Justia Insurance Law Opinion Summaries

An employee of a tribal enterprise sought to invoke the jurisdiction of the Oklahoma Workers' Compensation Court. Petitioner John A. Waltrip fell on a patch of ice while working as a surveillance supervisor at a casino and injured primarily his right shoulder. Petitioner initially obtained treatment from his personal physician but Tribal First, the employer Osage Million Dollar Elm Casino's claim administrator, sent him to an orthopedic specialist who recommended surgery in 2009. Petitioner filed a claim in the Oklahoma Workers' Compensation Court on July 17, 2009, seeking medical treatment and temporary total disability. The Casino and Insurer Hudson Insurance Company asserted that court lacked jurisdiction based on the tribe's sovereign immunity. A hearing was held solely on the jurisdictional issue; the Workers' Compensation Court denied jurisdiction and dismissed the claim holding that the tribe enjoyed sovereign immunity and that the provisions of the tribe's workers' compensation policy did not subject the insurance company to liability for claims in state court. The Court of Civil Appeals affirmed and the Supreme Court granted certiorari review. Upon review, the Supreme Court held that: (1) the tribe enjoyed sovereign immunity and was not therefore subject to the jurisdiction of the Oklahoma Workers' Compensation Court; and (2) the workers' compensation insurer did not enjoy the tribe's immunity and was estopped to deny coverage under a policy for which it accepted premiums computed in part on the employee's earnings. View "Waltrip v. Osage Million Dollar Elm Casino" on Justia Law

Defendant Paul Wentzlaff, an insurance agent, stole thousands of dollars from Harvey Severson, an elderly man who asked Defendant to help manage his financial affairs. Plaintiff Donald Hass, as personal representative for Severson’s estate, sued Defendant and two insurance companies who appointed Defendant as an agent, North American Company for Life and Health Insurance (North American) and Allianz Life Insurance of North America (Allianz). Hass and North American each moved for summary judgment and Allianz joined North American’s motion. After a hearing, the circuit court denied Plaintiff's motion and granted the insurance companies’ motion. Plaintiff appealed, arguing that the insurance companies were vicariously liable for Defendant's acts. Based on undisputed material facts on the record in this case, the Supreme Court found that Defendant Wentzlaff was not acting within the scope of his employment when he stole money from Severson, and thus, as a matter of law, North American and Allianz were not vicariously liable for his acts. The Court affirmed the circuit court's grant of summary judgment in favor of the insurance companies. View "Hass v. Wentzlaff" on Justia Law

Plaintiff appealed the district court's dismissal of her claim challenging the termination of her long-term disability benefits under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1132. Plaintiff challenged the district court's grant of summary judgment in favor of Unum on it's counterclaim for restitution of overpaid benefits. The court held that the district court abused its discretion by dismissing the claim for denial of benefits for failure to exhaust administrative remedies. The exhaustion requirement should have been excused because plaintiff acted reasonably in light of Unum's ambiguous communications and failure to engage in a meaningful dialogue. Accordingly, the court vacated the judgment in favor of Unum on plaintiff's claim for denial of benefits. View "Bilyeu v. Morgan Stanley Long Term Disability Plan, et al." on Justia Law

Defendant appealed the district court's grant of partial summary judgment in favor of CGI in its action seeking "appropriate equitable relief" under section 502(a)(3) of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 1001 et seq. CGI appealed the district court's grant of partial summary judgment in favor of defendant's counsel and codefendant, dismissing the codefendant from the action. CGI also appealed the district court's grant of proportional fees and costs to the codefendant, deducted from CGI's recovery from defendant. The court affirmed the district court's grant of summary judgment in favor of the codefendant, dismissing it from the action. However, because the court saw no indication that in fashioning "appropriate equitable relief" for CGI, the district court did more than interpret the plain terms of the reimbursement provision, and no indication that the district court considered traditional equitable principles in assigning responsibility to CGI for attorneys' fees and costs, the court vacated the judgment in favor of CGI, vacated the judgment that the codefendant deducted fees and costs from CGI's entitlement, and remanded to the district court for further proceedings. View "CGI Technologies and Solutions v. Rose, et al." on Justia Law

