Justia Insurance Law Opinion Summaries

The Supreme Court granted certiorari in this case to consider whether La. R.S. 23:1203.1 applied to a dispute arising out of a request for medical treatment where the request for treatment was submitted after the effective date of the statute and the medical treatment schedule, but the compensable accident and injury that necessitated the request occurred prior to that date. Both the Office of Workers’ Compensation (OWC) and the court of appeal ruled that La. R.S. 23:1203.1 applied to all requests for medical treatment submitted after the statute’s effective date, regardless of the date of accident and injury. Finding no reversible error, the Supreme Court affirmed. View "Cook v. Family Care Services, Inc." on Justia Law

Holder was an Illinois correctional officer since 2006. His wife began to suffer from mental health problems relating to opiate dependency. The Family and Medical Leave Act (FMLA) entitles eligible employees to 12 work weeks of leave during a 12-month period to care for a spouse with a serious medical condition, 29 U.S.C. 2612(a)(1). In October 2007, Holder submitted an FMLA certification form. His wife’s psychiatrist indicated that it would “be necessary for the employee to take off work only intermittently or to work less than a full schedule as a result of the condition,” and that the need for leave would continue for an “unknown” duration. The request was approved. The state never asked for additional medical documentation and paid its share of his health insurance premium until April 18, 2008. About 130 days of absence were recorded on a day-by-day basis. On April 18, 2008, Holder was advised that his FMLA leave had expired and that additional leave would be under the Illinois Family Responsibility Leave program, which allows up to a year of unpaid leave; the state only covers insurance premiums for six months. In April-June 2008, Holder took 29 absences, citing the state program. The Warden disapproved requests for June 8-9 and on the denied form, Holder wrote “last one!!!” Eight months later Central Management Services informed Holder that the state had mistakenly paid for his health insurance premiums beyond his entitlement and began deducting 25% of his earnings until he had refunded $8,291.83. Holder sued, claiming interference with FLMA rights. The jury returned a verdict in favor of the state, but the judge entered judgment awarding Holder $1,222.10 for January 2008, but entered a judgment for the state for the rest of the months. The Seventh Circuit affirmed. View "Holder v. IL Dep't of Corrs." on Justia Law

This case arose out of dispute over the administration of a workers’ compensation self-insurance plan (“Plan”) administered by Herkimer County. Dozens of municipalities participated in the Plan, including the Village of Herkimer. In 2005, the County passed a resolution to terminate the plan. To ensure funding for outstanding workers’ compensation claims, the County created an Abandonment Plan that allowed municipalities to withdraw from the plan and pay a lump sum withdrawal fee. Several of the participating municipalities, including the Village, filed an action challenging the Plan and Abandonment Plan based on alleged mismanagement by the County. The County counterclaimed for breach of contract, seeking to recover the withdrawal liability. The County prevailed on summary judgment as to the liability on its counterclaim for breach of contract against the Village. After a trial on damages, the jury awarded the full amount of damages sought by the County against the Village. The Appellate Division affirmed the damages award. The Court of Appeals affirmed as modified, holding that the fee for the Village’s withdrawal from the Plan reflected benefits to be paid in the future and therefore should have been discounted to its current value as of the date it was due. View "Village of Ilion v. County of Herkimer" on Justia Law

Workforce Safety and Insurance appealed a district court judgment affirming an administrative law judge's order finding William Snook and other similarly situated welders were independent contractors. The Supreme Court affirmed, concluding the ALJ's findings of fact were supported by a preponderance of the evidence and the conclusions of law were supported by those facts. View "WSI v. Larry's On Site Welding" on Justia Law

Dennis Whedbee appealed a district court judgment affirming Workforce Safety and Insurance's ("WSI") binding dispute resolution denying Whedbee's request for a myoelectric prosthesis and approving a body-powered prosthesis. Whedbee argued the binding dispute resolution was an abuse of discretion and violated his due process rights. He argued that WSI should have selected an independent medical examiner located closer to his residence and that his treating physician's opinion should have been given controlling weight. Finding no reversible error, the Supreme Court affirmed. View "Whedbee v. WSI" on Justia Law

Respondent-claimant, Ben Snell was employed by petitioner-employer Kentucky Fried Chicken of McAlester. He alleged that while at work he slipped and fell while carrying a tray of chicken weighing approximately 40 to 50 pounds. The trial court awarded claimant temporary total disability (TTD) and reasonable and necessary medical treatment for injuries to his neck, the second finger of his right hand, and aggravation of pre-existing conditions to his left knee and low back. All other issues were reserved. On appeal, the Court of Civil Appeals (COCA) sustained the award. In its opinion, COCA ruled the standard of review in this case was the "any competent evidence" standard because of a holding in a previous opinion by the same division, "Westoak Industries, Inc. v. DeLeon," which held 85 O.S. 2011 sec. 340(D)(4), setting out "against the clear weight of the evidence" as the appellate standard of review in workers' compensation cases, constituted a violation of the separation of powers provision of the Oklahoma Constitution. Westoak was completely at odds with another COCA opinion, "Harvey v. Auto Plus of Woodward." "Harvey" held section 340(D)(4) was not unconstitutional as a separation of powers violation. The Supreme Court granted certiorari to consider the issue as one of first impression since certiorari was not sought in either of the previous cases. The Court concluded that there was no constitutional separation of powers prohibition in in the Okla.Const., art IV, section 1 against the Legislature's adoption of the "against the clear weight of the evidence" standard of review in 85 O.S. 2011 sec. 340(D)(4). COCA's opinion was therefore vacated. Because "Westoak" and "Harvey" were totally inconsistent with the views expressed in this opinion, they were both specifically overruled. View "Kentucky Fried Chicken of McAlester v. Snell" on Justia Law

