Justia Insurance Law Opinion Summaries

Franklin Electric formed two new subsidiaries and started new unemployment experience accounts with a low introductory contribution rate for each one, which equaled about half the experience rating of Franklin Electric. The Department of Workforce Development later canceled the subsidiaries' experience accounts, and all experience balances and liabilities reverted to Franklin Electric. The Department also demanded back payments, interest, and a ten percent penalty. A liability administrative law judge (LALJ) affirmed the Department's determination that the three entities were a single employer but waived the penalty imposed by the Department. The court of appeals affirmed. The Supreme Court granted transfer and vacated the opinion of the court of appeals and affirmed the determination of the LALJ, holding (1) the new subsidiaries were not new employers because they were not distinct and segregable from Franklin Electric; (2) Franklin Electric's experience rating should have applied to contributions made by the subsidiaries; and (3) because there was no evidence suggesting improper conduct on the part of Franklin Electric, the penalty was not appropriate.

Appellant Thomas Pearson was struck by a forklift and was later determined to have been injured in the course of his employment with Archer-Daniels-Midland Milling Company (ADM). The workers' compensation court entered an award granting Pearson, among other benefits, certain future medical expenses. Pearson subsequently had a total knee replacement and sought reimbursement from ADM for those expenses as well as for expenses relating to a back injury. After ADM declined to pay the expenses, Pearson filed a motion to compel payment. A further award was entered (1) denying Pearson's motion with respect to the knee replacement but ordering ADM to pay expenses relating to the treatment of the back injury, and (2) applying the workers' compensation court's fee schedule to payments for the back injury, which had previously been paid by Pearson's health insurer. The workers' compensation court review panel affirmed. The Supreme Court affirmed in part and reversed in part, holding (1) the trial court incorrectly found that the original order denied knee replacement, and (2) the trial court did not err in applying the fee schedule to any reimbursement to a third party. Remanded.

An elderly woman requiring long-term medical care gave $120,000 to her son in February 2007. The mother believed that the gift would not prevent her from receiving Medicaid coverage if she lived long enough to exhaust her remaining assets. She relied on a provision in Alaska's Medicaid eligibility manual that suggested prospective Medicaid beneficiaries could give away a portion of their assets while retaining sufficient assets to pay for their medical care during the period of ineligibility that Medicaid imposes as a penalty for such gifts. But by the time the mother applied for Medicaid in September 2008, the Alaska legislature had enacted legislation with the retroactive effect of preventing the kind of estate planning the mother had attempted through her gift. The State temporarily denied the mother's application. The son appealed pro se on behalf of his mother, who died in 2009. Upon review, the Supreme Court found that the Alaska legislature's retroactive change to the Medicaid eligibility rules was valid. The Court thus affirmed the State's temporary denial of the mother's application.

Thomas Skinner received an award of benefits from the Workers' Compensation Commission for asbestosis under the scheduled loss provisions of Section 42-9-30 of the South Carolina Code.  Westinghouse Electric Corporation, Skinner's former employer, appealed that decision, arguing Skinner could not recover for a scheduled loss and must proceed under the "general disability" statutes found in Sections 42-9-10 and 42-9-20 of the South Carolina Code. Westinghouse's arguments on appeal concerned the impact of section 42-11-60 on Skinner's right to recover for his pulmonary disease.  In particular, it argued Skinner could only recover for total or partial disability under sections 42-9-10 and 42-9-20, respectively.  The Supreme Court agreed with Westinghouse and reversed the special referee's affirmation of Skinner's award based upon the clear language of section 42-11-60: "[i]n that section, the General Assembly specified that recovery for a pulmonary disease such as Skinner's hinges upon a showing of lost wages under section 42-9-10 and 42-9-20.  Because our resolution of this issue is dispositive of the appeal, it is not necessary for us to address the remaining issues raised by the parties."

Shannon Cave suffered a work-related injury and was awarded temporary total disability (TTD) benefits during her recovery. After Cave rejected an offer of temporary light duty work from her employer, the Wyoming Workers' Safety and Compensation Division (Division) reduced Cave's TTD benefits to one-third of the previously authorized amount in accordance with Wyo. Stat. Ann. 27-14-404(j). The Office of Administrative Hearings (OAH) upheld the reduction of TTD benefits. The district court reversed the OAH decision. The Supreme Court reversed the district court's order, holding that the OAH decision was supported by substantial evidence and was not contrary to law as the hearing examiner properly determined that the offer of light duty employment tendered to Cave was bona fide, and therefore, the OAH was obligated to reduce Cave's TTD benefits.

