Justia Insurance Law Opinion Summaries

Claimant Gary Brown filed a complaint with the Industrial Commission seeking disability benefits after he injured his back while working for The Home Depot. Arguing that the injuries caused by the accident in combination with his preexisting conditions, left him permanently and totally disabled, Claimant sought workers' compensation benefits from both Home Depot and the Idaho Industrial Special Indemnity Fund (ISIF). The Commission determined that Claimant was not permanently and totally disabled. Claimant contended on appeal that the Commission erred by evaluating his ability to find work based upon his access to the local labor market at the time his medical condition stabilized in 2005. He argued that his labor market access should have been evaluated as of the date of the Commission hearing in 2009. He also argued that the Commission based its finding that he was 95 percent disabled on an incorrect understanding of the expert testimony presented at the hearing. Upon review, the Supreme Court held that Claimant's labor market at the time of the disability hearing was the proper labor market to be used in evaluating his disability. But because the Commission applied an incorrect legal standard, the Court vacated the Commission's decision and remanded the case for further proceedings.

Appellant Lincoln McNulty worked as a ski patroller for Sinclair Services Company as a member of the Sun Valley Resort from 2005 to 2010. Once the ski season ended in 2009, Appellant filed for unemployment benefits effective April 2009, through November 2009. During those off-season months, he began working part-time at the Sawtooth Club for extra income. However, Appellant failed to report such employment or any earnings from the Sawtooth Club to the Idaho Department of Labor when he filed for unemployment benefits each week. The Idaho Department of Labor discovered the discrepancy and a claims investigator spoke with Appellant and ultimately issued an Eligibility Determination that Appellant was ineligible for benefits because he willfully made false statements or failed to report material facts in order to obtain benefits. Appellant appealed to the Supreme Court, arguing that his failure to report was not willful, the facts were not material, and that he should be eligible for a waiver of the requirement to repay the unemployment benefits. Upon review, the Court affirmed the Industrial Commission's conclusion that Appellant willfully failed to disclose material facts in order to obtain unemployment benefits and that he must repay the overpayment of both state and federal benefits as well as any applicable interest and penalties.

On June 28, 2010, Appellant Maria Gomez filed a Worker’s Compensation Complaint with the Industrial Commission (Commission) claiming benefits for an accident that occurred in 2009, when she injured her lower back lifting sixty-pound boxes. The injury occurred at Blackfoot Brass (Dura Mark). Appellant had previously suffered two work-related accidents while working with Dura Mark, one in 2002, the other in 2006, but had returned to work without restrictions after participating in physical therapy for both injuries. The issue before the Supreme Court centered on a Commission order denying reconsideration of Appellant's motion to reopen the record to allow for additional evidence on the issue of causation. The Industrial Commission previously ordered that Appellant had failed to prove the medical treatment she received for a back injury was related to an industrial accident and injury. At the emergency hearing pursuant to the Judicial Rules of Practice and Procedure adopted by the Commission, Appellant introduced evidence regarding her entitlement to reasonable and necessary medical care pursuant to I.C. 72-432, but the referee denied Appellant's claim on the grounds of causation. Upon review, the Supreme Court affirmed the Commission's judgment. In doing so, the Court wanted to provide a "clear message that without a specific stipulation that causation will be a contested issue at the hearing pursuant to I.C. 72-713, and especially if there is a difference of opinion as to causation by opposing parties and their experts, claimant’s attorneys should no longer be lulled by anything other than a stipulation to all legal prerequisites and elements for recovery and be prepared to present evidence of a causal connection between the industrial injury or sickness and the required treatment."

The Department of Public Welfare (DPW) and the Office of the Budget of the Commonwealth of Pennsylvania appealed a Commonwealth Court order which granted summary judgment to Appellees the Pennsylvania Medical Society and its individual members, and the Hospital and Healthsystem Association of Pennsylvania and its individual members. The court declared that the Commonwealth had an obligation under the Health Care Provider Retention Law (the Abatement Law) to transfer monies to the Medical Care Availability and Reduction of Error Fund (MCARE Fund) in an amount necessary to fund dollar for dollar, all abatements of annual assessments granted to health care providers for the years 2003-2007. Upon review of the Commonwealth Court record, the Supreme Court held that the Abatement Law gave the Secretary of the Budget the discretion, but not the obligation, to transfer monies into the MCARE Fund in an amount up to the total amount of abatements granted. Furthermore, the Court concluded that Apellees had no statutory entitlement to the funds held in abatement, nor a vested right to them.

