Justia Insurance Law Opinion Summaries

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

While working for Employer, Employee filed notice of a workers' compensation claim related to a lower back injury he received during the course of his employment. Employee was discharged approximately four years later pursuant to a termination agreement that provided that he agreed to release Employer from any and all workers' compensation claims. Employer later brought an action against Employee, alleging civil theft, fraud, unjust enrichment, and conversion based on Defendant's admission that he never intended to release his workers' compensation claim. Employee counterclaimed, claiming that Employer's cause of action was in retaliation for Employee's decision to exercise his rights under the Workers' Compensation Act. Employer filed a motion to dismiss the counterclaim, asserting that the doctrine of absolute immunity shielded Employer from the counterclaim. The trial court denied the motion. The Supreme Court affirmed the trial court's decision denying Plaintiff's motion to dismiss, holding that an employer's right to seek redress for its alleged grievances in court does not outweigh an employee's interest in exercising his rights under the Act without fear of retaliation by his employer, and therefore, absolute immunity did not shield Employer from Employee's counterclaim. View "MacDermid, Inc. v. Leonetti" on Justia Law

Appellant Annette Shoap sustained a work-related injury in the nature of a left shoulder injury while working as an employee of Phoenixville Hospital. She began receiving temporary total disability benefits pursuant to a Notice of Compensation Payable dated 2003. The treatment for Appellant’s injury included three surgeries and physical therapy. In 2007, the employer filed a modification petition alleging both that Appellant’s physical condition had improved and that work was generally available to her within her physical restrictions in the relevant geographical area, as demonstrated by two labor market surveys. Appellant denied the material allegations of Employer’s petition, and a hearing was held before a Workers’ Compensation Judge. After the WCJ ruled in the employer's favor, Appellant unsuccessfully appealed to the Workers' Compensation Appeal Board and Commonwealth Court. On appeal to the Supreme Court, Appellant asserted that the Commonwealth Court erred by concluding that “substantial gainful employment existed” for purposes of granting a modification of her compensation benefits pursuant to Section 306(b) of the Workers' Compensation Act, despite the fact that her application for the specific jobs involved failed to result in any offers of employment. Secondarily, Appellant argued that the Commonwealth Court, even if correct in its interpretation of Section 306(b), erred by not remanding the case for further evidentiary development based on its interpretation of Section 306(b), which Appellant contended represented a change in the standard for evaluating cases under that statute. After careful review, the Supreme Court agreed with Appellant's second contention, and reversed and remanded for further proceedings. View "Phoenixville Hospital v. WCAB (Shoap, Aplt)" on Justia Law

Claimant-appellee and cross-appellant-appellant Amanda Wyatt appealed a Superior Court judgment reversing an Industrial Accident Board finding that she had a compensable, work-related injury. The employer-appellant and cross-appellee-appellee is Wyatt’s former employer, Rescare Home Care. On appeal, Wyatt argued: (1) the Superior Court erred in reversing the Board’s decision that her injury was a compensable industrial accident, since the Board’s decision was based upon substantial evidence; and (2) the Board erred in denying the medical expenses for her emergency back surgery. After careful consideration, the Supreme Court concluded the Superior Court erred in reversing the Board’s decision that the Claimant had a compensable work related injury. Furthermore, the Court concluded the Board properly determined that her back surgery was not compensable. View "Wyatt v. Rescare Home Care" on Justia Law

Claimant was employed at a secure juvenile detention facility operated by the State Office of Children & Family Services (OCFS) when she was assaulted, raped, and abducted by a resident. Claimant received workers' compensation benefits for her injuries. Claimant also filed a civil rights lawsuit in federal district court against OCFS and three supervisory OCFS employees seeking, inter alia, punitive damages. The federal lawsuit was settled. The New York State Insurance Fund (SIF), the workers' compensation carrier in this case, approved the settlement. In so doing, SIF reserved its right to take a credit against Claimant's payments of benefits until the credit was exhausted. The Workers' Compensation Law judge (WCLJ) decided that SIF was not entitled to offset the proceeds of a civil rights lawsuit that sought punitive damages. On appeal, the Workers' Compensation Board found in SIF's favor. The Appellate Division affirmed. The Court of Appeals affirmed, holding that, in light of the terms of the settlement in this case, SIF could take a credit against the settlement proceeds of Claimant's lawsuit against her employer and coemployees for injuries arising from the same incident for which Claimant received worker's compensation benefits. View "Beth V. v. State Office of Children & Family Servs." on Justia Law

In 2007, Appellant purchased the assets of an indoor football team owned by Omaha Beef, LLC. In 2008, Appellant applied for workers' compensation insurance under the Nebraska Workers' Compensation Plan, arguing that it was entitled to a certain experience modifier (XMod), which is used when calculating the premium owed, because it was a new entity with no claims experience. The National Council on Compensation Insurance, Inc. determined that Appellant was a successor entity to Omaha Beef, and thus, the various XMods assigned to Omaha Beef for the relevant time periods must be transferred to Appellant. The director of the Department of Insurance affirmed. The district court affirmed, reasoning that Appellant was a successor to Omaha Beef and that the change in ownership resulted in the transfer of the workers' compensation rating for Omaha Beef to Appellant. The Supreme Court affirmed, holding that the district court did not err in finding (1) Appellant had the burden of proof to show there was no "change in ownership"; and (2) a "change in ownership" existed such that the XMod of Omaha Beef should be transferred to Appellant. View "Gridiron Mgmt. Group, LLC v. Travelers Indem. Co." on Justia Law

