Justia Insurance Law Opinion Summaries

Hayssen and its employees were parties to a Plant Closing Agreement that promised medical benefits upon retirement. In 1996, Bemis acquired Hayssen and assumed its obligations. Bemis reduced benefits under the Agreement: increasing co-pays and deductibles and eliminating its prescription drug program. Former employees sued under the Employee Retirement Income Security Act, 29 U.S.C. 1132, and the Labor-Management Relations Act, 29 U.S.C. 185(a). The court certified a class, but granted summary judgment to Bemis, reasoning that the Agreement did not establish a lifetime interest in a certain level of benefits. About a month later, Bemis eliminated all medical benefits under the Agreement. The Seventh Circuit reversed, concluding that the parties intended to provide lifetime medical coverage. On remand, the court granted a preliminary injunction forcing Bemis to restore the benefits eliminated in 2009 and provide a basic Medicare Part D drug benefit. The court awarded fees and costs, finding that the company’s position was not substantially justified. The judge struck billing entries that were vague or for time not reasonably expended on the case, concluded that the lawyers’ billing rates were reasonable, and calculated the lodestar amount to reach an award of $403,053.75, for four years of advocacy, including an appeal and trial preparation. The Seventh Circuit affirmed.View "Temme v. Bemis Co., Inc." on Justia Law

Plaintiff filed suit against his former employer, Annett, alleging that the company acted in bad faith when it failed to provide medical care and refused to pay him healing-period benefits. Annett counter-claimed for fraud. The court concluded that the district court correctly ruled that plaintiff was required to exhaust his claim with the commissioner; under Iowa law, Annett had a reasonable basis to believe that it could request plaintiff to undergo an examination by the company's chosen physician and plaintiff's refusal to submit to the examination made the propriety of the company's denial of healing-period benefits at least fairly debatable; therefore, the district court properly granted summary judgment for Annett on plaintiff's bad-faith failure to pay benefits claim; and, under either Iowa law or federal law, Annett was judicially estopped from proceeding against plaintiff because Annett had admitted liability in plaintiff's alternate care petition. Accordingly, the court affirmed the judgment of the district court. Annett's motion to strike portions of plaintiff's supplemental appendix was denied as moot. View "Spencer v. Annett Holdings, Inc." on Justia Law

Department of Health and Human Services (HHS) regulations implementing the 2010 Patient Protection and Affordable Care Act (ACA) require that employers’ group health plans furnish preventive care and screenings for women without cost sharing requirements, 42 U.S.C. 300gg–13(a)(4). Nonexempt employers must provide coverage for 20 FDA-approved contraceptive methods, including four that may have the effect of preventing a fertilized egg from developing. Religious employers, such as churches, are exempt from the contraceptive mandate. HHS has effectively exempted religious nonprofit organizations; an insurer must exclude contraceptive coverage from such an employer’s plan and provide participants with separate payments for contraceptive services. Closely held for-profit corporations sought an injunction under the 1993 Religious Freedom Restoration Act (RFRA), which prohibits the government from substantially burdening a person’s exercise of religion even by a rule of general applicability unless it demonstrates that imposing the burden is the least restrictive means of furthering a compelling governmental interest, 42 U.S.C. 2000bb–1(a), (b). As amended by the Religious Land Use and Institutionalized Persons Act of 2000 (RLUIPA), RFRA covers “any exercise of religion, whether or not compelled by, or central to, a system of religious belief.” The Third Circuit held that a for-profit corporation could not “engage in religious exercise” under RFRA and that the mandate imposed no requirements on corporate owners in their personal capacity. The Tenth Circuit held that the businesses are “persons” under RFRA; that the contraceptive mandate substantially burdened their religious exercise; and that HHS had not demonstrated that the mandate was the “least restrictive means” of furthering a compelling governmental interest.The Supreme Court ruled in favor of the businesses, holding that RFRA applies to regulations that govern the activities of closely held for-profit corporations. The Court declined to “leave merchants with a difficult choice” of giving up the right to seek judicial protection of their religious liberty or forgoing the benefits of operating as corporations. Nothing in RFRA suggests intent to depart from the Dictionary Act definition of “person,” which includes corporations, 1 U.S.C.1; no definition of “person” includes natural persons and nonprofit corporations, but excludes for-profit corporations. “Any suggestion that for-profit corporations are incapable of exercising religion because their purpose is simply to make money flies in the face of modern corporate law.” The Court rejected arguments based on the difficulty of ascertaining the “beliefs” of large, publicly traded corporations and that the mandate itself requires only insurance coverage. If the plaintiff companies refuse to provide contraceptive coverage, they face severe economic consequences; the government failed to show that the contraceptive mandate is the least restrictive means of furthering a compelling interest in guaranteeing cost-free access to the four challenged contraceptive methods. The government could assume the cost of providing the four contraceptives or could extend the accommodation already established for religious nonprofit organizations. The Court noted that its decision concerns only the contraceptive mandate, not all insurance-coverage mandates, e.g., for vaccinations or blood transfusions. View "Burwell v. Hobby Lobby Stores, Inc." on Justia Law

Appellant, an over-the-road truck driver, filed a claim for workers’ compensation benefits, alleging that he sustained injuries in the form of deep vein thrombosis and pulmonary embolism in an accident that occurred during the course and scope of his employment. The compensation court applied a split test of causation used in heart attack cases, which requires proof of both legal and medical causation. The court then dismissed Appellant’s claim for failure to establish the medical cause prong. The Supreme Court affirmed the dismissal of Appellant’s claim, holding (1) the split test was properly applied to Appellant’s injuries in this case, as deep vein thrombosis and pulmonary embolism present the same difficulties in attributing the cause of a heart attack to a claimant’s work and are similar in origin to a heart attack; and (2) the compensation court’s finding as to causation was not clearly wrong. View "Wingfield v. Hill Bros. Transp., Inc." on Justia Law