Thomas Tindira was a member of Ohio Police and Fire Pension Fund (OP&F) while working as a police officer with Lakewood Police Department. Before he resigned from the department, Tindira filed his application for disability benefits with OP&F, including in his list of disabling conditions PTSD, anxiety disorder, and major depression. The OP&F board of trustees determined that Tindira was disabled but denied his claim for disability benefits. The court of appeals denied Tindira a writ of mandamus to compel appellees, OP&F and its board of trustees, to vacate the board's denial of his claim and to award him disability benefits and attorney fees. The Supreme Court reversed and granted the writ, holding that the pension fund and its board abused their discretion in denying disability benefits as Tindira had established his entitlement to the benefits.

Petitioner Toni Weeks appealed a district court judgment that affirmed a decision by Workforce Safety and Insurance (WSI) that reduced her disability benefits. Petitioner was injured at work after being exposed to anhydrous ammonia while employed by Dakota Gasification Company, in Beulah, North Dakota. In 2009, WSI received confirmation that on November 1, 2009, Weeks' social security disability benefits would convert to social security retirement benefits. WSI issued a notice of intention to discontinue or reduce benefits, in which Petitioner was informed that her permanent total disability benefits would end on October 31, 2009, and she would receive an "additional benefit payable" beginning November 1, 2009. Petitioner requested reconsideration. In November 2009, WSI issued an order denying Petitioner further disability benefits after October 31, 2009. Upon review, the Supreme Court found that because Petitioner failed to adequately brief her argument that WSI's reduction of her wage loss benefits violated equal protection under the federal and state constitutions, the Supreme Court declined to address her argument and otherwise affirmed the judgment.

The State of Arizona appealed the district court's order granting a preliminary injunction to prevent a state law from taking effect that would have terminated eligibility for healthcare benefits of state employees' same-sex partners. The district court found that plaintiffs demonstrated a likelihood of success on the merits because they showed that the law adversely affected a classification of employees on the basis of sexual orientation and did not further any of the state's claimed justifiable interests. The district court also found that plaintiffs had established a likelihood of irreparable harm in the event coverage for partners ceased. The court held that the district court's findings and conclusions were supported by the record and affirmed the judgment.

Employee injured his knee while climbing into his employer-provided truck as he was preparing to leave on a work-related trip. The Wyoming Workers' Safety and Compensation Division (Division) denied Employee's requested workers' compensation benefits related to his injury. The Office of Administrative Hearings (OAH) granted summary judgment in favor of the Division. The district court affirmed the OAH's decision. At issue on appeal was whether Employee's injury was sustained while he was being transported by a vehicle of the employer as the statute requires. The Supreme Court affirmed, holding (1) the statute plainly and unambiguously requires that for an injury sustained during travel to be compensable, it must occur as the employer's vehicle is carrying the employee from one place to another; and (2) because Employee here was entering the vehicle in preparation for that transportation when he was injured, the injury he sustained was not compensable.

Plaintiffs, a class of economically vulnerable Arizonians who receive public health care benefits through the state's Medicaid agency, sued the U.S. Secretary of Health and Human Services (Secretary) and the Director of Arizona's medicaid agency (director)(collectively, defendants), alleging that the heightened mandatory co-payments violated Medicaid Act, 42 U.S.C. 1396a, cost sharing restrictions, that the waiver exceeded the Secretary's authority, and that the notices they received about the change in their health coverage was statutorily and constitutionally inadequate. The court affirmed the district court's conclusion that Medicaid cost sharing restrictions did not apply to plaintiffs and that Arizona's cost sharing did not violate the human participants statute. The court reversed the district court insofar as it determined that the Secretary's approval of Arizona's cost sharing satisfied the requirements of 42 U.S.C. 1315. The court remanded this claim with directions to vacate the Secretary's decision and remanded to the Secretary for further consideration. Finally, the court remanded plaintiffs' notice claims for further consideration in light of intervening events.