Justia Insurance Law Opinion Summaries

Respondent Denise Duncan sued Wal-Mart Stores, Inc. (Wal-Mart) for personal injuries she sustained at one of Wal-Mart’s stores while acting within the course and scope of her employment with Acosta, Inc. (Acosta). The trial court entered judgment finding Wal-Mart liable for Duncan’s injuries. Under Labor Code sections 3852 and 3856, appellant Hartford Accident & Indemnity Company (Hartford) applied for a lien on Duncan’s judgment to obtain reimbursement for the workers’ compensation benefits it paid Duncan, including medical expenses and temporary disability payments for lost wages. Although the judgment included compensation for Duncan’s medical expenses, it did not include compensation for Duncan’s lost wages because she did not seek those damages at trial. The court granted Hartford a lien on Duncan’s judgment, but reduced the lien amount to exclude the indemnity payments for lost wages. Hartford appealed the trial court’s postjudgment order, arguing the court exceeded its authority by reducing the lien amount for any item other than reasonable attorney fees and costs. The Court of Appeal agreed because section 3856’s plain language and the case law applying it granted Hartford a first lien on the judgment in the amount it paid Duncan for worker’s compensation benefits. Duncan’s choice not to seek lost wages at trial did not diminish Hartford’s lien rights under the workers’ compensation statutory scheme. View "Duncan v. Wal-Mart Stores, Inc." on Justia Law

In this case, we deny relief on a petition for review of an award of benefits made by the Workers' Compensation Appeals Board (WCAB). In 2006, while working at Pearson Ford, Leopoldo Hernandez accidentally slammed the trunk of a car on his left hand and crushed one of his fingers. Although no bones in his hand were broken, he was unable to continue working at Pearson Ford because of continuing pain in his hand and shoulder. Hernandez applied for and received workers' compensation benefits. Pearson Ford's workers' compensation carrier retained the services of a private investigator, who conducted video surveillance of Hernandez following each of the three visits to his doctor in early 2010. Following each visit, Hernandez was observed taking off his sling, using his left hand to get in and out of his truck or a car, using his left hand to steer his truck or car, and on one occasion stopping at a grocery store and using his left hand to carry a bag of groceries. After the investigator witnessed other instances of Hernandez using his allegedly injured left hand, the carrier notified the district attorney, who in turn, commenced its own investigation. In specified circumstances, a worker who engages in criminal fraud in attempting to recover workers' compensation benefits and is convicted of doing so is thereafter barred from recovering benefits growing out of the fraud. However, in given circumstances where, independent of any fraud, a worker is able to establish his or her entitlement to benefits, benefits may be awarded. Here, the WCAB found evidence, independent of a worker's fraud, that he had suffered a compensable injury and was entitled to benefits. In doing so the WCAB relied on the determination of a medical expert. The Court of Appeal found no error in the WCAB's determination the workers' claim was not barred by the eventual misdemeanor conviction for workers' compensation fraud and in the WCAB's adoption of the expert's finding of a permanent disability. The Court denied the petitioner any relief on its petition asking that it vacate the WCAB's award. View "Pearson Ford v. Workers' Comp. Appeals Bd." on Justia Law

Plaintiff Greggory Owings sustained an on-the-job injury, for which he received long-term disability benefits by defendant United of Omaha Life Insurance Company (United), under the terms of a group insurance policy issued by United to Owings’ employer. Owings disagreed with, and attempted without success to administratively challenge, the amount of his disability benefits. He then filed suit against United in Kansas state court, but United removed the action to federal district court, asserting that the federal courts had original jurisdiction over the action because the policy was governed by the Employee Retirement Income Security Act of 1974 (ERISA). The district court ultimately granted summary judgment in favor of United. Owings appealed. The Tenth Circuit concluded after review of this matter that United was arbitrary and capricious in determining the date that Owings became disabled and, in turn, in calculating the amount of his disability benefits. Consequently, the Court reversed the district court’s grant of summary judgment in favor of United and remanded with directions to enter summary judgment in favor of Owings. View "Owings v. United of Omaha Life" on Justia Law

An employee continued to work for over ten years after a job-related knee injury but had multiple surgeries on her injured knee. Over time, her employer made several permanent partial impairment payments, and she was eventually determined to be permanently and totally disabled because of the work injury. She began to receive Social Security disability at about the same time she was classified as permanently and totally disabled for workers’ compensation. Her employer asked the Alaska Workers’ Compensation Board to allow two offsets to its payment of permanent total disability (PTD) compensation: one related to Social Security disability benefits and one related to the earlier permanent partial impairment (PPI) payments. The Board established a Social Security offset and permitted the employer to deduct the amount of previously paid PPI. The employee appealed to the Alaska Workers’ Compensation Appeals Commission, arguing that the Board had improperly applied one of its regulations in allowing the PPI offset and had incorrectly calculated the amount of the Social Security offset. She also brought a civil suit against the State challenging the validity of the regulation. The State intervened in the Commission appeal; the lawsuit was dismissed. The Commission reversed the Board’s calculation of the Social Security offset and affirmed the Board’s order permitting the PPI offset. The employer appealed the Commission’s Social Security offset decision to the Alaska Supreme Court, and the employee cross- appealed the PPI offset. The Court affirmed that part of the Commission’s decision reversing the Board’s calculation of the Social Security disability offset and reversed that part of the Commission’s decision permitting an offset for permanent partial impairment benefits. The case was remanded back to the Commission for further proceedings. View "Alaska Airlines, Inc. v. Darrow" on Justia Law

