Justia Insurance Law Opinion Summaries

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

The City of Gadsden and certain members of the State Employees' Insurance Board appealed two circuit court orders that granted injunctive relief to John Boman. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. In 2000, Gadsden elected to join the 'Local Government Health Insurance Plan,' a health benefit plan administered by the Board. When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and other ailments. After his 65th birthday, Blue Cross began denying his claims for medical treatment based on the failure to provide Blue Cross with a 'record of the Medicare payment.' However, Boman had no Medicare credits. When the dispute over coverage arose, Boman sought review by the Board. The Board denied Boman's request for an appeal. Boman and 18 other active and retired Gadsden police officers sued Gadsden, alleging, among other things, that they had 'been deprived of Social Security and Medicare protection which other police officers have been provided' and that, after 20 years of service, they were being required to pay a higher pension charge or percentage of base pay than their counterparts who were hired after April 1, 1986. In 2011, Boman filed a 'motion for immediate relief for medical care.' The Supreme Court found that the circuit court issued preliminary injunctive relief against Gadsden without requiring Boman to give security and without making any specific findings. As such, the Supreme Court had "no alternative but to reverse" the preliminary injunction issued against Gadsden and remanded the case for further proceedings. View "City of Gadsden v. Boman " on Justia Law

While employed by Employer, Appellant sustained an injury. Appellant filed an industrial injury claim. Employer's insurer (Insurer) partly accepted the claim but later closed Appellant's claim. After unsuccessfully filing three requests to reopen his claim, Appellant filed a fourth request, which was again denied by Insurer. A hearing officer affirmed the denial. Appellant administratively appealed. Insurer moved to dismiss, arguing that Appellant was precluded from reopening his claim under the doctrine of res judicata. The appeals officer granted Insurer's motion. The district court denied Appellant's petition for judicial review, concluding that Apellant failed to state a new cause of action that could withstand the application of res judicata. The Supreme Court reversed, holding that because the district court failed to provide any findings of fact or conclusions of law, the court could not properly review the appeals officer's determination that there was no change of circumstances warranting reopening under Nev. Rev. Stat. 616C.390. Remanded. View "Elizondo v. Hood Machine, Inc." on Justia Law

In 2005, Patrick Richard sustained a work-related injury at the State Department of Transportation and Development ("DOTD"). After Mr. Richard's injury, DOTD began paying him workers' compensation benefits. Mr. Richard took disability retirement in 2007. Upon retiring, Mr. Richard spoke with a DOTD employee about the effect his receipt of workers' compensation benefits would have on his disability retirement benefits. Thereafter, Mr. Richard began simultaneously receiving disability retirement benefits through the Louisiana State Employees Retirement System ("LASERs"), and workers' compensation benefits through DOTD. In August 2007, DOTD informed Mr. Richard it had been overpaying him for workers' compensation benefits. In early 2011, DOTD filed a disputed claim for compensation, seeking an offset. In response, Mr. Richard filed an exception of prescription, arguing DOTD's claim for reimbursement was subject to a three-year prescriptive period. The matter proceeded to a trial before the Office of Workers' Compensation ("OWC"). The OWC denied Mr. Richard's exception of prescription. The OWC further held DOTD is entitled to an offset of $224.05 per week as of April 21, 2007, until Mr. Richard converted to regular retirement benefits at age 60. Mr. Richard appealed. The court of appeal affirmed in part and reversed in part. The court of appeal affirmed the OWC's denial of Mr. Richard's exception of prescription. However, the court found the OWC erred in holding DOTD was entitled to an offset of workers' compensation benefits. Upon review, the Supreme Court concluded the court of appeal incorrectly applied the law. Accordingly, the Court reinstated the OWC's judgment granting the employer an offset. View "Louisiana v. Richard" on Justia Law

