Justia Insurance Law Opinion Summaries

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

Laura Miller appeals from a summary judgment entered by the Jefferson Circuit Court ("the circuit court") in favor of the City of Birmingham ("the City"), Sandy Roberts, and Alice Crutchfield (collectively, "the City defendants"). Robert Miller, Laura's husband, was employed by the City as a firefighter. Unum Life Insurance Company of America ("Unum") issued a group life and accidental death and dismemberment policy. According to the summary of benefits, the policy included different life-insurance benefits for active employees and for retired employees. Under the policy, as an active employee, the City paid Robert's insurance premiums, thereby entitling him to a life-insurance benefit of $151,000. However, if Robert were to retire, he would be required to pay his life-insurance premiums and would be entitled to only a $50,000 life-insurance benefit. The summary of benefits specified that, in order to be eligible for a waiver of the life-insurance premiums, the insured had to "be disabled through your elimination period," which was nine months. In 2012, Robert was diagnosed with brain cancer and soon became unable to perform the duties of his job. Laura contended once the Millers learned of Robert's condition, they "sought to obtain information about [Mr. Miller's] life insurance benefit and all other benefits that might be available." The Millers did not have a copy of the policy or the summary of benefits at that time. The Millers and Ed Bluemly, Mrs. Miller's brother-in-law, met with Sandy Roberts, the assistant benefit administrator and the pension coordinator for the Jefferson County Personnel Board, and Alice Crutchfield, a personnel technician for the Jefferson County Personnel Board, to learn about the available benefits. The Millers asked for a copy of the policy, and there was a dispute over whether the Crutchfield gave the Millers a copy. The Millers ultimately sued the City for negligence with respect to the policy and collection of the benefits to which Robert was entitled. After review of this matter, the Supreme Court affirmed the circuit court's summary judgment in favor of the City insofar as the circuit court based its summary judgment in favor of the City on the City defendants' argument that the City was entitled to immunity from Laura's claim alleging wanton and reckless misrepresentation. However, the Court reversed the circuit court's summary judgment in favor of the City defendants in all other respects. The Case was remanded for further proceedings. View "Miller v. City of Birmingham et al." on Justia Law

Plaintiff were a class of state employees and retirees who were enrolled in an Anthem Insurance group health insurance plan at the time of the 2001 demutualization of Anthem Insurance Companies. Plaintiffs brought suit against former Governor John Rowland, the State, Anthem Insurance, and other insurance company defendants alleging that their participation in the plan entitled them to membership in Anthem Insurance and a share of the demutualization proceeds. Plaintiffs claimed that Anthem Insurance and the other insurance company defendants breached their contractual obligations by not paying Plaintiffs for their membership interests and instead distributing their share of the proceeds to the State. The Supreme Court concluded that Plaintiffs’ claims against Rowland and the State were barred by the doctrine of sovereign immunity or otherwise should have been dismissed. After a trial, the trial court rendered judgment for the remaining defendants. The Supreme Court affirmed, holding that the trial court correctly concluded that the relevant contract provisions were ambiguous as to Plaintiffs’ eligibility for membership in Anthem Insurance and their entitlement to a share of the demutualization proceeds and properly considered extrinsic evidence to determine their meaning. View "Gold v. Rowland" on Justia Law

The issue in this workers’ compensation case was whether claimant was entitled to benefits for his “combined condition” claim. Claimant filed- and his employer’s insurer, SAIF Corporation, initially accepted-a claim for a lumbar strain combined with preexisting lumbar disc disease and related conditions. SAIF later denied the combined condition claim on the ground that the lumbar strain had ceased to be the major contributing cause of the combined condition. Claimant objected. He did not contest that his lumbar strain had ceased to be the major contributing cause of his combined condition. Instead, he argued that the otherwise compensable injury was not limited to the lumbar strain that SAIF had accepted as part of his combined condition claim. In claimant’s view, an “otherwise compensable injury” within the meaning of ORS 656.005(7)(a)(B) referred not just to the condition that SAIF accepted, but also includes any other conditions not accepted that might have resulted from the same work-related accident that caused the lumbar strain, and that larger group of work-related conditions continued to be the major contributing cause of his combined condition. As a result, claimant contended that an employer could not close a combined condition claim if any of those non accepted conditions remained the major cause of the combined condition claim. The Workers’ Compensation Board rejected claimant’s argument and upheld SAIF’s denial of claimant’s combined condition claim, concluding that existing precedent defined the “otherwise compensable injury” component of combined conditions to consist of the condition or conditions that the employer has accepted as compensable. The Court of Appeals reversed, acknowledging that its holding was “potentially at odds” with existing precedents from both that court and the Oregon Supreme Court. It nevertheless concluded that those precedents were either distinguishable or should be reconsidered. The Supreme Court concluded that the Court of Appeals erred and that the Workers’ Compensation Board was correct. View "Brown v. SAIF Corp." on Justia Law

Employee-appellant Tracy Meeks sued an insurer for bad faith refusal to timely comply with several orders of the Workers' Compensation Court awarding employee temporary total disability benefits after the insurer, without good cause, withheld employee's benefits on twenty-six separate occasions. Insurer moved for dismissal, asserting employee failed to obtain a certification order from the Workers' Compensation Court (a jurisdictional prerequisite for commencing a bad-faith action in district court). The District Court granted insurer's motion, but the Supreme Court reversed. Because the certification requirements were met here, employee was free to proceed in district court on his bad-faith claim against insurer for insurer's alleged bad faith refusal to provide temporary total disability benefits as ordered by the WCC. View "Meeks v. Guarantee Insurance Co." on Justia Law