Justia Insurance Law Opinion Summaries

The Eastern Municipal Water District (EMWD) hired general contractor S.J. and Burkhardt, Inc. (SJB) for a public works construction project in 2006. Safeco Insurance Company (Safeco) executed performance and payment bonds for the project. Plaintiff Golden State Boring & Pipe Jacking, Inc. (GSB) was a subcontractor for the project, completing its work by September 2006, but it did not receive payment. In March 2008, SJB sent a voluntary default letter to Safeco. In July 2008, GSB sued SJB, EMWD, and Safeco for the unpaid amounts under the contract, separately seeking payment from Safeco under its payment bond. EMWD filed a cross-complaint to interplead retained sums. Safeco made a motion for summary judgment on the cause of action for payment under the bond on the ground that GSB’s claim was untimely. The trial court granted the motion, finding that there had been three cessations of labor that triggered GSB’s duty to file a stop notice in order to secure payment under Safeco's payment bond. At a subsequent court trial on the contract claims, GSB was awarded judgment against SJB, and Safeco was awarded judgment on the interpleader action. GSB appealed the summary judgment ruling, arguing: (1) the trial court erroneously overruled its objections to evidentiary matters presented in support of Safeco’s summary judgment; and (2) the court erred in finding the action was untimely. Finding no reversible error, the Court of Appeal affirmed. View "Golden State v. Eastern Municipal Water Dist." on Justia Law

The question before the Court of Appeals in these three consolidated cases was the appropriate method for crediting payments made under a workers’ compensation award when that award is increased on appeal. At issue was whether the credits should be computed on the basis of the number of weeks paid or the amount of money expended. The Court of Appeals resolved the issue in favor of the workers in each case by relying on legislation passed specifically to supersede earlier decisions of the Court, holding that, when crediting an employer/insurer for payments made under a workers’ compensation award that is subsequently amended, credit should be given for the total amount of dollars paid under the initial award.View "W.R. Grace & Co. v. Swedo" on Justia Law

After Elms Construction Company, owned by Richard Elms (Elms), began installing windows and doors for Renewal by Anderson (Renewal), Elms fell from a ladder and injured his right foot. Elms filed a workers’ compensation claim with the Workers’ Compensation Commission, alleging that he was Renewal’s common law employee at the time of the injury. The Commission concluded that Elms was an independent contractor, rather than a common law employee of Renewal, and was therefore not entitled to collect workers’ compensation benefits. The circuit court reversed, concluding that Elms was Renewal’s common law employee. The court of special appeals vacated the circuit court’s opinion and remanded. The Supreme Court vacated the court of appeals’ opinion and remanded with directions to affirm the circuit court’s judgment, holding (1) the Commission misconstrued the law as applied to the facts when it concluded that Elms was an independent contractor and not an employee of Renewal; (2) the court of special appeals erred when it held that a statutory employment analysis under section 9-508 of the Workers’ Compensation Act must precede a common law employment analysis; and (3) by application of the common law to the facts of this case, Elms was Renewal’s employee at the time of the accident. View "Elms v. Renewal by Anderson" on Justia Law

Seventy-year-old James Higginbotham was employed by Industrial Contractors, Inc. ("ICI") as a welder and pipefitter in May 2010 when he sustained an injury to his left rotator cuff. The medical records demonstrated that Higginbotham's injury arose out of and in the course of his work for ICI. Prior to his injury, Higginbotham made $34.61 per hour, but only worked part time. He often traveled to work sites some distance from his home near Hazen, including a site north of Mandan. Since his injury, Higginbotham was no longer able to make the trip from Hazen to Bismarck without stopping, and he could no longer perform welding or pipefitting work. Higginbotham lived in a mobile home near Hazen, approximately 70 miles from Bismarck and 80 miles from Minot. He indicated he was having difficulty paying bills, which he did not have before the injury, and he wanted to maintain the lifestyle he had prior to his injury. Following left rotator cuff surgery, WSI referred Higginbotham to vocational rehabilitation with Kim Hornberger, a vocational rehabilitation consultant, who identified the first appropriate rehabilitation option for Higginbotham and developed a vocational consultant's report ("VCR"). The VCR concluded that it was appropriate for Higginbotham to return to an occupation in the statewide job pool suited to his education, experience, and marketable skills: cashier, telephone sales representative, gaming dealer, and greeter, and the expected income of $332 per week exceeded 90% of Higginbotham's pre-injury income of $227 per week. WSI approved the vocational plan and notified Higginbotham that it intended to discontinue his benefits. Higginbotham asked for reconsideration, and WSI issued an order affirming the rehabilitation plan and denying further disability benefits. Higginbotham appealed, and an ALJ affirmed the WSI order. Higginbotham appealed the ALJ's decision, and the district court affirmed. Higginbotham now appeals the district court judgment. Finding no reversible error, the Supreme Court affirmed. View "Higginbotham v. WSI" on Justia Law

