee for his out of pocket expenses and reimbursed Employee’s insurer for payments it made on Employee’s behalf. Employee challenged the payment, arguing that Employer was required to pay the full medical expense without the health insurance discount. The Department concluded that Employer fulfilled its obligation. The circuit court reversed and found Employer liable for the full medical expense billed before adjustments. Employer appealed. The Supreme Court reversed the circuit court and reinstated the Department’s order, holding that the Department correctly applied the law in determining that Employer satisfied its statutory reimbursement obligation. View "Whitesell v. Rapid Soft Water & Spas, Inc." on Justia Law

Public Act 97-695 (eff. July 1, 2012), amended section 10 of the State Employees Group Insurance Act of 1971, 5 ILCS 375/10, by eliminating the statutory standards for the state’s contributions to health insurance premiums for members of three of the state’s retirement systems. The amendment requires the Director of Central Management Services to determine annually the amount of the health insurance premiums that will be charged to the state and to retired public employees. It is not limited to those who become annuitants or survivors on or after the statute’s effective date. The amendment was challenged by members of the affected entities: State Employees’ Retirement System (SERS), State Universities Retirement System (SURS), and Teachers’ Retirement System (TRS), as violation the pension protection clause, the contracts clause, and the separation of powers clause of the Illinois Constitution. Certain plaintiffs added common-law claims based on contract and promissory estoppel. The Illinois Supreme Court, on direct review, reversed dismissal, stating that health insurance subsidies are constitutionally protected by the pension protection clause and rejecting an argument that only the retirement annuity itself is covered. View "Kanerva v. Weems" on Justia Law

Claimant Andres Carbajal alleged he was injured when scaffolding he was on was blown over and he fell while working on a construction project in Okmulgee. He filed a claim in the Workers' Compensation Court and alleged that he was an employee of Precision Builders, Inc., and/or Mark Dickerson (Precision) when he fell. The tribunal denied the claim upon determining that claimant was an independent contractor and not an employee. The three-judge panel affirmed the trial tribunal and the panel's order was affirmed by the Court of Civil Appeals. The issue this case presented to the Oklahoma Supreme Court on certiorari was whether petitioner was an employee or independent contractor. "Considering each of the factors on which the evidence was presented leads us to the conclusion that claimant met his burden to show that he was an employee of Precision." The Court of Appeals' decision was vacated and the case remanded for further proceedings. View "Carbajal v. Precision Builders, Inc." on Justia Law

In December 2008, Appellee was performing his duties as an outdoor parking lot attendant when he developed frostbite. Appellee’s employer and its insurance company (Appellants) voluntarily paid for the medical treatment of Appellee’s frostbite injury and paid temporary total disability benefits through mid-2009. In September 2012, a partial amputation of the fifth metatarsal in Appellee’s right foot was performed. In January 2013, Appellee sought additional benefits for his work-related injury. The Workers’ Compensation Court awarded benefits. On appeal, Appellants argued that the Workers’ Compensation Court erred in finding that Appellee’s claim was not barred by the two-year statute of limitations. The Supreme Court affirmed, holding that the partial amputation of Appellee’s foot was a material change in condition and substantial increase in disability that would permit Appellee to seek benefits more than two years after Appellants’ last voluntary payment.View "Lenz v. Cent. Parking Sys. of Neb., Inc." on Justia Law

Jimmy Carty died in an accident during his employment for the state. The workers’ compensation carrier for state employees (carrier) began paying death benefits to Christy, Jimmy’s wife, and the couple’s three minor children. Christy, individually, as representative of her deceased husband’s estate, and as next friend of the couple’s children, brought suit against two defendants. The Cartys settled with the defendants. The district court subsequently calculated the carrier's reimbursement and apportioned the remainder of the settlement funds among Christy and the children “in the same ratio as they received death benefits.” The carrier appealed, challenging the apportionment. The court of appeals certified to the Supreme Court the question of “how a net recovery in excess of the amount of benefits paid by the workers’ compensation carrier should be apportioned among beneficiaries when multiple beneficiaries recover from a third-party tortfeasor.” The Supreme Court answered that when multiple beneficiaries recover compensation benefits through the same covered employee, the workers’ compensation carrier’s right to a third-party settlement is determined by treating the recovery as a single, collective recovery rather than separate recoveries by each beneficiary.View "State Office of Risk Mgmt. v. Carty" on Justia Law

A highly paid worker suffered a debilitating stroke while traveling for his employer. The employer did not think the stroke was work related, but it later accepted the claim and paid workers' compensation benefits. The statutory maximum compensation rate at the time of the injury was $700 a week. A little more than five months after the employee's stroke, an amended version of the Alaska Workers' Compensation Act took effect. Instead of an absolute maximum compensation rate, the amended statute set a variable rate indexed to the statewide average weekly wage. The employee asked for an increased rate of compensation, arguing that the law in effect at the time he was recognized as being permanently and totally disabled should govern his benefit amount. The Alaska Workers' Compensation Board, with one panel member dissenting, decided that the version of the statute in effect at the time of the injury was the applicable statute and consequently capped the employee's benefits at $700 a week for life. The dissenting panel member would have construed the statute as permitting increased benefits. The Alaska Workers' Compensation Appeals Commission affirmed the Board's decision. The employee appealed, arguing that the amount of his benefits did not fairly compensate him for lost wages during the period of his disability so that the date of his disability, rather than the date of his injury, should have been used to determine the version of the statute governing his claim. Finding no reversible error, the Supreme Court affirmed the Commission's decision.View "Louie v. BP Exploration (Alaska), Inc." on Justia Law

Plaintiff injured his shoulder while working for Employer. Plaintiff was terminated later that year for “reduction of staff due to lack of work.” Employer accepted Plaintiff’s injury as compensable. In January 2009, Plaintiff began to receive unemployment benefits from Employer and Insurer (together, Defendants). In December 2010, Defendants sought to terminate payment of compensation, alleging that Plaintiff could no longer show he was disabled. The Industrial Commission concluded that Plaintiff was not entitled to disability payments made after December 2010 and that Defendants were entitled to a credit for any payments they had made after that date, finding that Plaintiff’s inability to find work was not due to his injury but to large-scale economic factors. The Supreme Court affirmed, holding that the Commission properly concluded that Plaintiff failed to prove that his inability to earn the same wages as before his injury resulted from his work-related injury.View "Medlin v. Weaver Cooke Constr., LLC" on Justia Law

While working for Vista Care (Employer), appellant Sherrie Fowler suffered a back injury. Appellant began receiving TTD and subsequently underwent back surgery. Several years later, a physician determined that appellant reached maximum medical improvement (MMI). This case began when appellant filed a complaint with the Workers' Compensation Act (WCA) in 2010, for reinstatement of her TTD benefits and for an increase in her PPD rating. The Court of Appeals held that the Act limited appellant's eligibility for TTD benefits to 700 weeks of benefits and reversed a contrary decision of the Workers’ Compensation Administration judge. Upon review of the matter, the Supreme Court concluded that the Act imposed no such limitation; TTD benefits are payable during any period of total disability for the remainder of a worker’s life. View "Fowler v. Vista Care" on Justia Law