Justia Insurance Law Opinion Summaries

Articles Posted in Labor & Employment Law
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Angela Frye filed a workers' compensation claim against her employer alleging that in 2008 she suffered a work-related injury. The administrative law judge (ALJ) awarded Frye benefits related to the injury. In 2009, after the final hearing in the 2008 claim but before the ALJ took that claim under submission or rendered an opinion, Frye allegedly suffered a second work-related injury. In 2010, Frye filed a claim related to the 2009 accident. The ALJ dismissed the 2010 claim, concluding that Frye was required by Ky. Rev. Stat. 342.270(1) to file her claim for benefits related to the 2009 accident and join it to her pending 2008 claim, which she failed to do. The Workers' Compensation Board reversed, concluding that a claim is no longer pending for section 342,270(1) purposes after the date of the final hearing. The court of appeals affirmed. The Supreme Court affirmed, holding that in this case and under these facts, Frye's first injury claim was not pending between the date of the hearing and the date the ALJ rendered his opinion regarding that claim. Remanded. View "Saint Joseph Hosp. v. Frye" on Justia Law

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The worker was injured in a 2006 automobile accident near Cordova, where he was working temporarily for Venture. Cordova is 200 miles from Springfield, where he lived and where his plumbers’ and pipefitters’ union was. He was living a motel 30 miles from the worksite with a coworker, also from Springfield, who was driving when the accident occurred. An arbitrator denied his workers’ compensation claim. The Workers’ Compensation Commission reversed; the trial court set aside the Commission’s finding. The Workers’ Compensation Division of the Appellate Court granted relief to the worker. The Illinois Supreme Court reversed, holding that the worker was not a “traveling employee” and could not be compensated. An injury incurred by an employee in going to or returning from the place of employment is not compensable, because it is not arising out of or in the course of employment, unless the worker can be categorized as a “traveling employee.” The employer did not direct the worker to accept the position at the Cordova location; he accepted it with full knowledge of the commute involved. His course or method of travel was not determined by the demands and exigencies of the job. He was not reimbursed for travel time or expenses or told what route to take.View "The Venture-Newberg Perini Stone v. IL Workers' Compensation Comm'n" on Justia Law

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Steve Sangwin, a State employee, was a qualified subscriber and beneficiary of the State of Montana Employee Benefits Plan (Plan), which was administered by Blue Cross and Blue Shield of Montana (BCBS). Steve's daughter, McKinley, was also a beneficiary under the Plan. This case arose after BCBS denied a preauthorization request for a medical procedure for McKinley on the grounds that the procedure was "experimental for research." Steve and his wife (collectively, the Sangwins) initiated this action by filing an amended complaint setting forth five counts, including a request for certification of a class action. The Sangwins defined class members as other beneficiaries of the Plan who had their employee benefits denied by the State based on the experimental exclusion for research in the past eight years. The district court granted the Sangwins' motion for class certification. The State appealed. The Supreme Court (1) affirmed the district court's order defining the class; but (2) reversed and remanded with respect to the question certified for class treatment, holding that the district court abused its discretion in specifying for class treatment the question of whether the State breached its contract of insurance with the plaintiffs. View "Sangwin v. State" on Justia Law

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Plaintiff was injured during the course of his employment when he was struck by a sheet of plywood that fell from a building under construction. Plaintiff received workers' compensation benefits for his injuries and then filed this personal injury action. Thereafter, the insurance carrier for Plaintiff's employer filed a motion to discontinue Plaintiff's workers' compensation benefits. An administrative law judge found Plaintiff had no further causally-related disability and that he had no further need for treatment. The Workers' Compensation Board Panel (Board) affirmed. Subsequently, in this negligence action, Defendants moved for an order estopping Plaintiff from relitigating the issue of causally-related disability. Supreme Court granted the motion. The Appellate Division reversed, concluding that the determination of the Board was one of ultimate fact and thus did not preclude Plaintiff from litigating the issue of his ongoing disability. The Court of Appeals affirmed, holding that Defendants failed to establish that the issue decided in the workers' compensation proceeding was identical to that presented in this negligence action. View "Auqui v. Seven Thirty One Ltd. P'ship" on Justia Law

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Sherry Walker was denied disability benefits by the Public Employees’ Retirement System (PERS). The Circuit Court reversed PERS’s decision. The Court of Appeals reversed the circuit court, reinstating PERS’ denial of benefits. Upon review of the matter, the Supreme Court concluded PERS’ decision to deny Walker’s request for regular disability benefits was unsupported by substantial evidence. Accordingly, the Court reversed part of the appellate court's decision and reversed the Circuit Court's decision, and remanded the case with instructions to enter judgment in Walker’s favor on her regular disability benefits claim. View "Public Employees' Retirement System v. Walker" on Justia Law