Expedia (and several other hotel booking websites, collectively, "Petitioners") has been subject to approximately 80 underlying lawsuits by states, counties, and municipalities (collectively, taxing authorities) for purportedly failing to collect the right amount of local occupancy taxes from its hotel customers. Expedia tendered most of the suits to its insurer, Zurich, although some were tendered late. Zurich refused to defend Expedia on a number of grounds, including late tender and that the underlying suits may be excluded from the policies' coverage. The trial court declined to make a determination of Zurich's duty to defend Expedia, instead ordering discovery that Expedia claimed was prejudicial to the underlying actions. Petitioners sought adjudication of their summary judgment motion concerning their respective insurers' duty to defend them in cases brought by local taxing authorities. They further requested a stay of discovery in the coverage action that could prejudice them in the underlying litigation. Upon review of the matter, the Washington Supreme Court held that the trial court erred by delaying adjudication of Zurich's duty to defend Expedia. Accordingly, the Court vacated the trial court's order. The case was remanded to the trial court to determine Zurich's duty to defend Expedia in each of the 54 underlying cases subject to Expedia's motion. The trial court was furthermore ordered to stay discovery in the coverage action until it could make a factual determination as to which parts of discovery are potentially prejudicial to Expedia in the underlying actions. View "Expedia, Inc. v. Steadfast Ins. Co." on Justia Law

Employee was injured at work and underwent surgery. Employee’s health insurer covered the surgery’s costs at a discounted rate. After the Department of Labor found Employer liable for Employee’s condition Employer accepted Employee’s claim and reimbursed Employee for his out of pocket expenses and reimbursed Employee’s insurer for payments it made on Employee’s behalf. Employee challenged the payment, arguing that Employer was required to pay the full medical expense without the health insurance discount. The Department concluded that Employer fulfilled its obligation. The circuit court reversed and found Employer liable for the full medical expense billed before adjustments. Employer appealed. The Supreme Court reversed the circuit court and reinstated the Department’s order, holding that the Department correctly applied the law in determining that Employer satisfied its statutory reimbursement obligation. View "Whitesell v. Rapid Soft Water & Spas, Inc." on Justia Law

Public Act 97-695 (eff. July 1, 2012), amended section 10 of the State Employees Group Insurance Act of 1971, 5 ILCS 375/10, by eliminating the statutory standards for the state’s contributions to health insurance premiums for members of three of the state’s retirement systems. The amendment requires the Director of Central Management Services to determine annually the amount of the health insurance premiums that will be charged to the state and to retired public employees. It is not limited to those who become annuitants or survivors on or after the statute’s effective date. The amendment was challenged by members of the affected entities: State Employees’ Retirement System (SERS), State Universities Retirement System (SURS), and Teachers’ Retirement System (TRS), as violation the pension protection clause, the contracts clause, and the separation of powers clause of the Illinois Constitution. Certain plaintiffs added common-law claims based on contract and promissory estoppel. The Illinois Supreme Court, on direct review, reversed dismissal, stating that health insurance subsidies are constitutionally protected by the pension protection clause and rejecting an argument that only the retirement annuity itself is covered. View "Kanerva v. Weems" on Justia Law

