Justia Insurance Law Opinion Summaries

Sherry Walker was denied disability benefits by the Public Employees’ Retirement System (PERS). The Circuit Court reversed PERS’s decision. The Court of Appeals reversed the circuit court, reinstating PERS’ denial of benefits. Upon review of the matter, the Supreme Court concluded PERS’ decision to deny Walker’s request for regular disability benefits was unsupported by substantial evidence. Accordingly, the Court reversed part of the appellate court's decision and reversed the Circuit Court's decision, and remanded the case with instructions to enter judgment in Walker’s favor on her regular disability benefits claim. View "Public Employees' Retirement System v. Walker" on Justia Law

Appellant suffered work-related injuries in 2000 and received workers' compensation benefits until 2004. Appellant filed another first report of injury in 2009 based on the same injuries. Employer denied benefits. Appellant filed a petition for rehearing. The Department of Labor & Regulation, Division of Labor & Management found that S.D. Codified Laws 62-7-35.1 barred Appellant's second claim for workers' compensation benefits because more than three years had passed between the date of the last payment of benefits and the date Appellant filed a written petition for a hearing. The circuit court affirmed. Appellant appealed, arguing section 62-7-35.1 should not apply to this case because his injuries were from cumulative trauma. The Supreme Court affirmed, holding that the cumulative trauma doctrine did not change section 62-7-35.1's application to this case because the cumulative trauma doctrine applies to the date of injury, which is irrelevant to section 62-7-35.1. View "Schuelke v. Belle Fourche Irrigation Dist." on Justia Law

Employee was injured while working as a truck driver for Employer. Employee's claim was allowed for the injuries. The next year, Employee returned to work. Two days later, Employer terminated Employee for violating written work rules. A staff hearing officer later denied temporary total disability (TTD) compensation, determining that Employee's termination was a voluntary abandonment of employment that barred compensation for TTD. The court of appeals concluded that the Industrial Commission abused its discretion in determining that Employee was ineligible for TTD compensation based upon his termination from Employer and granted mandamus relief to Employee. The Supreme Court (1) reversed, holding that the Commission's order did not meet the standards of State ex rel. Noll v. Indus. Comm'n because the court did not specifically state the evidence relied upon or explain the reason behind its decision that Employee had voluntarily abandoned his employment with Employer; and (2) returned the matter to the Commission to issue a new order stating the evidence relied upon and explaining its reasoning consistent with Noll. View "State ex rel. Cline v. Abke Trucking, Inc." on Justia Law

Claimant-Appellant Dallas Clark appealed an Industrial Commission order that denied her workers' compensation benefits. Claimant worked for Shari's Management Corporation as an experienced server. During a graveyard shift, she suffered a herniated disc in her back while lifting a heavy tray onto a high shelf. She would later be diagnosed with sciatica attributed to the lifting injury from work. Shari's completed a Report of Injury, interviewing Claimant in the process. The investigator testified that Claimant attributed the injury as "standing wrong" at a salad bar, which left her unable to lift the tray. The Commission concluded after a hearing that Claimant was unable to prove an industrial accident had occurred. The Supreme Court agreed with the Commission and affirmed its order. View "Clark v. Shari's Management Corp" on Justia Law

The Superintendent of Insurance ordered Guarantee Trust Life Insurance Company (GTL) to pay a civil penalty of $150,000 after finding that GTL violated Me. Rev. Stat. Ann. 24-A, 1420-M(1), 1902, and 2412(1-A)(B), and that GTL was accountable, pursuant to Me. Rev. Stat. Ann. 24-A, 1445(1)(D) for violations committed by Cinergy Health, Inc., a company that acted as GTL's producer. The business and consumer docket affirmed the decision of the Superintendent. The Supreme Court affirmed, holding (1) GTL was accountable pursuant to section 1445(1)(D) for Cinergy's misconduct occurring before the date on which GTL formally appointed Cinergy as its producer; (2) the Superintendent did not err in concluding that GTL provided coverage to Maine residents and was liable under section 2412(1-A)(B); (3) the Superintendent's did not issue an untimely decision pursuant to the plain language of Me. Rev. Stat. Ann. 24-A, 235(2); (4) the Superintendent did not abuse her discretion by holding GTL liable under section 1420-M(1); and (5) the Superintendent did not abuse her discretion by penalizing GTL for violating section 1902. View "Guarantee Trust Life Ins. Co. v. Superintendent of Ins." on Justia Law

While working for Employer, Employee filed notice of a workers' compensation claim related to a lower back injury he received during the course of his employment. Employee was discharged approximately four years later pursuant to a termination agreement that provided that he agreed to release Employer from any and all workers' compensation claims. Employer later brought an action against Employee, alleging civil theft, fraud, unjust enrichment, and conversion based on Defendant's admission that he never intended to release his workers' compensation claim. Employee counterclaimed, claiming that Employer's cause of action was in retaliation for Employee's decision to exercise his rights under the Workers' Compensation Act. Employer filed a motion to dismiss the counterclaim, asserting that the doctrine of absolute immunity shielded Employer from the counterclaim. The trial court denied the motion. The Supreme Court affirmed the trial court's decision denying Plaintiff's motion to dismiss, holding that an employer's right to seek redress for its alleged grievances in court does not outweigh an employee's interest in exercising his rights under the Act without fear of retaliation by his employer, and therefore, absolute immunity did not shield Employer from Employee's counterclaim. View "MacDermid, Inc. v. Leonetti" on Justia Law

