Justia Insurance Law Opinion Summaries

Employee suffered an industrial injury and received surgery on his right shoulder, after which Employee returned to work for self-insured Employer. Employee experienced renewed shoulder complaints four years later and asked Employer to add new shoulder conditions to Employee's workers' compensation claim and authorize surgery to correct them. Employer and the Industrial Commission denied Employee's request after finding that the proposed procedure was unrelated to the conditions allowed in Employee's workers' compensation claim. At issue on appeal was a doctor's report upon which the Commission based its decision. The court of appeals granted a limited writ in mandamus that ordered the Commission to reconsider the application after finding inconsistencies within the report. The Supreme Court reversed, concluding that none of the alleged inconsistencies noted in the doctor's report affected the viability of the doctor's opinion that further surgery was not reasonably related to the allowed conditions, and therefore, the report was evidence supporting the Commission's decision.

This was an insurance coverage dispute between the County of Boise and its Insurer, Idaho Counties Risk Mangement Program (ICRMP). ICRMP refused to defend the County in Fair Housing Act (FHA) litigation in federal court, which the County claimed breached its insurance agreement. The district court determined the FHA claims against the County were excluded from the policy and granted summary judgment to ICRMP. Upon review, the Supreme Court concluded the district court properly granted summary judgment to ICRMP based on the land use exclusion in the Policy, and it therefore affirmed the district court's judgment.

In previous workers' compensation cases, the Montana Supreme Court had determined that its decisions apply retroactively to claims that are not "final" or "settled" at the time the decision was issued. Under statute, two types of claims fall under the definition of "settled," (1) claims where there has been a formal settlement agreement, and (2) claims that are "paid in full." In this case, the workers' compensation court (WCC) defined "paid in full" to mean that an injured worker received all the applicable benefits prior to a new judicial decision and had not received subsequent benefits on his or her pre-judicial decision claim. The Supreme Court affirmed, holding that the WCC properly applied retroactivity law in formulating its definition of "paid in full."

Petitioner Premium Research Services appealed a superior court's dismissal of its petition brought under the state Right-to-Know Law for disclosure of documents relating to disbursements from the second injury fund. Petitioner sought information so that it could know whether a carrier reported reimbursement to the National Council on Compensation Insurers. If reimbursements were reported, then the Council would reduce an employer's insurance premium. Petitioner sought to monitor the reimbursement process to ensure employers were not being overcharged for workers' compensation insurance. Petitioner filed its petition against the Department of Labor for disclosure of the documents. Upon review, the Supreme Court concluded that the documents sought were exempt from disclosure under the plain meaning of the RTK law. Accordingly, the Court affirmed the superior court's dismissal of Petitioner's petition.

Appellant Alexander Michau appealed a ruling by the Appellate Panel of the South Carolina Workers' Compensation Commission (Commission) denying his claim for repetitive trauma injuries to his shoulders. Specifically, Appellant challenged the Commission's interpretation and application of section 42-1-172 of the South Carolina Code. Prior to his injury in 2008, Appellant did not report any work-related problems with his arms to his employer, although he sought outside treatment. The Commission denied Appellant's claim on the grounds that "the greater weight of the medical evidence reflects [Appellant's] upper extremity and shoulder problems are related to pre-existing osteoarthritis and/or rheumatoid arthritis and not caused or aggravated by his employment with Georgetown County." Appellant disputed the admissibility of the Commission's expert doctor's report under South Carolina Code section 42-1-172 because it was not stated "to a reasonable degree of medical certainty." Appellant argued that without this evidence, the remaining competent evidence would support his claim of sustaining a compensable repetitive trauma injury. The Supreme Court concluded after a review of the Commission's record that the doctor was not Appellant's treating doctor, and his employer sought a medical "opinion" to decide the compensability of Appellant's claim. In this instance, the Court concluded that the doctor's testimony was indeed an "opinion" within the meaning of the Code, and therefore inadmissible against Appellant in adjudicating his claim. The Court reversed the Commission's decision to admit the doctor's medical opinion and remanded the case to determine whether the remaining competent evidence supported Appellant's claim of injury.

Appellant Indiana Spine Group provided medical services to employees of various businesses for injuries the employees sustained arising out of and during the course of their employment. The employers authorized the services and made partial payments. In each case, more than two years after the last payments were made to the injured employee, Appellant filed with the worker's compensation board an application for adjustment of claim seeking the balance of payments. The Board dismissed the applications as untimely. In each case the court of appeals reversed and remanded. At issue on appeal was what limitation period was applicable to a medical provider's claim seeking payment of outstanding bills for authorized treatment to an employer's employee when the Worker's Compensation Act was silent on the question. The Supreme Court reversed the Board, holding (1) the limitation period contained in the general statute of limitation enumerated in Ind. Code 34-11-1-2 controlled; and (2) because Appellant's claim was timely under the statute, the Board erred by dismissing Appellant's application.

