Justia Insurance Law Opinion Summaries

ANI, a risk retention group, filed suit seeking declaratory and injunctive relief against the Commissioner and the Division of Insurance under 42 U.S.C. 1983. ANI claimed that an order of the Commissioner violated the Liability Risk Retention Act (LRRA), 15 U.S.C. 3902(a)(1). The court held that the Commissioner's Order, which barred ANI from writing first dollar liability insurance policies in Nevada, was preempted by the LRRA. Therefore, the court affirmed the district court's entry of declaratory and injunctive relief in favor of ANI. However, the LRRA did not confer a right to be free from state law that could be enforced under 42 U.S.C. 1983, making fees under 42 U.S.C. 1988 unavailable. Thus, the court vacated the fee award. Finally, the court remanded so that the district court could enter a new summary judgment order consistent with this opinion. View "Alliance of Nonprofits for Ins. v. Kipper, et al" on Justia Law

An employee filed an affidavit of readiness for hearing in her workers' compensation case approximately four years after her employer filed a controversion of her written workers' compensation claim. The employer petitioned to dismiss her claim based on the statutory deadline for a hearing request. After a hearing, the Alaska Workers' Compensation Board dismissed her claim, and the Alaska Workers' Compensation Appeals Commission affirmed the Board's decision. Because the employee did not file a timely request for a hearing and was not excused from doing so, the Supreme Court affirmed the Commission's decision. View "Pruitt v. Providence Extended Care" on Justia Law

Claimant Dorothy Robinson was a police officer for the City of Pittsburgh. In 1997, she sustained a work-related injury, and the City placed her on light-duty. In 2001, while traveling for treatment of her injury, Claimant was involved in an automobile accident in which she sustained new injuries. After the accident, Claimant did not return to her light-duty position nor was she offered any other light-duty work. In late 2004, Claimant received a disability pension. In connection with Claimant’s claim of entitlement to a disability pension, she was examined by three physicians who certified that Claimant was unable to perform her pre-injury job as a police officer. Nearly three years later, an independent medical examiner concluded that although Claimant was not fit to perform her prior job as a police officer, she could perform modified-duty work. The City filed a Petition to Suspend Compensation Benefits, asserting that Claimant was capable of working, "but has voluntarily removed herself from the work force as she has not looked for or sought employment in the general labor market." Claimant filed a response, denying the averments of the suspension petition and asserting that she remained attached to the workforce and had registered for work with the Pennsylvania Job Center. She further claimed that she was not presently working only because of the unavailability of work and because the City had eliminated her light-duty position. The Workers' Compensation Judge denied the suspension petition, concluding that Claimant had not voluntarily removed herself from the workforce. The issue before the Supreme Court in this appeal concerned the assignment of the burden of proof when the employer sought to modify or suspend a claimant's benefits on the basis that the claimant had retired. The Commonwealth Court plurality devised a "totality of the circumstances" test and concluded that the City failed to show that the injured worker had voluntarily withdrawn from the workforce. The City appealed, but the Supreme Court concurred with the Commonwealth Court and affirmed. View "City of Pittsburgh v. WCAB (Robinson)" on Justia Law

A hotel worker fell and injured her back while cleaning a room. Her employer initially paid benefits, but it filed a controversion of benefits after its doctor doubted the accident’s occurrence and said any work injury was not the substantial cause of the worker’s continuing need for medical care. The Alaska Workers’ Compensation Board decided that the fall was the substantial cause of the worker’s disability, finding the worker’s testimony about the injury credible and the employer’s doctor’s testimony not credible. Based on the testimony of the worker and her treating physician, as well as an MRI showing a herniated disc, the Board decided that the injury was compensable. The Alaska Workers’ Compensation Appeals Commission reversed the Board’s decision because, in the its view, substantial evidence did not support the decision. Because the Commission incorrectly decided the substantial evidence question, the Supreme Court reversed the Commission’s decision. View "Sosa de Rosario v. Chenega Lodging" on Justia Law

Appellant was injured during the course of his employment with Employer. Appellant obtained a workers' compensation award that covered future medical treatment. Appellant subsequently underwent knee replacement surgery and sought a further award of benefits. The Workers' Compensation Court (WCC) denied the petition, finding that Appellant's knee replacement surgery was not established to be the product of the subject accident but, rather, was prompted by Appellant's preexisting degenerative knee condition. The Supreme Court affirmed, holding (1) the evidence provided sufficient competent evidence to support a finding that Appellant's knee replacement surgery was not the result of the work-related accident, and therefore, the WCC did not err in finding that Appellant's surgery was not compensable; and (2) in so holding, the WCC was not acting contrary to the original award but was enforcing the award's plain language. View "Pearson v. Archer-Daniels-Midland Milling Co." on Justia Law

