Justia Insurance Law Opinion Summaries

In 1999, Randall Simms was injured while on the job. Thereafter, Simms became totally disabled and, since 2006, had been receiving total disability benefits. Dr. Michael Schabacker was Simms’ workers’ compensation doctor from 2004 through 2007. In 2010, Simms filed a complaint against Schabacker and his employer, alleging that Schabacker had unlawfully disseminated his private, confidential healthcare information to a law enforcement officer without Simms' permission. The district court granted summary judgment in favor of Schabacker. The Supreme Court affirmed, holding that the district court did not err in concluding (1) Schabacker was statutorily authorized to release relevant healthcare information regarding Simms to the workers’ compensation insurer, and (2) Schabacker did not knowingly assist a law enforcement agency when he discussed Simms’ medical condition with the workers’ compensation insurer. View "Simms v. Schabacker" on Justia Law

Bibeau appealed the district court's grant of summary judgment and order directing it, as a related person to a disabled miner's former employer, to pay health insurance premiums, interest, and liquidated damages to the United Mine Workers of America 1992 Benefit Plan. The court concluded that Bibeau's laches claim was precluded under Petrella v. Metro-Goldwyn-Mayer, Inc. because each premium installment gives rise to a separate cause of action for legal relief for which Congress has enacted a statute of limitations to govern timeliness. Further, under the Coal Industry Retiree Health Benefit Act of 1992, 26 U.S.C. 9701-9722, which incorporates the Employee Retirement Income Security Act's (ERISA), 29 U.S.C. 1451(a)(1), enforcement scheme, the district court did not err in awarding interest and liquidated damages. Accordingly, the court affirmed the judgment. View "Holland v. Bibeau Construction Co." on Justia Law

Bonnie, a Trinity Health employee, enrolled her family in a Blue Cross group health plan. Trinity served as plan administrator. Bonnie took FMLA leave and then short-term disability leave, which expired June 8, 2011. Bonnie requested long-term disability benefits from Unum, which provisionally paid medical care claims under a “Reservation of Rights.” In October 2011 Unum denied Bonnie’s request but did not seek repayment. June 8, 2011 was the last day Bonnie qualified for benefits and was considered an employee. Her termination was not processed, so the family received benefits until Trinity deemed them retroactively terminated. The Coles were first alerted to their loss of insurance on June 1, 2012 by husband’s physician. They obtained insurance through husband’s employer, retroactively effective June 1, 2012. Blue Cross did not seek a refund of claims paid between January 1, and April 30, 2012. The Coles claimed violation of the Consolidated Omnibus Budget Reconciliation Act by failing to notify them of their right to continuing health care coverage. The district court declined to award statutory damages, reasoning that unreimbursed medical bills from May 2012 were less than the COBRA premiums they would have had to pay to maintain insurance. The Eighth Circuit affirmed. View "Cole v. Trinity Health Corp." on Justia Law

In 2000, while working at Homestake Mining Company, Michael Martz injured his shoulder. Martz was paid workers’ compensation benefits. In 2002, while working for McLaughlin Sawmill (Hills Materials), Martz injured the same shoulder. Hills Materials began paying benefits but, several years later, denied liability for further benefits. Martz petitioned the Department of Labor, contending that both employers were liable for benefits. Homestake was granted summary judgment on statute of limitations grounds. In regards Hills Materials, the Department rejected Martz’s argument that promissory estoppel precluded Hills Materials from denying liability and concluded that Martz failed to satisfy his burden of showing that the 2002 injury was a “major contributing cause” of his current condition. The circuit court affirmed. The Supreme Court affirmed, holding (1) Hills Materials was not estopped from denying liability for Martz’s current condition and need for treatment; and (2) Martz failed to establish that Hills Materials was liable for benefits where he did not prove a sufficient causal relationship between his 2002 injury and his current condition and need for treatment. View "Martz v. Hills Materials" on Justia Law