In 2004, Appellant fell while working and strained her back. Appellant was awarded worker’s compensation benefits. In 2009, Appellant slipped and fell at work and injured her ankle. In 2010, Appellant sought temporary total disability and medical pay benefits from the Workers Compensation Division, which denied Appellant’s requests. After a contested case hearing, the Office of Administrative Hearings (OAH) upheld the Division’s denial of Appellant’s request for benefits, concluding Appellant did not meet her burden of proving that she suffered aggravation of a preexisting back condition as a result of a work related injury or that she suffered a second compensable injury. The district court affirmed. The Supreme Court affirmed, holding that the OAH did not err by failing to find a causal connection between the 2009 workplace incident and Appellant’s delayed back pain. View "Hirsch v. State ex rel. Wyo. Workers' Safety & Comp. Div." on Justia Law

In 2009, Appellant suffered injuries to both of his knees in a work-related accident. Appellant filed a request for loss of earning compensation. The Workers’ Compensation Court concluded that, notwithstanding findings of permanent impairment, because no permanent physical restrictions were specifically assigned by an expert for Appellant’s left knee, the court could not perform a loss of earning capacity calculation authorized under the third paragraph of Neb. Rev. Stat. 48-121(3) and that Appellant was thus limited to scheduled member compensation. The Supreme Court reversed, holding that the compensation court erred as a matter of law in concluding that there must be expert opinion of permanent physical restrictions as to each injured member in order to perform a loss of earning capacity calculation under section 48-121(3). Remanded. View "Rodgers v. Neb. State Fair" on Justia Law

Between 1996 and 2003, Appellant filed several workers’ compensation claims, which were allowed for certain conditions. Appellant subsequently filed two applications for permanent-total-disability compensation. The Industrial Commission denied the applications, relying in part on the report of Dr. Lee Howard, a psychologist, who determined that Appellant could perform work without significant limitations. Appellant filed a complaint for a writ of mandamus, arguing that the Commission abused its discretion when it relied on Dr. Howard’s report because the report was stale. The court of appeals denied the writ, determining that Dr. Howard’s report was relevant evidence. The Supreme Court affirmed, holding that the Commission did not abuse its discretion when it relied on Dr. Howard’s report in denying permanent-total-disability compensation. View "State ex rel. Bailey v. Indus. Comm'n" on Justia Law

Robert Sheppard was injured while working for Employer. After Sheppard retired, he filed an application for permanent-total-disability (PTD) compensation, which a staff hearing officer granted. Employer filed a request for reconsideration on the basis that the staff hearing officer’s order contained mistakes of fact and law. After a hearing, the Industrial Commission issued an order confirming that the staff hearing officer’s order contained a clear mistake of law and denying the underlying request for PTD compensation. Sheppard filed a complaint for a writ of mandamus alleging that the Commission abused its discretion when it exercised continuing jurisdiction and denied PTD compensation. The court of appeals denied the writ, concluding (1) the staff hearing officer’s mistake of law was sufficient for the Commission to invoke its continuing jurisdiction; and (2) once the Commission properly invoked its continuing jurisdiction, it had authority to reconsider the issue of PTD compensation. The Supreme Court affirmed, holding (1) the staff hearing officer made a mistake of law justifying the exercise of continuing jurisdiction; and (2) the Commission’s continuing jurisdiction vested it with authority to issue a new order denying PTD compensation. View "State ex rel. Sheppard v. Indus. Comm'n" on Justia Law

Robert Corlew was an employee of Honda of America Manufacturing, Inc. when he was injured while working. Honda’s long-term-disability insurance carrier eventually determined that Corlew was not eligible for ongoing disability benefits because he was capable of gainful employment outside of Honda. Corlew subsequently retired because there was no position available at Honda. One year later, Corlew underwent surgery on his wrist. The Industrial Commission awarded temporary-total-disability (TTD) compensation to be paid during Corlew’s postsurgical recovery, concluding that Corlew had not voluntarily retired or abandoned the workforce. The court of appeals denied Honda’s request for a writ of mandamus, concluding that Corlew’s retirement was due to his industrial injury, and thus was involuntary, and that there was no evidence that Corlew had abandoned the entire workforce. The Supreme Court affirmed, holding that Corlew was eligible for TTD compensation even though he suffered no economic loss that could be directly attributed to his industrial injury. View "State ex rel. Honda of Am. Mfg., Inc. v. Indus. Comm'n" on Justia Law

The question before the Supreme Court was whether La. R.S. 23:1203.1 applied to requests for medical treatment and/or disputes arising out of requests for medical treatment in cases in which the compensable accident or injury occurred prior to the effective date of the medical treatment schedule. The Office of Workers’ Compensation (OWC) ruled that the medical treatment schedule applied to all requests for medical treatment submitted after its effective date, regardless of the date of injury or accident. The court of appeal reversed, holding that La. R.S. 23:1203.1 was substantive in nature and could not be applied retroactively to rights acquired by a claimant whose work-related accident antedated the promulgation of the medical treatment schedule. The Supreme Court disagreed with the conclusion of the court of appeal and found that La. R.S. 23:1203.1 was a procedural statute and, thus, did not operate retroactively to divest a claimant of vested rights. As a result, the statute applied to all requests for medical treatment and/or all disputes emanating from requests for medical treatment after the effective date of the medical treatment schedule, regardless of the date of the work-related injury or accident. View "Church Mutual Insurance Co. v. Dardar" on Justia Law