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Appellant suffered work-related injuries in 2000 and received workers' compensation benefits until 2004. Appellant filed another first report of injury in 2009 based on the same injuries. Employer denied benefits. Appellant filed a petition for rehearing. The Department of Labor & Regulation, Division of Labor & Management found that S.D. Codified Laws 62-7-35.1 barred Appellant's second claim for workers' compensation benefits because more than three years had passed between the date of the last payment of benefits and the date Appellant filed a written petition for a hearing. The circuit court affirmed. Appellant appealed, arguing section 62-7-35.1 should not apply to this case because his injuries were from cumulative trauma. The Supreme Court affirmed, holding that the cumulative trauma doctrine did not change section 62-7-35.1's application to this case because the cumulative trauma doctrine applies to the date of injury, which is irrelevant to section 62-7-35.1. View "Schuelke v. Belle Fourche Irrigation Dist." on Justia Law

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Employee was injured while working as a truck driver for Employer. Employee's claim was allowed for the injuries. The next year, Employee returned to work. Two days later, Employer terminated Employee for violating written work rules. A staff hearing officer later denied temporary total disability (TTD) compensation, determining that Employee's termination was a voluntary abandonment of employment that barred compensation for TTD. The court of appeals concluded that the Industrial Commission abused its discretion in determining that Employee was ineligible for TTD compensation based upon his termination from Employer and granted mandamus relief to Employee. The Supreme Court (1) reversed, holding that the Commission's order did not meet the standards of State ex rel. Noll v. Indus. Comm'n because the court did not specifically state the evidence relied upon or explain the reason behind its decision that Employee had voluntarily abandoned his employment with Employer; and (2) returned the matter to the Commission to issue a new order stating the evidence relied upon and explaining its reasoning consistent with Noll. View "State ex rel. Cline v. Abke Trucking, Inc." on Justia Law

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Claimant-Appellant Dallas Clark appealed an Industrial Commission order that denied her workers' compensation benefits. Claimant worked for Shari's Management Corporation as an experienced server. During a graveyard shift, she suffered a herniated disc in her back while lifting a heavy tray onto a high shelf. She would later be diagnosed with sciatica attributed to the lifting injury from work. Shari's completed a Report of Injury, interviewing Claimant in the process. The investigator testified that Claimant attributed the injury as "standing wrong" at a salad bar, which left her unable to lift the tray. The Commission concluded after a hearing that Claimant was unable to prove an industrial accident had occurred. The Supreme Court agreed with the Commission and affirmed its order. View "Clark v. Shari's Management Corp" on Justia Law

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The NECA-IBEW Health and Welfare Fund provides health benefits to members of a local union of electrical workers. The Fund negotiated a Local Agreement with Sav-Rx, a provider of prescription-drug benefits, under which Sav-Rx reimburses pharmacies for dispensing medication and then invoices the Fund for some of its costs. The Local Agreement does not call for arbitration. A few months later, Sav-Rx negotiated a different agreement with the national organization of the IBEW, with which the local is affiliated. The National Agreement offers locals reduced charges and more services than the Local Agreement and contains a mandatory arbitration clause. Local unions and funds could opt into the National Agreement, but the Fund's trustees never voted on the matter. Over the next eight years the Fund accepted from Sav-Rx services provided by the National Agreement. The Fund sued Sav-Rx for invoicing the Fund at rates not authorized by either the Local or National Agreement. The district court dismissed, finding that Fund had accepted the benefits of the National Agreement and was bound to it; Sav-Rx established that the Fund knew it was accepting benefits under the National Agreement. The Seventh Circuit affirmed. View "NECA-IBEW Rockford Local Union 364 Health & Welfare Fund v. A&A Drug Co." on Justia Law

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In consolidated appeals, the issue before the Supreme Court was whether the manifestation of an occupational disease outside of the 300-week period prescribed by Section 301(c)(2) of the Workers’ Compensation Act removes the claim from the purview of the Act, such that the exclusivity provision of Section 303(a) does not apply. After careful consideration, the Supreme Court concluded that claims for occupational disease which manifest outside of the 300-week period prescribed by the Act do not fall within the purview of the Act, and, therefore, that the exclusivity provision of Section 303(a) does not apply to preclude an employee from filing a common law claim against an employer. Accordingly, in these cases, the Court reversed the Superior Court's decision. View "Tooey v. AK Steel" on Justia Law