Hoey, who owns a farmers’ market that offers hay rides, pony rides, and pumpkin picking, hired Armbruster to run the hay wagon for eight weekends. Armbruster is now a paraplegic because an accident with the wagon crushed her spine. She sued for negligence in Michigan state court. Armbruster and Hoey also sought a declaratory judgment, again in state court, that Armbruster was covered by Hoey’s General Commercial Liability insurance policy. The insurer, Western, sought a federal declaratory judgment that Armbruster was not covered by the insurance policy. The cases were consolidated in federal court. Counsel, provided by Western to Hoey, filed a workers’ compensation claim on the theory that Armbruster was an “employee” eligible for workers’ compensation. The state tort claim has been stayed until the workers’ compensation claim is resolved. The district court accepted jurisdiction and construed the policy to exclude Armbruster’s injury from coverage. The Sixth Circuit affirmed, agreeing that it would be helpful for the parties to know whether Western was liable for Hoey’s legal fees, that Western was not playing procedural games, and that the federal forum could resolve the action without interfering in Armbruster’s tort suit or taking on difficult questions of state law. View "W. World Ins. Co. v. Armbruster" on Justia Law

Santana Morales died while working for Lawns Nursery and Irrigation Designs, Inc. (Lawns). Thereafter, Lawns’ surviving spouse entered into a workers’ compensation settlement agreement with Lawns and Zenith Insurance Company (Zenith), Lawns’ workers’ compensation and employer liability insurance carrier. In a separate wrongful death lawsuit, Morales’ Estate obtained a default judgment against Lawns. Zenith refused to pay the tort judgment, and the Estate sued Zenith under Lawns’ employer liability policy. A federal district court entered summary judgment for Zenith, holding that the policy’s workers’ compensation exclusion barred the Estate’s suit. On appeal, the Eleventh Circuit certified three questions of law to the Supreme Court. The Court answered (1) the Estate had standing to bring direct action against Zenith to recover the judgment against Lawns; (2) the workers’ compensation exclusion barred coverage of the Estate’s tort judgment under the employer liability policy; and (3) a release in the workers’ compensation settlement agreement, through which Mrs. Morales elected the consideration described in the agreement as the sole remedy with respect to the insurance coverage that Zenith provided to Lawns, precluded the Estate from collecting the tort judgment from Zenith. View "Morales v. Zenith Ins. Co." on Justia Law

Claimant-appellant Trudy Deon brought worker compensation claims against her employer, H&J, Inc., and its surety, Liberty Northwest, (Employer/Surety) and the Idaho Special Indemnity Fund (ISIF). Deon eventually settled with ISIF but the claim against Employer/Surety went to a hearing that resulted in the Idaho Industrial Commission finding Employer/Surety 100% liable for her total and permanent disability (TPD). The Commission decided sua sponte to reconsider its decision and invited the parties to brief the issue of whether Deon was estopped from arguing Employer/Surety was 100% liable, given her settlement with ISIF. In an order on reconsideration, the Commission held that Deon was so estopped and apportioned 23.92% of her TPD to Employer/Surety. Deon appealed. Upon review, the Supreme Court determined the Commission erred by sua sponte raising the issue of collateral estoppel. The Commission and Employer/Surety knew about the ISIF settlement agreement for months before a decision was rendered and never raised the estoppel issue. Deon filed complaints against both her Employer/Surety and the ISIF. As a result of mediation, she reached a tentative settlement agreement with ISIF on October 5, 2012. The agreement was reduced to writing, signed by the parties on October 19, 2012, and approved by the Commission on November 8, 2012. When the Commission issued its Decision, it determined that Deon was totally and permanently disabled and that Employer/Surety was 100% liable under the odd-lot doctrine as Deon had argued. After considering all the hearing evidence and the parties’ briefing, the Commission found apportionment between the ISIF and Employer/Surety “is not appropriate” because “[t]he record does not establish that Claimant’s pre-existing leg condition combined with her 2008 industrial accident to render her totally and permanently disabled. However, on the same day the Commission issued its Decision, it also issued a notice of reconsideration pursuant to Idaho Code section 72-718, which raised for the first time the collateral estoppel. Specifically, the Commission wanted to know whether Deon’s stipulation to ISIF’s partial liability for her TPD estopped her from then arguing that Employer/Surety was 100% liable. After the parties briefed the issue, the Commission issued a new order holding that Deon was estopped from asserting a position inconsistent with her stipulation that ISIF was partially liable for her TPD. It then apportioned TPD liability according to the "Carey" formula, changing Employer/Surety’s liability from 100% to 23.92%. The Supreme Court concluded the revised findings were hinged solely on the Commission’s erroneous view of the law, and were without any support in the hearing record. Therefore, the Court reversed the Order on Reconsideration. Because the Commission did, in fact, hear Deon’s claim against Employer/Surety on the merits and determined Employer/Surety was 100% liable, Deon was entitled to 100% of her benefits from Employer/Surety. View "Deon v. H &J, Inc." on Justia Law

