Justia Insurance Law Opinion Summaries

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

Appellant Matthew Mazzone appealed an Idaho Industrial Commission's order that denied him workers' compensation for psychological injuries allegedly arising as a result of an industrial accident wherein appellant tripped and fell into a deep fat fryer while employed at Texas Roadhouse. Appellant contended the Commission’s order was not based on substantial and competent evidence. During his time at a Burn Center, appellant was twice noted in medical records to be exhibiting exaggerated pain behaviors. At one point during his treatment, appellant stayed at a hotel in Salt Lake City so as to receive follow-up care. In a follow-up at the Burn Center, appellant had quit "cold turkey" his opioid medication, at which point he began to experience nightmares and flashbacks. Appellant was referred to an Idaho psychiatrist. The Idaho psychiatrist clarified that appellant's nightmares and anxiety were related to returning to work; appellant was assessed a GAF score of 55/85, the same assessment he had before the industrial accident. Three months after accident, appellant returned to work, but he was allegedly so overwhelmed that he asked to transfer to another Texas Roadhouse location in Massachusetts because he was nervous, sick, worried, and nauseous working at the site of the accident. Subsequent years following the accident, appellant sought additional counseling and medical treatment. He was eventually diagnosed with post-traumatic stress disorder (PTSD) and general anxiety and memory loss. Appellant then filed a complaint against Texas Roadhouse and its insurer. Upon review, the Supreme Court concluded that appellant did not suffer a compensable psychological injury, and that the evidence presented was substantial enough to support the Industrial Commission's order. View "Mazzone v. Texas Roadhouse" on Justia Law

Employee sustained injuries in the course of his employment with Four Star Transportation. Despite being hired by Four Star, Employee was initially considered an employee of Better Integrated Services. Better Integrated leased Employee to Beacon Enterprises, which then leased Employee to Four Star. Beacon had an insurance policy with Kentucky Employers' Mutual Insurance (KEMI). An ALJ determined (1) Employee's injury entitled him to benefits and a permanent partial disability award, and (2) KEMI's policy covered Employee's injury. The Workers' Compensation Board reversed, finding Employee was not covered under the KEMI policy due to the fact he was unaware that Four Star was leasing him from different entities, including Beacon. The court of appeals affirmed. The Uninsured Employers' Fund appealed. The Supreme Court affirmed, holding (1) Employee could not be considered Beacon's employee because he did not enter into a contract for hire with Beacon; (2) the Board did not act arbitrarily in finding that the ALJ's opinion was not supported by substantial evidence; and (3) the Board and lower court's decision was not based on Better Integrated and Beacon's failure to comply with Ky. Rev. Stat. 342.615. View "Ky. Uninsured Employers' Fund v. Hoskins" on Justia Law

Employee filed a claim for workers' compensation, alleging that he sustained injuries while working for Restaurant. Employee gained employment with Restaurant through a staff leasing company (Company). Employee agreed to a settlement of his claim. Later, Employee moved to re-open the workers' compensation award and to join the Uninsured Employers' Fund (UEF) as a party, asserting that Restaurant and Company were no longer available to pay for his continuing medical expenses. The ALJ subsequently joined the UEF. The ALJ found Employee's condition to have worsened so he was totally disabled and that the UEF was responsible for all benefits for which Employee was entitled. The Workers' Compensation Board vacated the portion of the ALJ's opinion regarding the amount of benefits Employee would receive and otherwise affirmed. The Supreme Court affirmed, holding (1) Employee's claim was properly reopened and the UEF joined as a party; (2) Employee presented sufficient evidence to show that his condition had worsened since the entry of his original workers' compensation award; and (3) although the original settlement agreement only listed Employee's lower back injury as compensable, Employee was not barred from raising a claim for his thoracic spine injury upon reopening. View "Commonwealth v. Allen" on Justia Law

Booker T. Washington, Jr. filed a claim against Porocel Corporation with the Workers' Compensation Commission, alleging exposure to asbestos and silica dust resulting in lung disease and silicosis. An ALJ found Washington's claim was barred by the statute of limitations. Washington subsequently filed suit against Porocel, alleging, inter alia, negligence and breach of implied warranty. Porocel moved to dismiss the complaint, contending that the Commission had exclusive jurisdiction of the claims alleged and that the Arkansas Workers Compensation Act (Act) was Washington's exclusive remedy. The circuit court denied Porocel's motion to dismiss, concluding that Washington's occupational disease was not one for which the Act provided coverage. Porocel then filed a petition for a writ of prohibition to prevent the circuit court from exercising jurisdiction over Washington's complaint. The Supreme Court granted the petition, holding that Washington's claim was covered by the Act. View "Porocel Corp. v. Circuit Court" on Justia Law

