Justia Insurance Law Opinion Summaries

Petitioner-claimant Jeanette Ball sought permanent total disability benefits from the Multiple Injury Trust Fund. The Workers' Compensation Court held that a "Crumby" finding of preexisting disability made simultaneously with the adjudication of an on-the-job injury could be combined with the adjudicated injury to render the Claimant a physically impaired person under 85 O.S. Supp. 2005 sec. 171 and awarded Petitioner permanent total disability benefits. The Fund appealed, and a three-judge panel reversed. Claimant then appealed, and the Court of Civil Appeals reversed the panel. After its review, the Supreme Court held that an employee must be a physically impaired person as defined by the applicable statute before he or she can seek benefits from the Fund. A "Crumby" finding of preexisting disability made simultaneously with an adjudication of an on-the-job injury could not be combined with such adjudicated injury to render the Claimant a physically impaired person under 85 O.S. Supp 2005 sec. 171. The Court of Appeals' decision was vacated and the case remanded for further proceedings. View "Ball v. Multiple Injury Trust Fund" on Justia Law

In December, 2009, Heelan, a Vernon Hills police officer for approximately 20 years, responded to an emergency call, slipped on ice, and fell. He was ultimately diagnosed with significant osteoarthritis in both hips, aggravated by the fall, and had two hip replacement surgeries. He did not return to work. The Village Police Pension Board awarded a line-of-duty disability pension, 40 ILCS 5/3-114.1. The Village sought a declaration that it was not obligated to pay Heelan’s health insurance premium under the Public Safety Employee Benefits Act (the Act), 820 ILCS 320/10. The circuit court entered judgment in favor of Heelan. The appellate court and Illinois Supreme Court affirmed, Proof of a line-of-duty disability pension establishes a catastrophic injury under section 10(a) of the Act as a matter of law; a public safety officer’s employer-sponsored health insurance coverage expires upon the termination of the officer’s employment by the award of the line-of-duty disability pension. The Act lengthens such health insurance coverage beyond the termination of the officer’s employment. View "Village of Vernon Hills v. Heelan" on Justia Law

Appellant, a self-employed delivery driver who contracted with FedEx Home Delivery for one of its delivery routes, fell and injured his shoulder while delivering packages. Under his FedEx service contract, Appellant was required to maintain workers’ compensation insurance, which he did through CorVel Corporation. Appellant received medical treatment, but with his physical restrictions, he could not complete his delivery route. Appellant hired a replacement driver until he canceled the service contract. Appellant sought temporary disability benefits, which CorVel denied. Appellant administratively appealed. The appeals officer denied both temporary total disability benefits and temporary partial disability benefits on the basis that Appellant could not establish a loss of any income without evidence of a salary. The district court denied Appellant’s petition for judicial review. The Supreme Court reversed, holding (1) for self-employed individuals, the lack of a salary associated with typical employment does not preclude an average monthly wage calculation for the purpose of determining lost income and rendering a workers’ compensation benefit decision; and (2) the appeals officer in this case should have determined the best method for calculating any loss to Appellant’s wages resulting from his industrial injury, taking into account both his business’s income and expenses. Remanded. View "Mensah v. CorVel Corp." on Justia Law

