Justia Insurance Law Opinion Summaries

Frank Hutson was working as a crane operator for the State Ports Authority when he suffered an injury to his lower back and legs while attempting to remove a container from a ship. He was diagnosed with a disc bulge for which he was treated with steroid injections, physical therapy, and used a back brace. After reaching maximum medical improvement, he filed a Form 50 with the workers' compensation commission for continued benefits alleging permanent and total disability pursuant to Sections 42-9-10 and 42-9-30 South Carolina Code (1976 & Supp. 2011) or, alternatively, a wage loss under Section 42-9-20. He also asked to receive the award in lump sum. Although the Ports Authority and its insurance carrier, the State Accident Fund (collectively, Respondents), admitted the accident and the back injury, they disputed the claims to his legs and argued he should receive only permanent partial disability benefits. They also objected to Hutson's request that his benefits be paid in a lump sum. The issue before the Supreme Court centered on whether speculative testimony by the claimant concerning his possible future work as a restaurateur qualified as substantial evidence to establish he did not sustain a wage loss pursuant to Section 42-9-20 of the South Carolina Code (1976). The Court held it did not, and therefore reversed and remanded the case for further proceedings. View "Hutson v. SC State Ports Authority" on Justia Law

Zaloudek Grain Company held a workers' compensation policy with CompSource Oklahoma for approximately ten years prior to 2011. Zaloudek was required each year to provide payroll audit information to CompSource. The audit information was used to determine the proper premium for each year. CompSource sent a notice in late 2010 to Zaloudek requesting audit information. In January, 2011, Zaloudek's policy was renewed for all of 2011 through January 1, 2012. On January 18, 2011, CompSource sent another letter requesting Zaloudek provide the necessary payroll audit information, but Zaloudek was unresponsive. Subsequently, CompSource sent Zaloudek a notification to inform the company that the process of canceling its policy would begin if CompSource did not receive the audit information. The audit information was not provided; CompSource ultimately canceled the policy when Zaloudek ignored several subsequent requests. CompSource issued a refund for payments made under the policy. Later that summer, two teenage workers were seriously injured in the grain auger at Zaloudek's facility. CompSource did not accept the company's new insurance application because it was incomplete and was not signed by an owner of Zaloudek. Zaloudek sued a few weeks following the rejection of its application, asking for a judgment against CompSource for breach of contract and bad faith and further requested declaratory relief in the form of an order requiring CompSource to provide workers' compensation coverage. Zaloudek filed a motion for summary judgment claiming CompSource lacked legal justification for terminating its policy and requested orders to establish there was no lapse in coverage and requiring CompSource to provide coverage for its two injured employees. Zaloudek further requested a finding that CompSource was in breach of contract. CompSource moved for summary judgment, arguing Zaloudek was not covered at the time of the incident and its policy was properly canceled. Zaloudek filed a counter-motion for summary judgment asserting CompSource should be estopped from denying coverage because it retained premiums and acted in a manner toward Zaloudek consistent with continued coverage. The trial court issued an order dismissing Zaloudek's bad faith claim but left pending its claims for breach of contract and declaratory relief. CompSource appealed. After its review, the Supreme Court concluded that CompSource was authorized to cancel a policy for an insured's failure to participate in the audit. The Court remanded the case for further proceedings on the other contract issues raised. View "Zaloudek Grain Co. v. CompSource Oklahoma" on Justia Law

The issue before the Supreme Court in this case centered on whether NRS 616B.227 allows an average monthly wage calculation for workers' compensation benefits to include untaxed tip income that an employee reports to his/her employer. Upon review, the Supreme Court concluded that NRS 616B.227 required an average monthly wage calculation to include the untaxed tips. The Court affirmed the district court's order in this case which denied appellant Sierra Nevada Administrators' petition for judicial review. View "Sierra Nevada Administrators v. Negriev" on Justia Law

