Justia Insurance Law Opinion Summaries

In 1990, Employee was working for Employer when she injured her left ankle. By 2009, Employee had multiple surgeries and was taking approximately fourteen medications. That same year, a Dr. Randolph concluded Employee required no further medical treatment for her 1990 industrial injury and other allowed conditions in her claim and that her current medications were no longer necessary. Employee subsequently filed a motion with the Industrial Commission for the loss of use of her left arm. Based on Dr. Randolph's addendum to his original report, a hearing officer denied Employee's motion for compensation for the loss of use of her arm. Employee filed a complaint for a writ of mandamus, which the court of appeals denied, concluding that Dr. Randolph's second and third reports, issued as addenda to his original report, constituted some evidence upon which the Commission could rely to support its decision denying Appellant's claim. The Supreme Court affirmed, holding that because the addenda of Dr. Randolph constituted some evidence to support the Commission's decision to deny Employee's request for compensation for the loss of use of her left arm, the Commission did not abuse its discretion, and the court of appeals properly denied the writ. View "State ex rel. Kish v. Kroger Co." on Justia Law

Michael Jassek appealed a district court judgment that affirmed the binding dispute resolution decision of Workforce Safety and Insurance ("WSI") that denied payment for a myoelectric prosthesis. Upon review of the matter, the Supreme Court concluded the district court did not have subject matter jurisdiction, and therefore vacated the judgment. Jassek contended that because WSI failed to explain its reasons for disregarding the medical evidence favorable to Jassek, its binding dispute resolution decision was arbitrary, and that WSI's binding dispute resolution procedure violated his right to due process because it failed to provide a formal hearing. The language of N.D.C.C. 65-02-20 unambiguously provides that "[a] dispute resolution decision under this section requested by a medical provider concerning . . . a request for . . . treatment is not reviewable by any court." The statute based appealability on the identity of the party who requests binding dispute resolution, not on who appeals the binding dispute resolution decision. Jassek’s orthotist was a "medical provider," and this dispute concernd "a request for diagnostic tests or treatment," specifically the determination of an appropriate prosthetic device. Accordingly, WSI's decision on the medical provider’s request for binding dispute resolution was not reviewable by the district court, the district court was without subject matter jurisdiction, and the judgment affirming WSI's decision was void. View "Jassek v. Workforce Safety and Insurance" on Justia Law

Employee was injured while working for Employer and was awarded permanent partial disability benefits. Employee subsequently petitioned to review-reopen his workers' compensation claim, seeking additional workers' compensation benefits, seeking reimbursement for additional postarbitration medical expenses, requesting a determination of the amount of workers' compensation benefits still owed by Employer and its insurer, and asking the court to decide whether the workers' compensation commissioner needed to enter an additional order compelling payment to enforce an arbitration award for the unpaid benefits. The district court (1) rejected Employee's petition for review as untimely; (2) affirmed denial of reimbursement for some of Employee's medical expenses; and (3) did not provide the requested calculation but ruled that a compel-payment order was unnecessary because Employee could seek a judgment to enforce the award. The Supreme Court (1) reversed as to the statute of limitations for a petition for review-reopening; and (2) affirmed as to the judgment regarding which medical expenses were causally connected to the work-related injury. Remanded to the district court for it to remand the matter to the commissioner with directions to decide the issues regarding the amount still owed to Employee by Employer and its insurer under the arbitration award. View "Coffey v. Mid Seven Transp. Co." on Justia Law

Employee, who was injured while working for Employer, sought enforcement of an arbitration award he received from the workers' compensation commissioner against Employer and Employer's insurer. Employee requested the district court to determine the amount Employer and its insurer (collectively, Appellees) owed him under the arbitration award in light of Employee's claim that Appellees failed to pay all of the medical benefits, mileage reimbursements, and interest due under the arbitration decision. Appellees claimed a credit against any amount they owed Employee due to his third-party settlements. After a hearing, the district court declined to answer the issues raised by the parties and declined to determine the amount still owed to Employee under the arbitration decision, concluding that addressing the issues in Employee's petition required the district court to exceed its authority. The Supreme Court reversed and remanded to the district court for the court to remand the matter to the commissioner with directions to decide the issues Employee raised in his petition for judgment. View "Coffey v. Mid Seven Transp. Co." on Justia Law