Penn Treaty Network America Insurance Company (“PTNA”) and its subsidiary, American Network Insurance Company (“ANIC”) (collectively, the “Companies”), were Pennsylvania life insurers specializing in long-term care insurance, covering skilled-nursing, nursing home, and assisted living and home health care for individuals with chronic illnesses or disabilities. In January 2009, the Commonwealth Court ordered the rehabilitation of the Companies, upon application of then-Insurance Commissioner Joel Ario, who cited the consent of both entities as the sole grounds for the orders of rehabilitation. Nine months after entry of the rehabilitation order, however, Commissioner Ario filed petitions to covert the Companies’ rehabilitations into liquidations. The Commonwealth Court, per a single-judge proceeding, conducted hearings spanning thirty days of testimony and encompassing the submission of thousands of pages of exhibits and documentary evidence. In May 2012, the Commonwealth Court entered an order denying the petitions to liquidate and directed the Commissioner to develop a plan of rehabilitation within ninety days. The Commonwealth Court concluded the Rehabilitator’s evidence did not show that a rehabilitation was tried and failed. "Rather, it showed that a rehabilitation plan was abandoned in its nascency. In short, the Rehabilitator did not prove that continued rehabilitation substantially increases the risk to policyholders, creditors and the public or is futile." A critical facet of the Commonwealth Court’s opinion concerned the degree of deference owing to a statutory rehabilitator on consideration of a conversion petition. The Commissioner challenged the Commonwealth Court’s decision in such regard, namely, that the court’s no-deference determination was, in fact, inconsistent with the case which it had referenced as being supportive. The Supreme Court affirmed: "In all events, deference does not require the courts to accede to a misuse of the process. In light of the above, and the former Commissioner’s accession at the outset of the rehabilitation proceedings that liquidations would be harmful to policyholders, as well as the Commonwealth Court’s supported finding that there is no present harm in moving forward in rehabilitation, we decline to impede that court’s review of the rehabilitation plan which it directed should be filed, and which has now been submitted. The judicial review, however, should proceed subject to a more deferential overlay relative to the new acting Commissioner." View "In Re: Penn Treaty Network" on Justia Law

The appeals before the Tenth Circuit in this opinion concerned the regulations (as a part of the Affordable Care Act ("ACA")) that required group health plans to cover contraceptive services for women as a form of preventive care ("Mandate"). In response to religious concerns, the Departments implementing the ACA (Health and Human Services ("HHS"), Labor, and Treasury) adopted a regulation that exempted religious employers (churches and their integrated auxiliaries) from covering contraceptives. When religious non-profit organizations complained about their omission from this exemption, the Departments adopted a regulation that allowed them to opt out of providing, paying for, or facilitating contraceptive coverage. Under this regulation, a religious non-profit organization could opt out by delivering a form to their group health plan’s health insurance issuer or third-party administrator or by sending a notification to HHS. The Plaintiffs in the cases here were religious non-profit organizations. They argued that complying with the Mandate or the accommodation scheme imposed a substantial burden on their religious exercise. The Plaintiffs argued the Mandate and the accommodation scheme violated the Religious Freedom Restoration Act (“RFRA”) and the Religion and Speech Clauses of the First Amendment. While Tenth Circuit recognized the sincerity of Plaintiffs’ beliefs and arguments, it concluded the accommodation scheme relieved Plaintiffs of their obligations under the Mandate and did not substantially burden their religious exercise under RFRA or infringe upon their First Amendment rights. The Court affirmed the district court’s denial of a preliminary injunction to the plaintiffs in Little Sisters of the Poor Home for the Aged v. Sebelius, (6 F.Supp. 3d 1225 (D. Colo. 2013)), and reversed the district courts’ grants of a preliminary injunction to the plaintiffs in "Southern Nazarene University v. Sebelius," (No. CIV-13-1015-F, 2013 WL 6804265 (W.D. Okla. Dec. 23, 2013)), and "Reaching Souls International, Inc. v. Burwell," (No. CIV-13-1092-D, 2013 WL 6804259 (W.D. Okla. Dec. 20, 2013)). View "Little Sisters of the Poor v. Burwell" on Justia Law

While in the course and scope of his employment with Employer, Plaintiff suffered serious injuries. Plaintiff recovered workers’ compensation insurance benefits in the amount of $207,147. Plaintiff subsequently brought this action against Employer, alleging that Employer was an uninsured employer under the Workers’ Compensation Act at the time of the accident. The district court granted summary judgment in favor of Employer, concluding that Employer was an insured employer under the Act and was therefore entitled to tort immunity pursuant to Mont. Code Ann. 39-71-411. The Supreme Court affirmed, holding that the district court did not err in concluding that Employer was an insured employer under the Act and therefore was entitled to tort immunity. View "Stokes v. Golden Triangle, Inc." on Justia Law