In December 2008, Appellee was performing his duties as an outdoor parking lot attendant when he developed frostbite. Appellee’s employer and its insurance company (Appellants) voluntarily paid for the medical treatment of Appellee’s frostbite injury and paid temporary total disability benefits through mid-2009. In September 2012, a partial amputation of the fifth metatarsal in Appellee’s right foot was performed. In January 2013, Appellee sought additional benefits for his work-related injury. The Workers’ Compensation Court awarded benefits. On appeal, Appellants argued that the Workers’ Compensation Court erred in finding that Appellee’s claim was not barred by the two-year statute of limitations. The Supreme Court affirmed, holding that the partial amputation of Appellee’s foot was a material change in condition and substantial increase in disability that would permit Appellee to seek benefits more than two years after Appellants’ last voluntary payment.View "Lenz v. Cent. Parking Sys. of Neb., Inc." on Justia Law

The South Carolina Supreme Court answered certified two questions from the U.S. District Court for the District of South Carolina. The case concerned supplemental health insurance policies, which differ from ordinary health insurance policies in both purpose and operation. The questions were: (1) whether the definition of "actual charges" contained within S.C. Code Ann. 38-71-242 be applied to insurance contracts executed prior to the statute's effective date; and (2) whether the South Carolina Department of Insurance could mandate the application of "actual charges" to policies already inexistence on the statute's effective dates by prohibiting an insurance company from paying claims absent the application of that definition. The South Carolina Supreme Court answered both questions "no." View "Kirven v. Central States" on Justia Law

This case involved a petition for injunctive and declaratory relief brought by plaintiffs Harbor Homes, Inc. and Gary Dube, Thomas Taylor, Cynthia Washington, and Arthur Furber against defendants the New Hampshire Department of Health and Human Services (DHHS), the Commissioner of DHHS, the Associate Commissioner of DHHS, and the Administrator of the Bureau of Behavioral Health seeking, in part, to enjoin DHHS from denying the individual plaintiffs the right to obtain Medicaid-funded services from their chosen provider, Harbor Homes. The individual plaintiffs received Medicaid-funded rehabilitative services from Harbor Homes. Since 1991, Harbor Homes participated in New Hampshire's Medicaid program pursuant to a Medicaid Provider Enrollment Agreement. On June 23, 2008, Harbor Homes entered into an interagency agreement (IAA) with a community mental health program, Community Council of Nashua, NH, now known as Greater Nashua Mental Health Center (GNMHC), which authorized Harbor Homes to provide certain Medicaid-funded rehabilitative services to GNMHC patients. In February 2011, Harbor Homes learned that GNMHC did not intend to renew its IAA and that the Medicaid reimbursable services provided by Harbor Homes would be transitioned to GNMHC. This was done pursuant to Administrative Rule He-M 426.04(a)(2), which meant that Harbor Homes would no longer have an IAA with a community mental health provider, and it would no longer be permitted to provide Medicaid funded mental health services to approximately one hundred and forty of its clients, including the individual plaintiffs in this case. Plaintiffs filed a petition for injunctive and declaratory relief, seeking a court order enjoining DHHS from "terminating or limiting Harbor Homes' status as a qualified Medicaid provider" and to direct the State to allow the individual plaintiffs to obtain community mental health services from Harbor Homes, the provider of their choice. Following two hearings, the court denied the plaintiffs' request for a preliminary injunction. Thereafter, all parties moved for partial summary judgment on the plaintiffs' claim that DHHS's reliance upon the IAA requirement as a reason to terminate Harbor Homes' status as a qualified Medicaid provider was improper because the requirement was invalid both on its face and as applied in this case. Plaintiffs appealed rulings of the Superior Court that denied their summary judgment motions and granting the defendants' cross-motions for summary judgment on two counts in the plaintiffs' petition. Upon review of the matter, the Supreme Court reversed the Superior Court's ruling that New Hampshire Administrative Rules, He-M 426.04(a)(2) did not violate the federal Medicaid Act. The case was remanded for further proceedings. View "Dube v. New Hampshire Dept. of Health & Human Svcs." on Justia Law