Minn. Stat. 176.081(1)(a) requires employers and insurers to pay attorney fees calculated by a statutory formula not subject to judicial review. In this case, Respondent injured his back while working for Employer. Employer and its insurer (together, Relators) settled with Respondent. Respondent’s attorney then sought an award of contingent attorney fees in an amount that was calculated by applying the statutory formula in section 176.081 but which disregarded the upper limit set by the formula. Relators objected, arguing that, in the absence of judicial review to ensure a fee award is not excessive, application of the statutory formula violates separation of powers principles. The compensation judge applied the statutory formula and concluded that $13,000 would adequately compensate Respondent’s attorney but refused to consider whether the statutory fee was reasonable. The Workers’ Compensation Court of Appeals affirmed the compensation judge’s fee award. The Supreme Court affirmed, holding (1) the Court will recognize the Legislature’s statutory formula as presumptively reasonable, and, absent exceptional circumstances, further judicial review of an award based on the statutory formula is unnecessary; and (2) Relators failed to present any exceptional circumstances to challenge this presumption. View "David v. Bartel Enters." on Justia Law

WTS Acquisition Corporation purchased Ameritemps, Inc. and then transferred the assets to its wholly owned subsidiary, RFFG, LLC. RFFG continued operating the business under the Ameritemps name. The Ohio Bureau of Workers’ Compensation notified RFFG that it had determined that RFFG was a successor employer for workers’ compensation purposes and that it intended to calculate RFFG’s workers’ compensation premium rate based on Ameritemps’ experience rating. RFFG filed a complaint for a writ of mandamus alleging that the Bureau had abused its discretion when it determined RFFG to be the successor in interest to Ameritemps. The court of appeals denied the writ. The Supreme Court affirmed, holding that the court of appeals did not err in concluding that the decision of the Bureau was supported by the evidence and was not an abuse of discretion. View "State ex rel. RFFG, LLC v. Ohio Bureau of Workers' Comp." on Justia Law

While working on a fall clean-up job for defendant All Star Specialists Plus, Inc., defendant Joseph Derry was loading leaves into a truck using a leaf vacuum machine when the machine tipped over, injuring him. At the time, All Star had three insurance policies issued by Auto-Owners Insurance Company: (1) a commercial general liability policy, (2) a commercial automobile insurance (no-fault) policy, and (3) a commercial workers’ compensation policy. The general liability policy excludes from coverage “[a]ny obligation of the insured under a workers[’] compensation . . . law,” and the no-fault policy excludes coverage for “any expenses that would be payable under any workers[’] compensation law . . . .” Derry brought a negligence suit against All Star and one of its owners, Jeffery Harrison, for his injuries and sued Auto-Owners for no-fault benefits. Plaintiff Auto-Owners later filed this declaratory judgment action, seeking a determination that Derry was an employee of All Star and, thus, that the only insurance coverage available was under the workers’ compensation policy. The trial court concluded that because it was uncontroverted that Derry held himself out to the public to perform the same services as the work he performed for All Star, Derry was an independent contractor at the time of his injury and not an employee, and that Derry was therefore entitled to coverage under Auto-Owners’ general liability and no-fault policies. The court denied Auto-Owners’ motion for summary judgment and granted summary judgment in favor of Derry. Auto-Owners appealed to the Court of Appeals, and the panel affirmed in part and reversed in part. The panel affirmed the trial court’s conclusion that Derry was an independent contractor for purposes of the Worker's Disability Compensation Act (WDCA). However, the panel only reached this conclusion because it was bound under MCR 7.215(J)(1) to follow the Court of Appeals’ prior decision in "Amerisure." A special panel was convened, and in a published 4-3 decision, the majority reversed the trial court’s order granting summary judgment in favor of Derry and, thus, its determination that Derry was an independent contractor. Because the Supreme Court believed the term “employee” as defined in the WDCA was properly interpreted in "Amerisure," the Court reversed the Court of Appeals. View "Auto-Owners Insurance Co. v. All Star Lawn Specialists Plus, Inc." on Justia Law