In a 2009 opinion, the Sixth Circuit held that, in a 1998 collective bargaining agreement, CNH agreed to provide health-care benefits to retirees and their spouses for life, but rejected the suggestion that the scope of this commitment in the context of healthcare benefits, as opposed to pension benefits, meant that CNH could make no changes to the healthcare benefits provided to retirees. The court remanded for a determination of reasonableness with respect to CNH’s proposed changes to its retiree healthcare benefits, under which retirees, previously able to choose any doctor without suffering a financial penalty, would be put into a managed-care plan. The court listed three considerations: Does the modified plan provide benefits “reasonably commensurate” with the old plan? Are the proposed changes “reasonable in light of changes in health care”? And are the benefits “roughly consistent with the kinds of benefits provided to current employees”? On remand, the district court granted CNH summary judgment without reaching the reasonableness question or creating a factual record from which the determination could be made on appeal. The Sixth Circuit again remanded.View "Reese v. CNH America LLC" on Justia Law

Plaintiff Wade Stancil was injured in 1995 while employed by Orient Originals. He received workers' compensation benefits from his employer's compensation carrier, defendant ACE USA (ACE). In 2006, following a trial, the court of compensation determined that Stancil was totally disabled. In 2007, Stancil filed a motion in the compensation court seeking an order compelling ACE to pay outstanding medical bills. During a hearing on the motion, the compensation judge commented that ACE had a history of failing to make payments when ordered to do so. The compensation judge granted Stancil's motion, warned ACE against any further violation of the order to pay, and awarded Stancil counsel fees. The parties returned to the compensation court for a further proceeding relating to the disputed bills. After finding that the bills identified in the earlier order remained unpaid and that ACE's failure to make payment was a willful and intentional violation of the order, the court issued another order compelling ACE to make immediate payment and again awarding counsel fees. In 2008, Stancil underwent additional surgery and psychiatric treatment. Stancil's physician attributed the need for additional treatment to an earlier treatment delay caused by the carrier's delay in paying medical providers. N.J.S.A. 34:15-1 to -142 (the Act), is the exclusive remedy for the claims pled in the complaint and therefore no damages could be awarded. The trial court granted ACE's motion effectively denying payments for Stancil's 2008 treatment. The Appellate Division affirmed. The issue on appeal to the Supreme Court was whether the employee could sue the carrier for pain and suffering caused by the carrier's delay in paying for medical treatment, prescriptions, and other services. Upon review, the Court concluded that an injured employee does not have a common law right of action against a workers' compensation carrier for pain and suffering caused by the carrier's delay because: (1) the workers' compensation system was designed to provide injured workers with a remedy outside of the ordinary tort or contract remedies cognizable in the Superior Court; (2) in amending the Workers' Compensation Act in 2008, the Legislature rejected a provision that would have given the compensation courts broader permission to authorize a resort to the Superior Court and adopted a remedy that permits compensation courts to act through a contempt power; and (3) allowing a direct common-law cause of action against a carrier would undermine the workers' compensation system by substituting a cause of action that would become the preferred manner of securing relief. View "Stancil v. ACE USA" on Justia Law

Adams worked in coal mines for 17 years, leaving A & E Coal in 1988, after 12 years, because he was having difficulty breathing. He has not worked since. Adams also smoked cigarettes for about 25 years, averaging a pack a day before quitting in 1998 or 1999. Adams filed his first claim for benefits under the Black Lung Benefits Act 30 U.S.C. 901 in 1988. His claim was denied: He did not prove that his pneumoconiosis was caused in part by his coal-mine work, or that his pneumoconiosis totally disabled him. In 2007, Adams filed a second claim. Two pulmonologists agreed that he was completely disabled, but disagreed on what lung diseases Adams had, and on what caused them. An Administrative Law Judge awarded benefits, finding that Adams had pneumoconiosis, that the disease was caused by Adams’s exposure to coal dust during his coal-mine employment, and that he was totally disabled because of the disease. The Benefits Review Board and the Third Circuit affirmed. Although the ALJ was not required to look at the preamble to the regulations to assess the doctors’ credibility, he was entitled to do so. View "A & E Coal Co. v. Adams" on Justia Law