Plaintiff-Appellant Eugene S. appealed a district court's denial of his motion to strike and its entry of summary judgment in favor of Defendant-Appellee Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). Plaintiff sought coverage for his son A.S.'s residential treatment costs from his employer's ERISA benefits insurer. Horizon's delegated plan administrator originally denied the claim. Having exhausted his administrative appeals, Plaintiff filed suit in district court challenging the denial of benefits. The parties filed cross-motions for summary judgment, but Horizon also filed a declaration that included the terms of Horizon's delegation of authority to the plan administrator to administer mental health claims in a Vendor Services Agreement. Plaintiff moved to strike that declaration as procedurally barred. The district court denied the motion and granted Horizon summary judgment, finding that neither Horizon nor its plan administrator acted in an arbitrary or capricious manner in denying the contested claim. Upon review, the Tenth Circuit found substantial evidence in the record that A.S. did not meet the criteria for residential treatment benefits under the plan, and as such, the plan administrator did not act in an arbitrary or capricious manner in denying Plaintiff's claim. The Court affirmed the district court's judgment.

Appellant Steven DeLoge, an inmate in the state penitentiary, was working in the kitchen when he was injured in an altercation with another inmate. Appellant filed a workers' compensation claim based on the injuries sustained from a head-butt from the other inmate. The Wyoming Workers' Safety and Compensation Division (Division) denied the claim. The Office of Administrative Hearings (OAH) concluded that Appellant's injuries were the result of illegal activity and were therefore not compensable under the Wyoming Worker's Compensation Act. The district court affirmed. The Supreme Court affirmed, holding that because the head-butt was a battery under the criminal statute then existing, and therefore an illegal activity, Appellant was not eligible for workers' compensation benefits.

The City of Scottsbluff implemented changes to police officers' health insurance coverage and related benefits without bargaining with the Scottsbluff Police Officers Association (the Union). The Union filed a petition with the Nebraska Commission of Industrial Relations (CIR), alleging that the City violated Nebraska's Industrial Relations Act (IRA) by unilaterally implementing changes in the health insurance hazardous activities exclusion and by unilaterally changing the group health care benefits. The CIR (1) determined that the City violated the IRA, ordered the City to return the parties to the status quo ante, and ordered the parties to commence good faith negotiations within thirty days; and (2) determined that the Union had not violated the IRA in refusing to execute a previously ratified agreement. The Supreme Court affirmed in part and reversed in part, holding (1) the portion of the CIR's order requiring the parties to commence good faith negotiations on the health insurance issues was affirmed; and (2) the Union's refusal to execute the previously ratified agreement constituted a prohibited practice under the IRA. Remanded to determine what remedies were available to the City for the Union's violation.

Petitioner Carolyn Holmes began working for linen company Respondent National Service Industries (National). According to Petitioner, the work environment at the facility was "very hot" and "sticky" with "a lot of lint and dust in the air," and was poorly ventilated. Petitioner was exposed to the fumes of bleach and did not wear a protective mask. In 1992, she began experiencing breathing and sinus problems. Petitioner never experienced breathing or sinus problems prior to working for National. In 1995, Petitioner was diagnosed with sarcoidosis, a respiratory and pulmonary condition. Petitioner testified that her doctor did not know what caused her sarcoidosis and that, in light of this statement, she took no further steps to determine the cause of her condition. In July 2005, Petitioner got a second opinion. Petitioner's second doctor stated in his report that it was unclear whether Petitioner's work exposure at National caused her sarcoidosis, but that it was more likely that her exposure to the airborne particles and fumes worsened her condition, which had previously developed. Based on this, Petitioner filed a workers' compensation claim alleging a compensable injury by accident to her lungs and respiratory system arising out of and in the scope of her employment with National on July 12, 2005, the date she alleges she first discovered her sarcoidosis was related to her employment. A single commissioner found Petitioner sustained a compensable injury. The full commission reversed the commissioner, finding petitioner's claim was barred by a two-year statute of limitations. Specifically, the full commission found petitioner was aware of her working conditions and, with some diligence on her part, could have discovered she had a claim more than two years before her filing date. Petitioner appealed. The circuit court and Court of Appeals affirmed the full commission's determination that petitioner failed to file her claim within the statute of limitations. Upon review, the Supreme Court found that the trial and appellate courts correctly found substantial evidence in the record to support the full commission's findings that Petitioner's claim was barred by the statute of limitations. Accordingly, the Court affirmed the appellate courts' decisions.