Justia Insurance Law Opinion Summaries

In this insurance coverage dispute, the driver involved in an accident filed a claim with the Insurer of the other vehicle involved in the accident. The Insurer denied the claim. The Office of the Insurance Commissioner reviewed the denial and ordered the Insurer to adjust and resolve the claim. The Insurer did not file an appeal and instead filed a complaint for declaratory and injunctive relief in the federal district court. The district court dismissed the federal court action on res judicata grounds. The First Circuit Court of Appeals affirmed, holding that res judicata barred this action and no exceptions to res judicata applied. View "Universal Ins. Co. v. Office of the Ins. Comm'r" on Justia Law

Appellant, an over-the-road truck driver, filed a claim for workers’ compensation benefits, alleging that he sustained injuries in the form of deep vein thrombosis and pulmonary embolism in an accident that occurred during the course and scope of his employment. The compensation court applied a split test of causation used in heart attack cases, which requires proof of both legal and medical causation. The court then dismissed Appellant’s claim for failure to establish the medical cause prong. The Supreme Court affirmed the dismissal of Appellant’s claim, holding (1) the split test was properly applied to Appellant’s injuries in this case, as deep vein thrombosis and pulmonary embolism present the same difficulties in attributing the cause of a heart attack to a claimant’s work and are similar in origin to a heart attack; and (2) the compensation court’s finding as to causation was not clearly wrong. View "Wingfield v. Hill Bros. Transp., Inc." on Justia Law

In 2004, Appellant fell while working and strained her back. Appellant was awarded worker’s compensation benefits. In 2009, Appellant slipped and fell at work and injured her ankle. In 2010, Appellant sought temporary total disability and medical pay benefits from the Workers Compensation Division, which denied Appellant’s requests. After a contested case hearing, the Office of Administrative Hearings (OAH) upheld the Division’s denial of Appellant’s request for benefits, concluding Appellant did not meet her burden of proving that she suffered aggravation of a preexisting back condition as a result of a work related injury or that she suffered a second compensable injury. The district court affirmed. The Supreme Court affirmed, holding that the OAH did not err by failing to find a causal connection between the 2009 workplace incident and Appellant’s delayed back pain. View "Hirsch v. State ex rel. Wyo. Workers' Safety & Comp. Div." on Justia Law

In 2009, Appellant suffered injuries to both of his knees in a work-related accident. Appellant filed a request for loss of earning compensation. The Workers’ Compensation Court concluded that, notwithstanding findings of permanent impairment, because no permanent physical restrictions were specifically assigned by an expert for Appellant’s left knee, the court could not perform a loss of earning capacity calculation authorized under the third paragraph of Neb. Rev. Stat. 48-121(3) and that Appellant was thus limited to scheduled member compensation. The Supreme Court reversed, holding that the compensation court erred as a matter of law in concluding that there must be expert opinion of permanent physical restrictions as to each injured member in order to perform a loss of earning capacity calculation under section 48-121(3). Remanded. View "Rodgers v. Neb. State Fair" on Justia Law

Plaintiff sought insurance coverage for gastric lap band surgery. Defendant, a health-care insurer that covered Plaintiff by virtue of Plaintiff’s husband’s employment with the federal government, refused to cover the full cost of the surgery. Plaintiff brought tort and breach of contract claims against Defendant in the Puerto Rico Court of First Instance. Defendant removed the action to the federal district court, asserting, inter alia, that the Federal Employees Health Benefits Act of 1959 (FEHBA) completely preempted Plaintiff’s local-law claims, thus conferring original jurisdiction on the federal court. Defendant then moved to dismiss the case, arguing that the FEHBA demanded exhaustion of administrative remedies. Plaintiff, in the meantime, requested that the district court remand the case to the Court of First Instance. The district court (1) denied Plaintiff’s motion to remand, holding that the FEHBA completely preempted Plaintiff’s claims and, thus, federal jurisdiction attached; and (2) dismissed the action for Plaintiff’s failure to exhaust administrative remedies. The First Circuit Court of Appeals reversed the district court’s judgment of dismissal and its order denying remand, holding that the court erred in concluding that the FEHBA afforded complete preemption. View "Lopez-Munoz v. Triple-S Salud, Inc. " on Justia Law