Claimant was injured at work as she walked out a door used by employees to exit Employer's school building. A rug outside the door slipped out from under her, causing her to fall. At the time of this accident, claimant was leaving work early due to a family medical emergency. The Workers' Compensation Court found this injury to be compensable, but the Court of Civil Appeals ruled it was not. The Court of Civil Appeals held that claimant was on a personal mission at the time of the injury and vacated the award of benefits. The dispositive question for the Supreme Court's review was whether Claimant's injury while leaving work in response to a family medical emergency arose out of her employment. The Workers' Compensation Court answered this question in the affirmative. Upon review, the Supreme Court agreed, and reversed the Court of Appeals. View "Graham Public Schools v. Priddy" on Justia Law

Plaintiffs worked until 2006, when the plant closed, and retired under a collective bargaining agreement (CBA); that provided that the employer would provide health insurance, either through a self-insured plan or under a group insurance policy and identified the employer’s contribution to the premium. The CBAs provided that the coverage an employee had at the time of retirement or termination at age 65 or older other than a discharge for cause “shall be continued thereafter provided that suitable arrangements for such continuation[] can be made… In the event… benefits … [are] not practicable … the Company in agreement with the Union will provide new benefits and/or coverages as closely related as possible and of equivalent value." In 2011 TRW (the employer’s successor) stated that it would discontinue group health care coverage beginning in 2012, but would be providing “Health Reimbursement Accounts” (HRAs) and would make a one-time contribution of $15,000 for each eligible retiree and eligible spouse in 2012, and in 2013, would provide a $4,800 credit to the HRAs for each eligible party. The HRAs shifted risk, and potentially costs, to plaintiffs. TRW did not commit to funding the HRAs beyond 2013. Plaintiffs sued, claiming that the change breached the CBAs, in violation of the Labor-Management Relations Act, 29 U.S.C. 185, and the Employee Retirement Income Security Act, 29 U.S.C. 1001. The district court certified a class and granted summary judgment, ruling that the CBAs established a commitment to lifetime health care benefits. The Sixth Circuit affirmed View "United Steel, Paper, Forestry, Rubber, Mfg. Energy, Allied Indus. & Serv. Workers Int'l Union v. Kelsey-Hayes Co." on Justia Law

Levon Flowers made a workers' compensation claim against his former employer Crown Cork & Seal USA. The Supreme Court granted Crown’s petition for certiorari to review the compensability of a foot injury Flowers sustained in 2007. The Workers’ Compensation Commission denied Flowers’s request for permanent disability benefits for this injury and awarded temporary total disability benefits for the period between the injury and the date Flowers was cleared by his doctor to return to work. The Court of Appeals reversed, finding that Flowers was entitled to receive temporary total disability benefits until he reached maximum medical improvement (MMI) for his foot injury, which had not yet been determined by his doctors. Upon review, the Supreme Court found that the Court of Appeals reached the correct result in this case, but the Supreme Court reached that conclusion based on different precedent. The record in this case reflected that Crown refused to reinstate or rehire Flowers after his doctors released him to return to work. There was also evidence that Flowers underwent an unsuccessful search for alternative employment after Crown refused to rehire him. However, the ALJ and the Commission did not determine when Flowers reached MMI for his foot injury. From the testimony of Flowers' doctor, Flowers had not yet reached MMI as of January 14, 2008. Therefore, this case was not controlled by the Court's holding in "Jordan:" "[the Court] reiterate[d] that it is a primary duty of the Commission to analyze the evidence and determine whether and when a claimant has reached MMI. [. . .] After determining when Flowers reached MMI for his foot injury, the Commission must decide from the evidence presented whether Flowers is entitled to permanent disability benefits." View "Flowers v. Crown Cork & Seal USA, Inc." on Justia Law

Employee worked for Employer from 1977 through the date of the trial of this matter. Employee began having problems with his arms and hands in 2005. In 2009, Employee had carpal tunnel release surgery performed on his arms. Employee began having problems with his right thumb shortly after his surgeries. A surgical procedure to release the thumb was performed in 2010. In 2013, the trial court awarded permanent partial disability benefits to Employee but ruled that Employee’s injury should be apportioned to the arm, which was subject to an impairment “cap.” Employee appealed, arguing that the award should have been apportioned to the thumb, which was not subject to the cap. The Supreme Court affirmed, concluding that the trial court correctly chose to apportion Employee’s injury to the arm. View "Evans v. Fidelity & Guar. Ins. Co. " on Justia Law