Justia Insurance Law Opinion Summaries

CareFirst, Inc., a nonstock, nonprofit Maryland corporation, is a holding company with two subsidiaries that provides health insurance for millions of Maryland residents. State law confers broad authority on the Maryland Insurance Commissioner to oversee its operation and adherence to its mission. This case arose from the termination of Leon Kaplan, a former executive of CareFirst. CareFirst declined to pay part of the post-termination compensation set forth in Kaplan's employment contract, reasoning that the compensation was not for "work actually performed," as that standard had been interpreted by the Commissioner. The Commissioner affirmed the decision not to pay the benefits, concluding that the payments would violate Md. Code Ann. Ins. 14-139. The Court of Appeals affirmed, holding (1) the Commissioner's determination was not preempted by ERISA; (2) the Commissioner's construction of the insurance code was legally correct; and (3) there was substantial evidence to support the Commissioner's determination in this case. View "Md. Ins. Comm'r. v. Kaplan" on Justia Law

Appellant was placed on disability leave from work. Appellant was covered under a long term disability (LTD) policy that her employer obtained from Medical Group Insurance Services (MGIS). The policy was written by Sun Life Assurance Company (Sun Life). After leaving her job, Appellant filed a claim with MGIS seeing long term disability benefits. Sun Life denied Appellant's request for benefits. Appellant filed an action against Sun Life, asserting various state law claims. The federal district court dismissed the action based on ERISA preemption. Appellant then amended her complaint to add ERISA claims and asked the district court to apply de novo review in its evaluation of her ERISA claims. The court denied the motion and granted summary judgment for Sun Life, concluding that Sun Life's decision to deny benefits was not arbitrary and capricious, and thus complied with ERISA's requirements. The First Circuit Court of Appeals vacated the judgment, holding (1) the safe harbor exception to ERISA did not apply to the policy covering Appellant, and therefore, Appellant's state law claims were preempted; but (2) the benefits denial was subject to a de novo review, rather than the highly deferential "arbitrary and capricious" review prescribed for certain ERISA benefits decisions. Remanded. View "Gross v. Sun Life Assurance Co. of Canada" on Justia Law

At issue in this case was a worker’s compensation claim stemming from an accident at an onion processing plant. Petitioner James Clark was injured when his right forearm was caught in a roller machine which resulted in significant soft-tissue damage. The Industrial Commission determined that Clark suffered a compensable injury and that he was entitled to medical treatment for approximately one year. The Commission also found that Clark had a permanent partial impairment (PPI) of 10% of the whole person and a permanent partial disability rated at 25% of the whole person. Clark appealed that determination pro se, arguing the Commission relied on fraudulent evidence because his medical records were fraudulently obtained. Finding no error, the Supreme Court affirmed. View "Clark v. State Ins Fund" on Justia Law

Retirees, dependents of retirees, and the union filed a class action suit against the retirees’ former employer, M&G, after M&G announced that they would be required to make health care contributions. The district court found M&G liable for violating a labor agreement and an employee welfare benefit plan and ordered reinstatement of the plaintiffs to the current versions of the benefits plans they were enrolled in until 2007, to receive health care for life without contributions. The Sixth Circuit affirmed. The district court properly concluded that the retirees’ right to lifetime healthcare vested upon retirement after concluding that documents, indicating agreement between the union and the employers to “cap” health benefits and several “side” letters were not a part of the applicable labor agreements. View "Tackett v. M&G Polymers USA, LLC," on Justia Law

Frazier, a sorter for Publishers Printing, was covered by Publishers’ employee benefit plan, which provided disability insurance. In 2009, at age 42, she left her job due to back pain that radiated down her legs, which she thought was caused by arthritis and a bulging disc, though she could not remember any fall or injury that initiated the pain. An MRI revealed mild disc dislocation. Her family physician diagnosed her with lower back pain and radiculopathy and in 2010 opined that Frazier was unable to return to work at regular capacity. Frazier participated in limited physical therapy. Another physician prescribed lumbar epidural injections and eventually permitted her to return to work. The plan denied Frazier’s claim for long-term disability benefits after reviewing medical evidence and job descriptions from Publishers and the U.S. Department of Labor. A Functional Capacity Evaluation indicated that Frazier “is currently functionally capable of meeting the lower demands for the Medium Physical Demand level on a 8 hour per day.” Frazier sued under the Employee Retirement Income Security Act, 29 U.S.C. 1001. The district court granted judgment for the plan, reasoning that the administrator had discretion to deny Frazier’s claim, and that denial of benefits was not arbitrary. The Sixth Circuit affirmed. View "Frazier v. Life Ins. Co. of N. Am." on Justia Law