The Supreme Court granted certiorari in this case to address two issues: (1) whether a political-subdivision employer may be required to provide workers' compensation benefits to an off-duty employee injured while providing services to a private entity; and (2) whether, under the facts presented, the claimant's salaries from his full-time employment as a deputy sheriff and his part-time job as a security officer may be combined when determining the amount of benefits to which the employee is entitled. Respondent-claimant John David Waldenville was injured while acting as a security guard for petitioner Cattlemen's Steakhouse, Inc. Initially, Cattlemen's contended that Waldenville was an independent contractor but later conceded that it had workers' compensation coverage for him through their insurer. Nevertheless, the employer continued to assert that Waldenville was an employee of respondent, Oklahoma County Sheriff's Department when injured. The trial court determined that: Cattlemen's was the employing entity when the employment-related injury occurred; Oklahoma County should be dismissed pursuant to 85 O.S. 2001 sec. 2b(G); Cattlemen's was estopped to dispute employee status based on the payment of workers' compensation premiums associated with Waldenville's employment; no evidence existed indicating that the employee was acting in his official capacity as a Deputy Sheriff at the time of the incident; and because the duties that Waldenville was carrying out at the time of his injury were the same or similar to those he executed as a Deputy Sheriff, the claimant's salaries were to be combined for establishment of weekly rates. The Supreme Court held that: (1) the "plain, clear, unmistakable, unambiguous, mandatory, and unequivocal" language of 85 O.S. 2011 sec. 313(G) mandated that private employers, hiring off-duty municipal employees, alone shall be responsible for the payment of workers' compensation benefits arising from incidents occurring during the hours of actual employment by the private employer; and (2) under the facts of this case, claimant was engaged in the same, or substantially similar, employment to that of his profession as a Major with the Oklahoma County Sheriff's Department when he was injured, warranting the combination of salaries for purposes of determining workers' compensation benefits. View "Cattlemen's Steakhouse, Inc. v. Waldenville" on Justia Law

Plaintiff filed suit against Prudential, the plan administrator, and BioMerieux, her employer, after Prudential denied her long-term disability and short-term disability benefits. The district court entered summary judgment in favor of Prudential and BioMerieux. Plaintiff appealed. The court concluded that the language at issue in both plans was ambiguous and did not clearly confer discretionary decision-making authority on the plan administrator. Therefore, the administrator's eligibility determinations denying benefits to a covered employee were subject to de novo judicial review, and the district court erred in reaching a contrary conclusion. The court further held that the district court erred in concluding that the employer's group insurance plan required objective proof of disability in order for an employee to qualify for plan benefits. Accordingly, the court vacated and remanded for further proceedings. View "Cosey v. The Prudential Ins. Co." on Justia Law

The City of Gadsden and certain members of the State Employees' Insurance Board appealed two circuit court orders that granted injunctive relief to John Boman. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. In 2000, Gadsden elected to join the 'Local Government Health Insurance Plan,' a health benefit plan administered by the Board. When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and other ailments. After his 65th birthday, Blue Cross began denying his claims for medical treatment based on the failure to provide Blue Cross with a 'record of the Medicare payment.' However, Boman had no Medicare credits. When the dispute over coverage arose, Boman sought review by the Board. The Board denied Boman's request for an appeal. Boman and 18 other active and retired Gadsden police officers sued Gadsden, alleging, among other things, that they had 'been deprived of Social Security and Medicare protection which other police officers have been provided' and that, after 20 years of service, they were being required to pay a higher pension charge or percentage of base pay than their counterparts who were hired after April 1, 1986. In 2011, Boman filed a 'motion for immediate relief for medical care.' The Supreme Court found that the circuit court issued preliminary injunctive relief against Gadsden without requiring Boman to give security and without making any specific findings. As such, the Supreme Court had "no alternative but to reverse" the preliminary injunction issued against Gadsden and remanded the case for further proceedings. View "City of Gadsden v. Boman " on Justia Law

While employed by Employer, Appellant sustained an injury. Appellant filed an industrial injury claim. Employer's insurer (Insurer) partly accepted the claim but later closed Appellant's claim. After unsuccessfully filing three requests to reopen his claim, Appellant filed a fourth request, which was again denied by Insurer. A hearing officer affirmed the denial. Appellant administratively appealed. Insurer moved to dismiss, arguing that Appellant was precluded from reopening his claim under the doctrine of res judicata. The appeals officer granted Insurer's motion. The district court denied Appellant's petition for judicial review, concluding that Apellant failed to state a new cause of action that could withstand the application of res judicata. The Supreme Court reversed, holding that because the district court failed to provide any findings of fact or conclusions of law, the court could not properly review the appeals officer's determination that there was no change of circumstances warranting reopening under Nev. Rev. Stat. 616C.390. Remanded. View "Elizondo v. Hood Machine, Inc." on Justia Law