Anthem Health Plans of Maine appealed from a judgment entered in the Business and Consumer Docket affirming a decision by the Superintendent of Insurance (1) determining that Anthem's proposed rate increase for its individual health insurance products was excessive and unfairly discriminatory, and (2) indicating that an average rate increase with a lower profit margin for those products would be approved. Anthem appealed, contending that the Superintendent's decision violated Me. Rev. Stat. Ann. 24-A, 2736 (the statute) and the state and federal Constitutions because the approved rate increase eliminated Anthem's opportunity to earn a reasonable profit on its line of individual health insurance products. The Supreme Court affirmed, holding (1) the Superintendent properly balanced the competing interests within the statutory framework of the statute in arriving at its approved rate increase; and (2) because the approved rate provided a built-in risk and profit margin, Anthem's argument that the Superintendent improperly cross-subsidized between Anthem's regulated and unregulated product lines, and the corollary argument that the approved rate resulted in an unconstitutional confiscatory taking, necessarily failed as a matter of law.

In 2005, pursuant to the Black Lung Benefits Act's administrative provisions, an Administrative Law Judge (ALJ) awarded lifetime benefits to Merrill Lambright and survivor benefits to his widow, Delores Ashmore. Lambright's claims arose out of his employment with Petitioner Bridger Coal Company. In 2006, a three-member panel of the U.S. Department of Labor Benefits Review Board vacated the ALJ's decision and remanded to the ALJ for reconsideration. In 2008, the ALJ denied benefits on both the lifetime and survivor claims. In 2009, a three-member panel of the Board reversed this decision and reinstated the 2005 award of benefits. The issue on appeal was the characterization of Ms. Ashmore's 2002 request for a modification in her survivor benefits: "it appears the director interpreted Ashmore's motion as a motion for modification based on change in conditions, but only to the extent Ashmore alleged she was entitled to additional (survivor) benefits due to Lambright's death. To the extent the order granting modification was based on a change in conditions, the ruling only implicated the claim for survivor benefits, not Lambright's original claim for lifetime benefits." On reconsideration en banc, the full five-member Board was unable to reach a disposition in which at least three permanent members concurred. As a result, the 2009 panel decision stood. Petitioner appealed, challenging the scope of the 2009 panel's authority to review the 2008 ALJ decision, the standard used in determining whether to award benefits, and the onset-date determination. Upon review, the Tenth Circuit affirmed the 2009 panel decision.

In this appeal the Supreme Court was asked to determine whether the parties' indemnity agreement clearly and unequivocally indemnified the Snohomish County Public Transportation Benefit Area Corporation (doing business as Community Transit) for losses resulting from its own negligence. Upon review, the Court concluded that the language of the agreement, and in particular language providing that indemnity would not be triggered if losses resulted from the sole negligence of Community Transit, clearly and unequivocally evidenced the parties' intent that the indemnitor, FirstGroup America, Inc. (doing business as First Transit) indemnify Community Transit for losses that resulted from Community Transit's own negligence. The Court reversed the Court of Appeals' decision to the contrary and remanded the case to the trial court for further proceedings.

The issue on appeal to the Supreme Court was whether the circuit court erred in granting summary judgment for the Mississippi Insurance Guaranty Association (MIGA), and in denying a cross-motion for summary judgment for nursing homes and nursing-home residents. The circuit court found that MIGA was entitled to a credit, which would reduce the amount MIGA must pay to indemnify nursing-home owners and operators for damage claims of two nursing-home residents that were allegedly caused by a series of negligent acts and omissions over the course of many years. Upon review, the Court found "the factual and legal predicates necessary to formulate an opinion on coverage issues are lacking, which would preclude any court from rendering a valid ruling on coverage." The Court reversed the circuit court's judgment that granted MIGA's motion for summary judgment and that denied the cross-motions for summary judgment.

In July 2006, Respondent Paul Cook's workers' compensation claim was dismissed for failure to file a properly completed prehearing statement. In December 2006, his "Motion for an Order Re-Instating Claim" was denied for failing to "attach a properly completed prehearing statement . . . ." In August 2008, Respondent's "Amended Motion to Reinstate" was dismissed as barred under a one-year statute of limitations. The full Commission affirmed the dismissal, as did the circuit court and a unanimous Mississippi Court of Appeals. The Supreme Court granted Respondent's petition for certiorari and affirmed: "Cook's claim was properly dismissed. To hold otherwise would eviscerate the Commission's rules and rulings of their statutorily intended effect, since '[a] rule which is not enforced is no rule at all.'"

ESBC, billing agent for the Fire Department, determined that each of the individual defendants owned a vehicle involved in a collision to which the Fire Department responded and each had insurance coverage, and billed response costs incurred for each collision. The defendants refused to pay and ESBC sought a declaration that defendants were liable under the Comprehensive Environmental Response, Compensation, and Liability Act, 42 U.S.C. 9601. Under CERCLA, the owner of a “facility” from which hazardous substances have been released is responsible for response costs that result from the release. Insurer-defendants counterclaimed for injunctive relief from ESBC’s billing practices and alleging violation of the Fair Debt Collection Practices Act, 15 U.S.C. 1692, unjust enrichment, unlawful fee collection, fraud, constructive fraud, and insurance fraud. The district court granted defendants judgment on the pleadings and dismissed counterclaims without prejudice. The Seventh Circuit affirmed. Motor vehicles for personal use fall under the "consumer product in consumer use” exception to CERCLA’s definition of facility