Justia Insurance Law Opinion Summaries

The issue before the Supreme Court in this case concerned the scope of Clackamas County's contractual obligation to provide health insurance benefits to command officer retirees of the County Sheriff's Office. A contract between the county and command officers, including Plaintiff Neil James, required the county to use a particular fund to pay for a certain level of benefits to command officers after they retired. The contract added that the obligation to pay benefits was "contingent upon the availability of sufficient funding in said fund to pay for the same." After plaintiff retired, the cost of insurance premiums increased to the point where the fund was and would for the foreseeable future continue to be insufficient to pay for the benefits required. The county entered into a new contract with certain union employees to provide lesser benefits from a more stable fund, and plaintiff (a retired officer, not a union employee) also was provided those lesser benefits. Plaintiff brought an action against the county, asserting breach of contract. He maintained that the first contract required the county to pay him full health insurance benefits and argued that the contingency provision did not apply because of the creation of the new fund, which had sufficient money to pay for those benefits. The trial court entered judgment in favor of plaintiff, but the Court of Appeals reversed. Upon review, the Supreme Court concluded that the new fund was the product of a contract that was separate and independent from the earlier contract. Because the prior fund was insufficient to provide the agreed level of benefits, the county did not breach its contractual obligation to provide that level of benefits. Accordingly, the Court affirmed the appellate court's decision. View "James v. Clackamas County" on Justia Law

In 2002, Employee suffered injuries in a work-related accident and was rendered a paraplegic. Employer and its insurer accepted liability for Employee's injuries and paid various workers' compensation benefits. In 2010, Employee filed a medical request seeing payment for the installation of a ceiling-mounted motorized lift system. A compensation judge (1) determined that the cost of making the structural changes was compensable under Minn. Stat. 176.135 because those changes were necessary to provide Employee with reasonable and necessary medical treatment, and (2) ordered Employer and its insurer to pay for the modifications in their entirety. The workers' compensation court of appeals reversed, concluding that the changes to Employee's home necessary to permit installation of the lift system constituted "alteration or remodeling" of Employee's home and that Employer's liability was therefore limited by Minn. Stat. 176.137. The Supreme Court affirmed, holding that the cost of the structural modifications to Employee's residence that were necessary to permit the ceiling-mounted track system to be installed were "alteration or remodeling" costs subject to section 176.137 and were not costs of medical treatment. View "Washek v. New Dimensions Home Health & State Fund Mut. Ins. Co. " on Justia Law

Appellant Mary E. Spellman ("Spellman") petitioned the Industrial Accident Board (the "Board") for a workers' compensation award against her employer, Appellee Christiana Care Health Services ("Christiana"). The Board denied the petition and the Superior Court affirmed. Appellant worked as a home health aide, where she used her personal vehicle to attend to Christiana's clients at their homes. While Appellant was reimbursed for mileage between client appointments, she was not reimbursed for travel to the first appointment, from the last appointment, or "off the clock" when she attended to personal business. In the middle of her work day, Appellant was off the clock when her car hit a patch of ice causing Appellant to crash her car. She sustained injuries to her head and hip. In her petition, Appellant argued that her status as a traveling employee exempted her from the "going and coming" rule that precludes workers' compensation for injuries suffered while going or coming from work. Alternatively, Appellant argued her injuries were compensable because she was engaged in a "mixed purpose" trip at the time of her accident. Having "no difficulty" sustaining the judgment of the Superior Court, the Supreme Court affirmed. View "Spellman v. Christiana Care Health Services" on Justia Law

Petitioner-Claimant Nancy Bertrand injured her right foot when she slipped on a wet floor while employed as a child care worker for Respondent Laura Dester Center (Employer). She sought certiorari review of the opinion of the Court of Civil Appeals (COCA) which sustained the Workers' Compensation Court's (WCC) denial of her request for travel costs to and from a vocational rehabilitation facility. Claimant contended that her allowance for travel expenses was effectively eliminated under the new Workers' Compensation Code, enacted August 26, 2011, which set a minimum for reimbursement of twenty miles round-trip. Claimant's total round-trip mileage was fourteen miles for which she was previously paid prior to the effective date of the Code. The trial court ordered the new law was procedural and could be applied retroactively. But after its review, the Supreme Court concluded that the WCC ordered vocational rehabilitation before August 26, 2011, and the treatment facility was outside the city limits of Claimant's hometown. As such, the Supreme Court reversed. View "Bertrand v. Laura Dester Center" on Justia Law

An employee filed an affidavit of readiness for hearing in her workers' compensation case approximately four years after her employer filed a controversion of her written workers' compensation claim. The employer petitioned to dismiss her claim based on the statutory deadline for a hearing request. After a hearing, the Alaska Workers' Compensation Board dismissed her claim, and the Alaska Workers' Compensation Appeals Commission affirmed the Board's decision. Because the employee did not file a timely request for a hearing and was not excused from doing so, the Supreme Court affirmed the Commission's decision. View "Pruitt v. Providence Extended Care" on Justia Law