The issue before the Supreme Court in this case was one of first impression: whether the Louisiana Workers’ Compensation Law (specifically La. R.S. 23:1036) as the exclusive remedy for a volunteer firefighter in claims for personal injury against the "fire company," similarly applies to claims for personal injury against fellow volunteer members. After reviewing the record and the law, the Court found the defendant failed to establish that the Workers’ Compensation Law granted immunity to fellow volunteer members of a volunteer fire company from suits in tort. Accordingly, the Court affirmed the decisions of the lower courts in denying the defendants’ motion for summary judgment. View "Champagne v. American Alternative Ins. Corp." on Justia Law

KCC, Inc., d/b/a Vital Care of Meridian (Vital Care) filed a complaint against the Mississippi State and School Employees' Life and Health Plan ("the Plan") and the Plan’s pharmacy benefits manager, Catalyst Rx, alleging that the Plan and Catalyst had violated Mississippi Code Section 83-9-6 by designating Walgreens Pharmacy as the sole provider of specialty pharmacy services. Later, Vital Care moved for partial summary judgment on the question of whether Section 83-9-6 applied to the Plan. The Chancery Court granted Vital Care’s motion for partial summary judgment, and the Plan and Catalyst appealed. Upon review of the applicable statute, the Supreme Court found that Section 83-9-6 applied to the Plan because it applies to "all health benefit plans providing pharmaceutical services benefits, including prescription drugs, to any resident of Mississippi" and was not ambiguous. View "Mississippi State & School Employees' Life and Health Plan v. KCC, Inc." on Justia Law

K&D Enterprises, through its manager, Mid-America, contracted to purchase an apartment complex. Prior to the closing, K&D Enterprises created a new company, Euclid-Richmond Gardens, and assigned its rights under the purchase agreement to that new company. Euclid-Richmond Gardens hired K&D Group, Inc., a property-management company, to manage the apartment. K&D Group hired former employees of Mid-America and assumed the operations of the complex. The Bureau of Workers' Compensation later conducted an audit and determined K&D Group was the successor in interest to the business operations of Mid-America, a determination that authorized the Bureau to base K&D Group's experience rating, in part, on Mid-America's past experience, which included a large workers' compensation claim. After K&D Group's administrative appeal was denied, K&D Group unsuccessfully filed a mandamus action in the court of appeals. The Supreme Court reversed the judgment of the court of appeals and issued the writ of mandamus, holding that K&D Group was not a successor in interest for purposes of workers' compensation law, and thus, the Bureau abused its discretion when it transferred part of Mid-America's experience rating to K&D Group. View "State ex rel. K&D Group, Inc. v. Buehrer" on Justia Law

Petitioner Michael Crisp, Jr. worked for Employer SouthCo, Inc., seeding grass and performing odd construction jobs. In 2004, Petitioner and other workers were installing silt fencing to combat ground erosion. Petitioner held a pole while another worker operated the Bobcat. As Petitioner bent down to reach for a pole, the bucket of the Bobcat fell on Petitioner, covering him. Petitioner suffered injuries to his head and hands. At the emergency room, Petitioner was treated for abrasions and bruises to the back of the head and neck and a complex fracture in his right hand. There was no mention of a brain injury in Petitioner's hospital records. Nearly two years after his injury, Petitioner's doctor opined that Petitioner sustained physical brain injury as a result of his 2004 injury. Petitioner's eventual workers' compensation claim for the brain injury was denied, and he petitioned the Supreme Court for review of an appellate court's decision to reverse a circuit court's finding that he sustained a compensable brain injury. Upon review, the Supreme Court reversed the appellate court and remanded the case for further consideration of whether Petitioner sustained physical brain damage as contemplated under the Workers' Compensation Act which would entitle him to benefits for life. View "Crisp v. SouthCo." on Justia Law

Palmetto Hardwood, Inc. employed Petitioner Clifton Sparks as a saw operator. Petitioner suffered three work-related injuries during this employment, the first two of which injured Petitioner's lower back. In the third incident, Petitioner was required to remove a piece of metal from under a gang saw. In the process, the metal exploded and a three- to four-inch cubic piece struck him in the head. Petitioner subsequently sought workers' compensation for his injuries. Six doctors opined regarding whether Petitioner had suffered a physical brain injury. The Commission found that Petitioner had sustained a compensable injury to his head. It also found him to be totally and permanently disabled. The Commission ruled that Petitioner should receive only five hundred weeks of compensation as a result of his total and permanent disability and medical expenses causally related to the three compensable injuries. On appeal, the circuit court remanded to the Commission for it: (1) to explain whether the "physical brain injury" it found "border[ed] on the frivolous" was intended to be the same as or different from "physical brain damage" as used in section 42-9-10 (C); and (2) to reconcile the order's seemingly contradictory findings that Petitioner suffered a compensable injury to the head with its finding of no physical brain injury. On appeal, the circuit court affirmed the Commission's order. Petitioner subsequently appealed to the Court of Appeals, which affirmed in an unpublished opinion. On appeal to the Supreme Court, Petitioner argued that the Court of Appeals erred when it applied an improper definition of "physical brain damage" within the meaning of section 42-9-10(C). The Supreme Court disagreed and affirmed the circuit court. View "Sparks v. Palmetto Hardwood" on Justia Law