"At its most basic level, this case presents a policy dispute: whose policy choice concerning health insurance premiums for State employees controls—the General Assembly's or the Budget and Control Board's?" The issue before the Supreme Court centered on "maintaining and enforcing the constitutional and statutory framework through which such issues must be resolved. " Upon review of the arguments of the parties and the applicable case law, the Supreme Court found that the General Assembly had and exercised the power to determine the contribution rates of enrollees for the State's health insurance plan in 2013. The Court held that the Budget and Control Board violated the separation of powers provision by substituting its own policy for that of the General Assembly, entered judgment for the petitioners, and directed the Board to use the appropriated funds for premium increases and return the premium increases previously collected from enrollees. View "Hampton v. Haley" on Justia Law

Appellant, a medical doctor, challenged the partial denial of personal injury protection benefits after treating a patient insured by Appellee. While Appellant's request for an administrative hearing was pending in the Insurance Division of the State Department of Commerce and Consumer Affairs, the patient's available benefits under her policy were exhausted on account of payments to Appellant and other medical providers. Because of the exhaustion, the Insurance Division dismissed Appellant's claim. The circuit court and intermediate court of appeals (ICA) affirmed. The circuit court also denied Appellant's request for attorney's fees and costs under Haw. Rev. Stat. 431:10C-211(a), which allows fees and costs to be awarded even when a party does not prevail on its claim for benefits, finding Appellant's pursuit of the benefits to be unreasonable. The ICA affirmed. Appellant appealed the denial of attorney's fees. The Supreme Court vacated the ICA's judgment and the circuit court's final judgment, holding that the circuit court and ICA erred in concluding that Appellant's claim was unreasonable due to exhaustion of benefits where Plaintiff had made his claim prior to that exhaustion. Remanded. View "Jou v. Schmidt" on Justia Law

The issue before the Supreme Court in this case concerned the scope of Clackamas County's contractual obligation to provide health insurance benefits to command officer retirees of the County Sheriff's Office. A contract between the county and command officers, including Plaintiff Neil James, required the county to use a particular fund to pay for a certain level of benefits to command officers after they retired. The contract added that the obligation to pay benefits was "contingent upon the availability of sufficient funding in said fund to pay for the same." After plaintiff retired, the cost of insurance premiums increased to the point where the fund was and would for the foreseeable future continue to be insufficient to pay for the benefits required. The county entered into a new contract with certain union employees to provide lesser benefits from a more stable fund, and plaintiff (a retired officer, not a union employee) also was provided those lesser benefits. Plaintiff brought an action against the county, asserting breach of contract. He maintained that the first contract required the county to pay him full health insurance benefits and argued that the contingency provision did not apply because of the creation of the new fund, which had sufficient money to pay for those benefits. The trial court entered judgment in favor of plaintiff, but the Court of Appeals reversed. Upon review, the Supreme Court concluded that the new fund was the product of a contract that was separate and independent from the earlier contract. Because the prior fund was insufficient to provide the agreed level of benefits, the county did not breach its contractual obligation to provide that level of benefits. Accordingly, the Court affirmed the appellate court's decision. View "James v. Clackamas County" on Justia Law

In 2002, Employee suffered injuries in a work-related accident and was rendered a paraplegic. Employer and its insurer accepted liability for Employee's injuries and paid various workers' compensation benefits. In 2010, Employee filed a medical request seeing payment for the installation of a ceiling-mounted motorized lift system. A compensation judge (1) determined that the cost of making the structural changes was compensable under Minn. Stat. 176.135 because those changes were necessary to provide Employee with reasonable and necessary medical treatment, and (2) ordered Employer and its insurer to pay for the modifications in their entirety. The workers' compensation court of appeals reversed, concluding that the changes to Employee's home necessary to permit installation of the lift system constituted "alteration or remodeling" of Employee's home and that Employer's liability was therefore limited by Minn. Stat. 176.137. The Supreme Court affirmed, holding that the cost of the structural modifications to Employee's residence that were necessary to permit the ceiling-mounted track system to be installed were "alteration or remodeling" costs subject to section 176.137 and were not costs of medical treatment. View "Washek v. New Dimensions Home Health & State Fund Mut. Ins. Co. " on Justia Law