Dakota Trailer Manufacturing, which makes radiator components for an unrelated company, performs its component work in one of Dakota Trailer’s locations that was originally classified as a “machine shop” for workers compensation insurance rating purposes. After an inspection, the National Council on Compensation Insurance changed the location’s classification to “welding or cutting.” Both the Workers’ Compensation Appeals Board and the South Dakota Department of Labor affirmed the new classification. The circuit court reversed and reinstated the machine shop code. The Supreme Court reversed, holding that the circuit court properly found that Dakota Trailer’s activities fit within the machine shop code. View "Dakota Trailer Mfg. v. United Fire & Cas. Co." on Justia Law

McGinnes Industrial Waste Corporation dumped pulp and paper mill waste sludge into disposal pits near the San Jacinto River in Pasadena, Texas (the site). After environmental contamination was discovered at the site, the Environmental Protection Agency (EPA) instituted superfund cleanup proceedings under the federal Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA). During the period that McGinnes was dumping waste at the Site, it was covered by standard-form commercial general liability (CGL) insurance policies issued by Phoenix Insurance Company and Travelers Indemnity Company (together, the Insurers). McGinnes requested a defense in the EPA proceedings from the Insurers. The Insurers refused, determining that the proceedings were not a “suit” under the policy. McGinnes sued the insurers in federal court seeking a declaration that the policies obligated them to defend the EPA’s CERCLA proceedings. The district court granted the Insurers’ motion for partial summary judgment on the duty-to-defend issue. The U.S. Court of Appeals for the Fifth Circuit certified a question regarding the issue to the Texas Supreme Court. The Supreme Court answered that “suit” in the CGL policies at issue must also include CERCLA enforcement proceedings by the EPA. View "McGinnes Indus. Maint. Corp. v. Phoenix Ins. Co." on Justia Law

The Patient Protection and Affordable Care Act (42 U.S.C 18001) includes “guaranteed issue” and “community rating” requirements, which bar insurers from denying coverage or charging higher premiums based on health; requires individuals to maintain health insurance coverage or make a payment to the IRS, unless the cost of buying insurance would exceed eight percent of that individual’s income; and seeks to make insurance more affordable by giving refundable tax credits to individuals with household incomes between 100 per cent and 400 percent of the federal poverty line. The Act requires creation of an “Exchange” in each state— a marketplace to compare and purchase insurance plans; the federal government will establish “such Exchange” if the state does not. The Act provides that tax credits “shall be allowed” for any “applicable taxpayer,” only if the taxpayer has enrolled in an insurance plan through “an Exchange established by the State under [42 U.S.C. 18031],” An IRS regulation interprets that language as making credits available regardless of whether the exchange is established by a state or the federal government. Plaintiffs live in Virginia, which has a federal exchange. They argued Virginia’s Exchange does not qualify as “an Exchange established by the State,” so they should not receive any tax credits. That would make the cost of buying insurance more than eight percent of their income, exempting them from the coverage requirement. The district court dismissed their suit. The Fourth Circuit and Supreme Court affirmed. Tax credits are available to individuals in states that have a federal exchange. Given that the text is ambiguous, the Court looked to the broader structure of the Act and concluded that plaintiffs’ interpretation would destabilize the individual insurance market in any state with a federal exchange. It is implausible that Congress meant the Act to operate in that manner. Congress made the guaranteed issue and community rating requirements applicable in every state, but those requirements only work when combined with the coverage requirement and tax credits. View "King v. Burwell" on Justia Law

Candelario Lopez, who was hired by Interstate Treating to work on the installation of a gas processing plant, was transporting two other Interstate Treating employees to the job site when he died in an automobile accident. Lopez’s wife, Maximina Lopez, sought death benefits from Interstate Treating’s workers’ compensation insurance carrier, SeaBright Insurance Co. SeaBright denied coverage, concluding that Lopez was not acting in the course and scope of his employment at the time of the accident. A hearing officer, however, determined that Lopez was acting in the course and scope of his employment and ordered SeaBright to pay death benefits. The trial court affirmed the administrative decision. The court of appeals affirmed the trial court’s judgment. The Supreme Court affirmed, holding that Lopez was acting in the course and scope of his employment when he died, and Maximina was entitled to benefits. View "Seabright Ins. Co. v. Lopez" on Justia Law