Claimant Dorothy Robinson was a police officer for the City of Pittsburgh. In 1997, she sustained a work-related injury, and the City placed her on light-duty. In 2001, while traveling for treatment of her injury, Claimant was involved in an automobile accident in which she sustained new injuries. After the accident, Claimant did not return to her light-duty position nor was she offered any other light-duty work. In late 2004, Claimant received a disability pension. In connection with Claimant’s claim of entitlement to a disability pension, she was examined by three physicians who certified that Claimant was unable to perform her pre-injury job as a police officer. Nearly three years later, an independent medical examiner concluded that although Claimant was not fit to perform her prior job as a police officer, she could perform modified-duty work. The City filed a Petition to Suspend Compensation Benefits, asserting that Claimant was capable of working, "but has voluntarily removed herself from the work force as she has not looked for or sought employment in the general labor market." Claimant filed a response, denying the averments of the suspension petition and asserting that she remained attached to the workforce and had registered for work with the Pennsylvania Job Center. She further claimed that she was not presently working only because of the unavailability of work and because the City had eliminated her light-duty position. The Workers' Compensation Judge denied the suspension petition, concluding that Claimant had not voluntarily removed herself from the workforce. The issue before the Supreme Court in this appeal concerned the assignment of the burden of proof when the employer sought to modify or suspend a claimant's benefits on the basis that the claimant had retired. The Commonwealth Court plurality devised a "totality of the circumstances" test and concluded that the City failed to show that the injured worker had voluntarily withdrawn from the workforce. The City appealed, but the Supreme Court concurred with the Commonwealth Court and affirmed. View "City of Pittsburgh v. WCAB (Robinson)" on Justia Law

A hotel worker fell and injured her back while cleaning a room. Her employer initially paid benefits, but it filed a controversion of benefits after its doctor doubted the accident’s occurrence and said any work injury was not the substantial cause of the worker’s continuing need for medical care. The Alaska Workers’ Compensation Board decided that the fall was the substantial cause of the worker’s disability, finding the worker’s testimony about the injury credible and the employer’s doctor’s testimony not credible. Based on the testimony of the worker and her treating physician, as well as an MRI showing a herniated disc, the Board decided that the injury was compensable. The Alaska Workers’ Compensation Appeals Commission reversed the Board’s decision because, in the its view, substantial evidence did not support the decision. Because the Commission incorrectly decided the substantial evidence question, the Supreme Court reversed the Commission’s decision. View "Sosa de Rosario v. Chenega Lodging" on Justia Law

Appellant was injured during the course of his employment with Employer. Appellant obtained a workers' compensation award that covered future medical treatment. Appellant subsequently underwent knee replacement surgery and sought a further award of benefits. The Workers' Compensation Court (WCC) denied the petition, finding that Appellant's knee replacement surgery was not established to be the product of the subject accident but, rather, was prompted by Appellant's preexisting degenerative knee condition. The Supreme Court affirmed, holding (1) the evidence provided sufficient competent evidence to support a finding that Appellant's knee replacement surgery was not the result of the work-related accident, and therefore, the WCC did not err in finding that Appellant's surgery was not compensable; and (2) in so holding, the WCC was not acting contrary to the original award but was enforcing the award's plain language. View "Pearson v. Archer-Daniels-Midland Milling Co." on Justia Law

Plaintiffs, 91 current and former special investigators (SIs) employed by Nationwide Mutual Insurance claimed that Nationwide improperly classified SIs as administrative employees exempt from the overtime requirements of the Fair Labor Standards Act, 29 U.S.C. 207 and 213(a)(1)) and analogous provisions of New York and California law. The district court entered partial summary judgment in favor of Nationwide, then ruled in the company’s favor following trial on other issues. The Sixth Circuit affirmed. A reference to investigators, 29 C.F.R. 541.3(b)(1), read in context, pertains to law enforcement and public safety personnel and not to the Sis employed by Nationwide. Plaintiffs perform work “directly related” to Nationwide’s “general business operations.” The district court properly found that their investigations, with the purpose of resolving the indicators of fraud and the legitimacy of the suspicious claims, are unlike the narrower more formulaic background investigations into facts and records that have been found to not involve the exercise of discretion and independent judgment with respect to matters of significance. View "Foster v. Nationwide Mut. Ins. Co" on Justia Law

Two employees of Connections CSP, Inc. were killed in an automobile collision during the course and scope of their employment. Connections owned the vehicle and had purchased underinsured motorist insurance (UIM) for the vehicle and also worker's compensation insurance which covered the employees. The UIM insurer paid its policy limit of $1,000,000. The worker's compensation insurer also paid benefits to the representatives of the decedents. The worker's compensation insurer then sought to enforce a lien upon the UIM payment equal to the worker's compensation benefits it paid. But the UIM policy specifically excluded the direct or indirect benefit of any insurer or self-insurer under a worker's compensation claim. Notwithstanding this exclusion, the Superior Court enforced the lien based upon its interpretation of 19 Del. C. 2363(e), which allows reimbursement of a worker's compensation carrier "from the third party liability insurer." The UIM insurer appealed. Upon review, the Supreme Court held that General Assembly eliminated the ability of a worker's compensation insurer to assert a lien against the UIM payments made pursuant to the employer's UIM policy. Because the Superior Court erred as a matter of law in enforcing a lien, the Supreme Court reversed its decision and remanded the case for further proceedings. View "Simendinger v. National Union Fire Insurance Co." on Justia Law