Appellant Annette Shoap sustained a work-related injury in the nature of a left shoulder injury while working as an employee of Phoenixville Hospital. She began receiving temporary total disability benefits pursuant to a Notice of Compensation Payable dated 2003. The treatment for Appellant’s injury included three surgeries and physical therapy. In 2007, the employer filed a modification petition alleging both that Appellant’s physical condition had improved and that work was generally available to her within her physical restrictions in the relevant geographical area, as demonstrated by two labor market surveys. Appellant denied the material allegations of Employer’s petition, and a hearing was held before a Workers’ Compensation Judge. After the WCJ ruled in the employer's favor, Appellant unsuccessfully appealed to the Workers' Compensation Appeal Board and Commonwealth Court. On appeal to the Supreme Court, Appellant asserted that the Commonwealth Court erred by concluding that “substantial gainful employment existed” for purposes of granting a modification of her compensation benefits pursuant to Section 306(b) of the Workers' Compensation Act, despite the fact that her application for the specific jobs involved failed to result in any offers of employment. Secondarily, Appellant argued that the Commonwealth Court, even if correct in its interpretation of Section 306(b), erred by not remanding the case for further evidentiary development based on its interpretation of Section 306(b), which Appellant contended represented a change in the standard for evaluating cases under that statute. After careful review, the Supreme Court agreed with Appellant's second contention, and reversed and remanded for further proceedings. View "Phoenixville Hospital v. WCAB (Shoap, Aplt)" on Justia Law

Claimant was employed at a secure juvenile detention facility operated by the State Office of Children & Family Services (OCFS) when she was assaulted, raped, and abducted by a resident. Claimant received workers' compensation benefits for her injuries. Claimant also filed a civil rights lawsuit in federal district court against OCFS and three supervisory OCFS employees seeking, inter alia, punitive damages. The federal lawsuit was settled. The New York State Insurance Fund (SIF), the workers' compensation carrier in this case, approved the settlement. In so doing, SIF reserved its right to take a credit against Claimant's payments of benefits until the credit was exhausted. The Workers' Compensation Law judge (WCLJ) decided that SIF was not entitled to offset the proceeds of a civil rights lawsuit that sought punitive damages. On appeal, the Workers' Compensation Board found in SIF's favor. The Appellate Division affirmed. The Court of Appeals affirmed, holding that, in light of the terms of the settlement in this case, SIF could take a credit against the settlement proceeds of Claimant's lawsuit against her employer and coemployees for injuries arising from the same incident for which Claimant received worker's compensation benefits. View "Beth V. v. State Office of Children & Family Servs." on Justia Law

In 2007, Appellant purchased the assets of an indoor football team owned by Omaha Beef, LLC. In 2008, Appellant applied for workers' compensation insurance under the Nebraska Workers' Compensation Plan, arguing that it was entitled to a certain experience modifier (XMod), which is used when calculating the premium owed, because it was a new entity with no claims experience. The National Council on Compensation Insurance, Inc. determined that Appellant was a successor entity to Omaha Beef, and thus, the various XMods assigned to Omaha Beef for the relevant time periods must be transferred to Appellant. The director of the Department of Insurance affirmed. The district court affirmed, reasoning that Appellant was a successor to Omaha Beef and that the change in ownership resulted in the transfer of the workers' compensation rating for Omaha Beef to Appellant. The Supreme Court affirmed, holding that the district court did not err in finding (1) Appellant had the burden of proof to show there was no "change in ownership"; and (2) a "change in ownership" existed such that the XMod of Omaha Beef should be transferred to Appellant. View "Gridiron Mgmt. Group, LLC v. Travelers Indem. Co." on Justia Law

The Supreme Court granted certiorari in this case to address two issues: (1) whether a political-subdivision employer may be required to provide workers' compensation benefits to an off-duty employee injured while providing services to a private entity; and (2) whether, under the facts presented, the claimant's salaries from his full-time employment as a deputy sheriff and his part-time job as a security officer may be combined when determining the amount of benefits to which the employee is entitled. Respondent-claimant John David Waldenville was injured while acting as a security guard for petitioner Cattlemen's Steakhouse, Inc. Initially, Cattlemen's contended that Waldenville was an independent contractor but later conceded that it had workers' compensation coverage for him through their insurer. Nevertheless, the employer continued to assert that Waldenville was an employee of respondent, Oklahoma County Sheriff's Department when injured. The trial court determined that: Cattlemen's was the employing entity when the employment-related injury occurred; Oklahoma County should be dismissed pursuant to 85 O.S. 2001 sec. 2b(G); Cattlemen's was estopped to dispute employee status based on the payment of workers' compensation premiums associated with Waldenville's employment; no evidence existed indicating that the employee was acting in his official capacity as a Deputy Sheriff at the time of the incident; and because the duties that Waldenville was carrying out at the time of his injury were the same or similar to those he executed as a Deputy Sheriff, the claimant's salaries were to be combined for establishment of weekly rates. The Supreme Court held that: (1) the "plain, clear, unmistakable, unambiguous, mandatory, and unequivocal" language of 85 O.S. 2011 sec. 313(G) mandated that private employers, hiring off-duty municipal employees, alone shall be responsible for the payment of workers' compensation benefits arising from incidents occurring during the hours of actual employment by the private employer; and (2) under the facts of this case, claimant was engaged in the same, or substantially similar, employment to that of his profession as a Major with the Oklahoma County Sheriff's Department when he was injured, warranting the combination of salaries for purposes of determining workers' compensation benefits. View "Cattlemen's Steakhouse, Inc. v. Waldenville" on Justia Law