While employed by Zing LLC, Josue Barrios (“Claimant”) was totally and permanently disabled as a result of an industrial accident when he fell about twelve feet from a ladder and hit his head face first on a concrete floor. He suffered multiple facial fractures, a frontal bone fracture, the loss of sight in his left eye, and a severe traumatic brain injury that caused a major neurocognitive disorder and speech language deficits. This case was an appeal of an Industrial Commission order requiring an employer and its surety to pay the cost of a guardian and a conservator for Barrios. Finding no reversible error in the Commission's order, the Idaho Supreme Court affirmed. View "Barrios v. Zing, LLC" on Justia Law

KESA, the Kentucky Workers’ Compensation Fund, on behalf of its insureds, filed five separate medical fee disputes against the Injured Workers’ Pharmacy (IWP) and the insureds’ employees and former employees, all of whom had their prescriptions filled by IWP. The chief administrative law judge (CALJ) found (1) a pharmacy/pharmacist is a medical provider, which entitles an injured worker to choose where to have his or her prescriptions filled; (2) the pharmacy fee schedule is based on the amount a pharmacist pays a wholesaler for medication, and IWP is entitled to interest on any underpayment by KESA; and (3) because KESA brought its medical fee disputes without reasonable ground and without reasonable medical or factual foundation, KESA was required to pay the cost of the proceedings. The Workers’ Compensation Board reversed the award of costs but otherwise affirmed. The court of appeals affirmed. The Supreme Court affirmed in part, vacated in part, and remanded, holding (1) the court of appeals did not err regarding the assessment of interest and sanctions or in concluding that a pharmacy is a medical provider; but (2) the remainder of the court of appeals opinion is vacated and remanded because the CALJ did not make a determination regarding the actual average wholesale price paid by IWP. View "Steel Creations by and through KESA, the Kentucky Workers’ Compensation Fund v. Injured Workers’ Pharmacy" on Justia Law

The Court of Appeals affirmed the finding of the Workers’ Compensation Commission (WCC) that Employer and Insurer (collectively, Respondents) were entitled to offset the ordinary disability benefits already paid to Petitioner against the temporary total disability benefits paid to him by Respondents.Petitioner suffered injuries primarily to his back and neck while working for Employer. Employer received two different sets of disability benefits from Employer and Insurer, each awarded by a different state agency. Specifically, Petitioner was granted temporary total disability benefits by the WCC and ordinary disability benefits by the State Retirement Agency. The WCC found that Respondents were entitled to a credit for the ordinary disability benefits already paid to Petitioner. On judicial review, the circuit court granted summary judgment in favor of the WCC. The Court of Appeals affirmed, holding that because both sets of benefits compensated Petitioner for the same injury, pursuant to Md. Code Ann. Lab. & Empl. 9-610, the statutory offset properly applied to prevent a double recovery for the same injury. View "Reger v. Washington County Board of Education" on Justia Law

This appeal arose out of an agent contract dispute between Bret Kunz (“Bret”) and Nield, Inc. (“N.I.”) authorizing Bret to sell insurance on behalf of N.I. N.I. is owned by two brothers, Bryan Nield (“Bryan”) and Benjamin Nield. A dispute arose concerning the method and type of compensation available to Bret under the Contract. Bret filed a complaint seeking, inter alia, a declaratory judgment interpreting the Contract. The district court held the 2009 Contract did not provide for profit sharing as Bret claimed. Bret and his wife, Marti, (collectively, the “Kunzes”) appealed. Finding no reversible errors with respect to how the district court interpreted the Contract, the Idaho Supreme Court affirmed. View "Kunz v. Nield, Inc." on Justia Law

While employed by a company now known as Asurion Services, LLC, Christy Harris filed industrial injury claims for two different incidents. Lumbermens Mutual Casualty Company adjusted Harris’s workers’ compensation claims until it was declared insolvent. Montana Insurance Guaranty Association (MIGA) subsequently assumed the handling of Harris’s claims. Thereafter, MIGA notified Asurion that it would seek reimbursement for the benefits it paid to Harris pursuant to Mont. Code Ann. 33-10-114(2). Asurion filed a declaratory judgment action against MIGA. The district court granted motion for Asurion based on the exclusivity provision of the Montana Workers’ Compensation Act (Act), concluding that because Asurion met its obligation to obtain workers’ compensation insurance, it had no payment obligations to Harris, and therefore, Mont. Code Ann. 33-10-114(2) did not afford MIGA relief. The Supreme Court affirmed, holding that because Asurion provided workers’ compensation coverage in accordance with the Act, Asurion was not required to reimburse MIGA for benefits paid to Harris. View "Asurion Services, LLC v. Montana Insurance Guaranty Ass’n" on Justia Law

Leticia Salinas injured her back while working for Bridgeview Estates (“Employer”). After receiving medical treatment for roughly six weeks, her workers’ compensation benefits were temporarily denied by Old Republic Insurance Company. Nearly two years later, Salinas filed a claim for reimbursement for medical costs and all future medical care. The Idaho Industrial Commission concluded that Salinas failed to prove that she was entitled to payment of compensation. Notwithstanding that conclusion, the Commission awarded Salinas attorney’s fees. The Employer appealed the award. The Supreme Court concluded the Commission erred in awarding attorney’s fees, and vacated the judgment. View "Salinas v. Bridgeview Estates" on Justia Law