The issue before the Supreme Court was whether an employee who filed an injury claim against his employer under the State Workers' Compensation Act and receives compensation in exchange for a "no liability" settlement with his employer that is approved by the State Board of Workers' Compensation may then turn around and sue the co-employee who caused the injury in a tort action. Ten years ago, the Court of Appeals answered this question no, holding that the Act's exclusive remedy provision bars such a lawsuit based on the same injury for which the employee has already received a remedy. In this appeal, however, the Court of Appeals was equally divided as to whether the underlying case law should be overruled, and the case was sent to the Supreme Court for resolution. Upon review, the Supreme Court held that "Ridley" was correctly decided. Thus, appellant Joseph Smith, having previously entered a Board-approved settlement with his employer in exchange for compensation, would be barred from suing appellee John Ellis for the same injury in tort if Ellis qualified as an "employee of the same employer" as Smith, rather than a "third-party tort-feasor," as those phrases are used in the applicable statutory authority. However, the evidence did not establish that Ellis was acting as "an employee of the same employer" in the course of his employment, at the time he injured Smith. The trial court therefore erred in granting summary judgment to Ellis, and that judgment was reversed. View "Smith v. Ellis" on Justia Law

An employee (Employee) of the Austin Independent School District (AISD), a self-insured governmental entity, was injured on the job. AISD acknowledged that Employee had been injured but disputed whether the compensable injury extended to two alleged conditions. A hearing officer sided with Employee on the contested issues, as did the administrative appeals panel. In the district court, Employee filed a counterclaim seeking attorney fees. AISD filed a nonsuit, leaving only the counterclaim for fees. After a jury trial, Employee won a judgment on the verdict that included pre-nonsuit and post-nonsuit attorney fees. The court of appeals found (1) the evidence was sufficient to support the pre-nonsuit fee award, but (2) the post-nonsuit fee award could not stand. AISD brought a petition for review in the Supreme Court, arguing for the first time that governmental immunity from suit barred the award of attorney fees. The Supreme Court reversed in part, holding (1) the defense of sovereign immunity may be raised for the first time on appeal; and (2) AISD was immune from Employee's claim for attorney fees. View "Manbeck v. Austin Indep. Sch. Dist." on Justia Law

At issue in this case was whether the workers' compensation courts had the authority to hear a petition filed by Insured to determine whether Insurer had a duty to defend and indemnify Insured under a policy for workers' compensation insurance. Insurer moved to dismiss Insured's petition, arguing that the compensation judge did not have subject matter jurisdiction to hear the petition because it asserted a breach of contract claim rather than one arising under the workers' compensation laws. The compensation judge disagreed and denied Insurer's motion to dismiss. The workers' compensation court of appeals (WCCA) affirmed, concluding that Insured was seeking a declaration that its insurance coverage with Insurer was still "in effect," a question within the compensation judge's authority to decide. The Supreme Court affirmed, holding that the workers' compensation courts had jurisdiction to decide the issues presented in Insured's petition for declaration of insurance coverage, as the real nature of the claim was whether Insured's insurance coverage was in effect, a question that was within the authority of the compensation judge to answer. View "Giersdorf v. A & M Constr., Inc." on Justia Law

Employee was injured while working for Employer. Five years later, Employee was fired for violating the company's attendance policy. Employee's termination was later the basis for the Industrial Commission of Ohio's denial of his request for temporary total disability compensation (TTC). The Commission found that Employee's discharge amounted to a voluntary abandonment because it was consequence of behavior that Employee willingly undertook. The court of appeals reversed, holding that the deliberate misconduct necessary to support a finding of voluntary abandonment could not be imputed to Employee. The Supreme Court affirmed and issued a limited writ of mandamus that vacated the Commission's order and returned the cause to it for further consideration, as the hearing officer did not carefully examine the totality of the circumstances in finding that a simple allegation of misconduct existed to preclude temporary total disability compensation. View "State ex rel. Brown v. Hoover Universal, Inc." on Justia Law