A pharmaceutical distributor/repackager sought review of an appellate court decision that reversed a decision of the Louisiana Office of Workers' Compensation Administration. The Office awarded certain unpaid invoices for physician-dispensed medications (subject to a statutory limit) in favor of the distributor/repackager. The appellate court reversed based on a finding that the distributor/repackager did not have a right of action. After considering the applicable law, the Supreme Court found the anti-assignment language of La. R.S. 23:1205(A) did not prohibit the assignment of a health care provider's claims to a third party, an express contractual novation was effective, and an agent could statutorily be considered a health care provider based on the definition contained in La. R.S. 23:1021(6). Accordingly, the Court reversed the court of appeal's decision and remanded the case back to that court for further proceedings. View "Rebel Distributors Corp., Inc. v. Luba Workers' Comp." on Justia Law

Appellant Windham County Sheriff’s Department (WCSD) appealed a decision of the Employment Security Board that held it liable for reimbursement of unemployment compensation benefits as a base-period employer of a former employee. WCSD argued that because the employee was terminated for gross misconduct, and because an amendment to the statute governing reimbursement of unemployment compensation benefits that would have removed its liability for payments for employees terminated for gross misconduct took effect before the employee became eligible to receive any benefits, it should not have been held liable for reimbursement payments. Finding no error in the Board's decision, the Supreme Court affirmed. View "Windham County Sheriffs Department v. Department of Labor" on Justia Law

Plaintiff's property was insured by a standard flood insurance policy (SFIP) issued by Allstate Insurance Company, a private insurer participating in the National Flood Insurance Program (NFIP). Allstate issued Plaintiff's SFIP on behalf of FEMA, the federal agency that administers the NFIP. After Plaintiff's property was damaged by a flood, Allstate paid him for some but not all claims. Plaintiff sued Allstate for the alleged remaining unpaid covered losses, and the district court entered judgment in favor of Plaintiff. The First Circuit Court of Appeals reversed and remanded with directions to enter summary judgment in favor of Allstate, holding that Plaintiff's failure to comply with the SFIP's requirement that he file a proof of loss as to all damages sought barred recovery under his policy for those damages and required dismissal. View "DeCosta v. Allstate Ins. Co." on Justia Law

The Georgia Insurance Insolvency Pool (GIIP) brought a declaratory judgment action against two insureds who purchased workers compensation insurance from the Southern United States Insurance Company (SEUS) before SEUS became a member of GIIP. SEUS insureds whose claims predated June, 2006 were not covered by GIIP, and those insureds faced exposure when SEUS was liquidated in October, 2009. In 2010, the Georgia Legislature enacted a law to expand GIIP's "covered claims" to include certain insureds who obtained insurance from a captive insurer that later became insolvent. The effect of the 2010 amendment was to retroactively cover the previously excluded claims of SEUS insureds. GIIP claimed that extension of coverage would decrease GIIP's reserves and increase the assessments levied on member insurance companies. The defendants, whose claims would be covered only because of the 2010 amendment, filed a motion to dismiss, asserting GIIP lacked standing to bring suit. The trial court granted the motion and the appellate court affirmed. Upon review, the Supreme Court concluded the legislature gave GIIP the power to sue and be sued, and as such, had no standing to challenge the 2010 statutory amendment. View "Georgia Insurer's Insolvency Pool v. Hulsey Environmental Services, Inc." on Justia Law

Appellant Hugo Rosales suffered an injury working on a fish-processing vessel. He filed both a workers' compensation claim and a maritime lawsuit. Appellant and the employer ultimately entered into a global settlement of both cases. The state Workers' Compensation Board initially rejected the settlement. Appellant later tried to withdraw from the settlement but changed his mind. At a hearing, he testified that the though the settlement was in his best interests. The Board approved the settlement after the hearing. Several months later, appellant moved to have the agreement set aside. The Board denied this request. The Workers' Compensation Appeals Commission affirmed the Board's decision. Finding no error in the Commission's decision, the Supreme Court affirmed. View "Rosales. v. Icicle Seafoods, Inc." on Justia Law