Claimant-appellant Stephen Arrants appealed a superior court order that affirmed an Industrial Accident Board's order granting employer-appellee Home Depot's petition to terminate appellant's total disability benefits. Appellant raised two claims on appeal: (1) the Board's decision was in error because all experts agreed that his condition had not improved since the 2007 Board finding of total disability; and (2) the Board's decision was not supported by competent evidence in the record. Upon review, the Supreme Court concluded that both arguments were without merit, and affirmed the superior court. View "Arrants v. Home Depot" on Justia Law

Employee suffered an accident arising out of the course of his employment on October 23, 2007. Employee filed a workers' compensation action on February 28, 2012 against Employer, seeking relief under an amended version of Neb. Rev. Stat. 48-121(3), alleging that he was entitled to benefits calculated on the basis of the loss of earning capacity pursuant to this amendment. The Legislature specified that the operative date of the amendment to the statute was January 1, 2008. The workers' compensation court granted summary judgment for Employer, concluding that the amendment was substantive rather than procedural and that because Employee's accident and injuries occurred prior to the operative date of the amendment, Employee could not recover for a loss of earning capacity under the amendment. The Supreme Court affirmed, holding that because the amendment to section 48-121(3) did not apply to Employee's action, he could not recover for an alleged loss of earning capacity on that basis. View "Smith v. Mark Chrisman Trucking, Inc." on Justia Law

Respondent, a firefighter, filed a claim for workers' compensation benefits after he was diagnosed with cancer within four years from the commencement of his employment with the City. Respondent asserted that his cancer was a compensable occupational disease that resulted from his work as a firefighter. The City denied the claim for benefits. A hearing officer with the Department of Administration Hearings Division affirmed the denial of the claim because Defendant had not been employed as a firefighter for five years pursuant to Nev. Rev. Stat. 617.453. An appeals officer reversed, holding that Defendant satisfied Nev. Rev. Stat. 617.440's requirements for proving a compensable occupational disease. The district court affirmed. The Supreme Court affirmed, holding (1) the district court did not err in upholding the appeals officer's determination that a firefighter such as Evans, who fails to qualify for section 617.453's rebuttable presumption can still seek workers' compensation benefits pursuant to section 617.440 by proving that his cancer is an occupational disease that arose out of his employment; and (2) the appeals officer correctly found Respondent's cancer was a compensable occupational disease. View "City of Las Vegas v. Evans" on Justia Law

Appellant was employed by Employer when he suffered a compensable work-related brain injury. Appellant, who was permanently and totally disabled, filed a workers' compensation claim seeking benefits and also requested benefits for the nursing care services his mother was providing. The workers' compensation commission (Commission) found Appellant's injury was compensable but denied the requested nursing service benefits. Appellant subsequently made a second request for additional benefits in the form of nursing services at Timber Ridge Ranch, an assisted living facility. The Commission denied Appellant benefits, finding that the services at Timber Ridge were not nursing services as defined by the law. The court of appeals affirmed. The Supreme Court reversed, holding that the Commission's findings and conclusions were not supported by substantial evidence and that the services provided at Timber Ridge qualified as nursing services under the applicable statutes. Remanded. View "Pack v. Little Rock Convention Ctr. & Visitors Bureau" on Justia Law

Appellant was injured during the course and scope of his employment. Appellant filed a motion for temporary total disability compensation, which a hearing officer granted. The Industrial Commission later terminated temporary total disability compensation based on the report of doctor who stated that the allowed conditions in Appellant's workers' compensation claim had reached maximum medical improvement. Appellant filed a complaint in mandamus, alleging that the Commission acted contrary to law when it relied on the report of the doctor. The court of appeals denied the writ, concluding that the doctor's report constituted some evidence upon which the Commission could rely. The Supreme Court affirmed, holding that the doctor's report was sufficiently reliable to constitute some evidence to support the Commission's decision. View "State ex rel. Coleman v. Schwartz" on Justia Law

Veteran filed a claim for workers' compensation benefits alleging that he sustained an injury during the course of his employment with Employer. Veteran received care and treatment for that injury at a United States Department of Veterans Affairs (VA) medical facility, which Employer did not authorize. The VA petitioned for a writ to compel the chief ALJ to allow the VA's intervention in the proceeding, claiming entitlement to intervene as a matter of right under 38 U.S.C. 1729 and the U.S. Constitution's supremacy clause. The circuit court denied the VA's petition. The Supreme Court reversed and issued a permanent writ of mandamus, holding that section 1729 and the supremacy clause gave the VA the right to intervene in Veteran's workers' compensation claim to assert its claim for recovery of health care provided to him. View "U.S. Dep't of Veterans Affairs v. Boresi" on Justia Law