Justia Insurance Law Opinion Summaries

Jason Morris worked for Owensboro Grain, a refinery located on the Ohio River. Morris suffered a work-related injury while performing deckhand duties, including loading items onto a barge. Morris received benefits from Owensboro Grain's Longshore and Harbor Workers' Compensation Act (LHWCA) insurance policy. Later, Morris filed a claim for Kentucky workers' compensation benefits. Owensboro Grain denied the claim on the grounds that the injury was not covered under the Kentucky Workers' Compensation Act. An ALJ dismissed Morris's claim, finding that Morris's injury fell under the LHWCA, and therefore, Kentucky had no subject matter jurisdiction over his claim. The Workers' Compensation Board and court of appeals affirmed. The Supreme Court affirmed, holding (1) because Morris was covered under the LHWCA, he was exempt from Kentucky's workers' compensation law unless Owensboro Grain provided him voluntary coverage; and (2) there was insufficient evidence to prove that Owensboro Grain provided voluntary workers' compensation coverage to Morris. View "Morris v. Owensboro Grain Co., LLC" on Justia Law

Sarah Crossett was employed by Jackson Purchase Medical Associate (JPMA), which leased space within a medical pavilion. Crossett was injured when she slipped and fell in snow that had accumulated outside of the building. Crossett filed for workers' compensation. JPMA disputed Crossett's claim, asserting that the injury did not occur on its operating premises under the going and coming rule, which provides that injuries that occur while an employee is on the way to or from a worksite are not compensable. An ALJ concluded that Crossett's injury was compensable, finding that Crossett fell within the operating premises of JPMA. The court of appeals affirmed. The Supreme Court affirmed, holding that because JPMA could assert control over the parking area and because Crossett was not taking an unreasonable path between her car and her office, she was entitled to workers' compensation benefits for her injury. View "Jackson Purchase Med. Assocs. v. Crossett" on Justia Law

The day after Julie served her husband Steven with a summons and complaint for divorce, Steven shot and killed Julie near her car in Julie's employer's parking lot. The personal representative of Julie's estate sought worker's compensation benefits for her death, asserting that Julie's death arose out of her employment. Julie's employer (Employer) denied benefits, as did the South Dakota Department of Labor and Regulation. The circuit court affirmed. The Supreme Court also affirmed, holding that even though the assault occurred on Employer's premises, the assault could not be attributed to Julie's employment, and therefore, Julie's death did not "arise out of" her employment. View "Voeller v. HSBC Card Servs., Inc." on Justia Law

CareFirst, Inc., a nonstock, nonprofit Maryland corporation, is a holding company with two subsidiaries that provides health insurance for millions of Maryland residents. State law confers broad authority on the Maryland Insurance Commissioner to oversee its operation and adherence to its mission. This case arose from the termination of Leon Kaplan, a former executive of CareFirst. CareFirst declined to pay part of the post-termination compensation set forth in Kaplan's employment contract, reasoning that the compensation was not for "work actually performed," as that standard had been interpreted by the Commissioner. The Commissioner affirmed the decision not to pay the benefits, concluding that the payments would violate Md. Code Ann. Ins. 14-139. The Court of Appeals affirmed, holding (1) the Commissioner's determination was not preempted by ERISA; (2) the Commissioner's construction of the insurance code was legally correct; and (3) there was substantial evidence to support the Commissioner's determination in this case. View "Md. Ins. Comm'r. v. Kaplan" on Justia Law

Appellant was placed on disability leave from work. Appellant was covered under a long term disability (LTD) policy that her employer obtained from Medical Group Insurance Services (MGIS). The policy was written by Sun Life Assurance Company (Sun Life). After leaving her job, Appellant filed a claim with MGIS seeing long term disability benefits. Sun Life denied Appellant's request for benefits. Appellant filed an action against Sun Life, asserting various state law claims. The federal district court dismissed the action based on ERISA preemption. Appellant then amended her complaint to add ERISA claims and asked the district court to apply de novo review in its evaluation of her ERISA claims. The court denied the motion and granted summary judgment for Sun Life, concluding that Sun Life's decision to deny benefits was not arbitrary and capricious, and thus complied with ERISA's requirements. The First Circuit Court of Appeals vacated the judgment, holding (1) the safe harbor exception to ERISA did not apply to the policy covering Appellant, and therefore, Appellant's state law claims were preempted; but (2) the benefits denial was subject to a de novo review, rather than the highly deferential "arbitrary and capricious" review prescribed for certain ERISA benefits decisions. Remanded. View "Gross v. Sun Life Assurance Co. of Canada" on Justia Law