This case arose from a contract between Roanoke Healthcare Authority (doing business as Randolph Medical Center) and Batson-Cook Company, a general contractor, to renovate the medical center, located in Roanoke. Batson-Cook received written notice from Roanoke Healthcare that work on the renovation project had been suspended. Batson-Cook notified one of its subcontractors, Hardy, of the suspension and stated that "[t]he contract has been suspended by [Roanoke Healthcare] through no fault of Batson-Cook ... or its subcontractors. [Roanoke Healthcare] is currently out of funding and has subsequently closed the facility while seeking a buyer." Liberty Mutual, the project's insurer, alleged in its answer that Roanoke Healthcare failed to pay Batson-Cook $241,940.51 for work performed pursuant to the contract. Batson-Cook sent Hardy a change order the change order deducted from the subcontract the $147,000 in equipment and materials another subcontractor Hardy hired, Johnson Controls, Inc. (JCI), had furnished for the renovation project and for which it has not received payment. JCI notified Liberty Mutual, Roanoke Healthcare, Batson-Cook, and Hardy by certified letters of its claim on a payment bond. The letters identified Batson-Cook as the general contractor and Hardy as the debtor. Liberty Mutual denied the claim. JCI sued Liberty Mutual, alleging JCI was entitled to payment on the payment bond Liberty Mutual had issued to Batson-Cook. Upon review, the Supreme Court concluded JCI was a proper claimant on the payment bond. Therefore, the circuit court erred in entering a summary judgment in favor of Liberty Mutual and denying JCI's summary judgment motion. View "Johnson Controls, Inc. v. Liberty Mutual Insurance Company " on Justia Law

Between 1996 and 2003, Appellant filed several workers’ compensation claims, which were allowed for certain conditions. Appellant subsequently filed two applications for permanent-total-disability compensation. The Industrial Commission denied the applications, relying in part on the report of Dr. Lee Howard, a psychologist, who determined that Appellant could perform work without significant limitations. Appellant filed a complaint for a writ of mandamus, arguing that the Commission abused its discretion when it relied on Dr. Howard’s report because the report was stale. The court of appeals denied the writ, determining that Dr. Howard’s report was relevant evidence. The Supreme Court affirmed, holding that the Commission did not abuse its discretion when it relied on Dr. Howard’s report in denying permanent-total-disability compensation. View "State ex rel. Bailey v. Indus. Comm'n" on Justia Law

Robert Sheppard was injured while working for Employer. After Sheppard retired, he filed an application for permanent-total-disability (PTD) compensation, which a staff hearing officer granted. Employer filed a request for reconsideration on the basis that the staff hearing officer’s order contained mistakes of fact and law. After a hearing, the Industrial Commission issued an order confirming that the staff hearing officer’s order contained a clear mistake of law and denying the underlying request for PTD compensation. Sheppard filed a complaint for a writ of mandamus alleging that the Commission abused its discretion when it exercised continuing jurisdiction and denied PTD compensation. The court of appeals denied the writ, concluding (1) the staff hearing officer’s mistake of law was sufficient for the Commission to invoke its continuing jurisdiction; and (2) once the Commission properly invoked its continuing jurisdiction, it had authority to reconsider the issue of PTD compensation. The Supreme Court affirmed, holding (1) the staff hearing officer made a mistake of law justifying the exercise of continuing jurisdiction; and (2) the Commission’s continuing jurisdiction vested it with authority to issue a new order denying PTD compensation. View "State ex rel. Sheppard v. Indus. Comm'n" on Justia Law

Robert Corlew was an employee of Honda of America Manufacturing, Inc. when he was injured while working. Honda’s long-term-disability insurance carrier eventually determined that Corlew was not eligible for ongoing disability benefits because he was capable of gainful employment outside of Honda. Corlew subsequently retired because there was no position available at Honda. One year later, Corlew underwent surgery on his wrist. The Industrial Commission awarded temporary-total-disability (TTD) compensation to be paid during Corlew’s postsurgical recovery, concluding that Corlew had not voluntarily retired or abandoned the workforce. The court of appeals denied Honda’s request for a writ of mandamus, concluding that Corlew’s retirement was due to his industrial injury, and thus was involuntary, and that there was no evidence that Corlew had abandoned the entire workforce. The Supreme Court affirmed, holding that Corlew was eligible for TTD compensation even though he suffered no economic loss that could be directly attributed to his industrial injury. View "State ex rel. Honda of Am. Mfg., Inc. v. Indus. Comm'n" on Justia Law

The question before the Supreme Court was whether La. R.S. 23:1203.1 applied to requests for medical treatment and/or disputes arising out of requests for medical treatment in cases in which the compensable accident or injury occurred prior to the effective date of the medical treatment schedule. The Office of Workers’ Compensation (OWC) ruled that the medical treatment schedule applied to all requests for medical treatment submitted after its effective date, regardless of the date of injury or accident. The court of appeal reversed, holding that La. R.S. 23:1203.1 was substantive in nature and could not be applied retroactively to rights acquired by a claimant whose work-related accident antedated the promulgation of the medical treatment schedule. The Supreme Court disagreed with the conclusion of the court of appeal and found that La. R.S. 23:1203.1 was a procedural statute and, thus, did not operate retroactively to divest a claimant of vested rights. As a result, the statute applied to all requests for medical treatment and/or all disputes emanating from requests for medical treatment after the effective date of the medical treatment schedule, regardless of the date of the work-related injury or accident. View "Church Mutual Insurance Co. v. Dardar" on Justia Law