The plant’s union and TRW negotiated collective bargaining agreements, which included provisions for healthcare benefits for retirees. The last CBA became effective in 1993 and was scheduled to expire in 1996. The plant closed in 1997. TRW and the union entered into a termination agreement that provided that any beneficiary, who is receiving or entitled to receive any payment and/or benefit under the CBA, “shall continue to receive or be entitled to receive such payment and/or benefit as though the CBA and Pension Plan had remained in effect.” In 2011, TRW terminated prescription drug coverage for Medicare-eligible retirees, replacing it with an annual contribution to a health reimbursement account. Plaintiffs claimed that this change modified their benefits in violation of TRW’s contractual obligation and filed a purported class action under the Labor Management Relations Act, 29 U.S.C. 185(a), and a claim for benefits under the Employment Retirement Income Security Act, 29 U.S.C. 1132(a)(1)(B). The district court granted TRW’s motion to compel arbitration. The Sixth Circuit affirmed as to the two named Plaintiffs, declining to address the rights of hypothetical plaintiffs. View "VanPamel v. TRW Vehicle Safety Sys., Inc." on Justia Law

Petitioner Allen Davenport appealed a judgment affirming a Workforce Safety and Insurance ("WSI") decision to terminate benefits on his claim for treatment of his cervical spine and left shoulder and denying his claims for benefits for treatment of his anxiety and depression and lower back condition. He argued his anxiety and depression and his cervical spine, left shoulder and back conditions were "compensable injuries." Upon further review, the Supreme Court concluded Davenport failed to establish by a preponderance of the evidence that work incidents subject to this claim substantially accelerated the progression of, or substantially worsened the severity of, his existing conditions and that his physical injury caused at least 50 percent of his anxiety and depression. View "Davenport v. WSI" on Justia Law

Following Appellant Darren Pollack's injury on the job, his employer accommodated his work restrictions by providing him light duty employment. Later, Appellant was discharged for violating a company policy by failing to report an accident involving an employer vehicle. Appellant filed a claim seeking Temporary Total Disability benefits. The Workers' Compensation Commission denied the claim, holding Appellant's termination and resulting incapacity to earn wages was due to his violation of company policy and not his work-related injury. Finding no error in the Commission's decision, the Supreme Court affirmed. View "Pollack v. Southern Wine & Spirits" on Justia Law

Plaintiff injured his shoulder while working for his employer, who was insured by the Montana State Fund. The State Fund paid for Plaintiff's two shoulder injuries and paid temporary total disability (TTD) benefits after informing Plaintiff that if he returned to gainful employment without the State Fund's knowledge and continued to receive benefits, he would be subject to legal action or criminal prosecution. After the State Fund discovered that Plaintiff had built and sold furniture and worked at a vacuum cleaner store while receiving TTD benefits, the assistant attorney general charged Plaintiff with theft, a felony. The State Fund subsequently terminated Plaintiff's TTD benefits. Plaintiff filed suit against the State fund and its private investigators, alleging that Defendants violated Montana's Insurance Code regarding unfair claim settlement practices and pleaded a variety of common law causes of action. The district court ruled in favor of Defendants. The Supreme Court affirmed the district court's entry of judgment in favor of the State Fund, holding that the district court did not err in (1) granting the State Fund's motion to dismiss Defendant's claims under the Insurance Code; and (2) granting the State Fund's motion for summary judgment regarding Plaintiff's common law claims. View "White v. State ex rel. Mont. State Fund" on Justia Law

Defendant City of Burlington Retirement System appealed a superior court judgment that reversed its decision to terminate the disability retirement of plaintiff, a former City firefighter. Upon review, the Supreme Court concluded the record fully supported the superior court's conclusion that there was no reasonable basis for the Board's decision to terminate plaintiff's disability retirement. View "Preston v. Burlington City Reitrement System" on Justia Law