Petitioner Allen Davenport appealed a judgment affirming a Workforce Safety and Insurance ("WSI") decision to terminate benefits on his claim for treatment of his cervical spine and left shoulder and denying his claims for benefits for treatment of his anxiety and depression and lower back condition. He argued his anxiety and depression and his cervical spine, left shoulder and back conditions were "compensable injuries." Upon further review, the Supreme Court concluded Davenport failed to establish by a preponderance of the evidence that work incidents subject to this claim substantially accelerated the progression of, or substantially worsened the severity of, his existing conditions and that his physical injury caused at least 50 percent of his anxiety and depression. View "Davenport v. WSI" on Justia Law

Defendant City of Burlington Retirement System appealed a superior court judgment that reversed its decision to terminate the disability retirement of plaintiff, a former City firefighter. Upon review, the Supreme Court concluded the record fully supported the superior court's conclusion that there was no reasonable basis for the Board's decision to terminate plaintiff's disability retirement. View "Preston v. Burlington City Reitrement System" on Justia Law

After receiving a work-related injury during his employment by Employer, Employee applied for worker's compensation benefits. An ALJ ordered that further medical procedures were required to determine whether Employee was permanently and totally disabled, but the Labor and Industry Review Commission (LIRC) proceeded to award benefits to Employee for his permanent total disability. Employer filed a complaint seeking judicial review of LIRC's decision. The circuit court affirmed. The court of appeals reversed, concluding that the circuit court was required to dismiss Employer's complaint for lack of competency based on Employer's failure to name its insurer (Insurer) as an "adverse party" pursuant to Wis. Stat. 102.23(1)(a). The Supreme Court reversed and remanded with instructions to affirm LIRC's decision, holding (1) the circuit court had competency to adjudicate Employer's complaint notwithstanding Employer's omission of Insurer because Insurer was not an "adverse party" for purposes of section 102.23(1)(a); and (2) LIRC did not exceed its authority in awarding Employee permanent total disability benefits, and its finding that Employee was entitled to benefits on an odd-lot basis was supported by credible and substantial evidence. View "Xcel Energy Servs., Inc. v. Labor & Ind. Review Comm'n " on Justia Law

Petitioner was traveling home from work in his personal vehicle when he sustained back injuries in a car accident. Petitioner applied for workers' compensation benefits, but his application was denied under the "going and coming rule," which deems injuries occurring during a work commute outside the course of employment and thus not compensable. Petitioner appealed, arguing that in light of the benefits his employer received through various work-related uses of his vehicle, he was "in the course of employment" during the accident. The labor commission and court of appeals rejected Petitioner's claim that he qualified under the "instrumentality" exception of the going and coming rule. The Supreme Court affirmed, holding that Petitioner fell within the rule and not the exception. View "Jex v. Utah Labor Comm'n" on Justia Law

States participating in Medicaid in a managed care environment are required to make, at least every fourth month, supplemental “wraparound” payments to federally-qualified health centers (FQHCs) equal to the difference between a rate set by statute multiplied by the number of Medicaid patient encounters, and the amount paid to FQHCs by managed care organizations (MCOs) for all Medicaid-covered patient encounters, 42 U.S.C.1396. Concerned that gaps in FQHC claim verification led to overpayments, the New Jersey Department of Human Services changed its calculation: instead of basing wraparound payments solely on the number of Medicaid encounters and total MCO receipts as self-reported by FQHCs, the state would rely on data reported by MCOs absent receipt of certain additional data from the FQHCs. Because MCOs report only encounters that they have approved and paid, prior MCO payment would be a prerequisite to wraparound reimbursement under the new system. An association of FQHCs sued, claiming that the change violated their due process rights as well as state and federal law, resulting in budget shortfalls. The district court granted the association summary judgment and a preliminary injunction. The Third Circuit affirmed the holding that the requirement that wraparound payments be contingent on prior MCO payment violated the Medicaid statute’s requirement that FQHCs receive timely full wraparound payment for all Medicaid-eligible claims. View "NJ Primary Care Assoc. v. NJ Dep't of Human Servs." on Justia Law