Claimant Barton J. Rodr was a full-time computer programmer employed by Yzer, Inc. He suffered a heart attack while doing lawn work for his employer on the employer's premises. He was not paid anything additional for the lawn work. Claimant sought workers' compensation benefits, which were denied: the employer denied that he was working as an employee at the time of injury and claimed that the injury was not incurred during the course and scope of his employment. Employer asserted that the claimant was acting as a volunteer when injured. The workers' compensation court awarded benefits, determining that Claimant was not acting as a volunteer arising out of and in the course of his employment. The three-judge panel unanimously affirmed. The employer appealed, asserting that Claimant did not meet the statutory definition of an employee under the workers' compensation act and that the accidental injury did not occur in the course and scope of employment. The Court of Civil Appeals vacated the order, finding it to be against the clear weight of the evidence and contrary to law because Claimant's performance of lawn work at the time of his injury was outside his employment and was not related to or incidental to his computer programmer job, and was therefore not compensable. Claimant timely appealed. The Supreme Court found that the test here was whether the work was necessary for the benefit of the employer: "Here, the employer specifically asked for volunteers to help with the yard work to make the grounds look nice for the grand reopening of Automobile Alley. The claimant and his thirteen-year-old son performed those duties. The employer then hired claimant's thirteen-year-old son to continue the yard work. . . . The employer's yard crew had quit and the claimant was performing that task to help out the employer, at the employer's request. The yard work was for the benefit of the employer and was not in furtherance of a personal mission. The facts reflect that the claimant was performing a special task for his employer and that his accidental injury arose out of and was within the course of his employment." The Court vacated the appellate court's decision and sustained the award entered by the workers' compensation court.

The district court overturned an employee benefit plan's denial of a former employee's claim for permanent and total disability life insurance benefits. On appeal, Defendant Owens-Illinois Hourly Employees Welfare Benefit Plan contended the district court erred in rejecting Defendant’s argument that the employee was not eligible for this benefit under the Plan’s life insurance coverage provisions because his PTD life insurance claim was not filed until after he retired. Upon review, the Tenth Circuit concluded that the district court should have entered judgment in favor of Plaintiff on the administrative record rather than remanding for further administrative proceedings. The Tenth Circuit therefore remanded the case with directions for the district court to modify its order and enter judgment in favor of Plaintiff.

The issue before the Supreme Court in this case centered on whether Appellant Six L's Packing Company and its claims administrator Broadspire Services, Inc. bore liability for workers' compensation benefits as a statutory employer of an injured truck driver employed as an independent contractor. Appellant owns and leases various farms and distribution and processing facilities in North America. Claimant suffered injuries in a vehicle accident on a Pennsylvania roadway while transporting Appellant’s tomatoes between a warehouse in Pennsylvania and a processing facility in Maryland. Appellant submitted evidence to establish that it did not own trucks or employ drivers, but, rather, utilized independent contractors to supply transportation services. Appellant thus took the position that it was not Claimant’s employer. The WCJ found Appellant liable for payment of workers' compensation benefits. On further appeal, the Commonwealth Court affirmed on essentially the same reasoning as that of the WCJ. In its review, the Supreme Court affirmed the Commonwealth Court, recognizing "a degree of ambiguity inherent in the overall scheme for statutory employer liability, arising out of differences in the definitions for “contractor” as used in various provisions of the Workers' Compensation Act (WCA); the idiosyncratic conception of subcontracting fashioned in Section 302(a) [of the Act]; the substantial overlap between Sections 302(a) and (b); and the apparent differences in the depiction of the concept of statutory employment as between the Act’s liability and immunity provisions. Viewing the statutory scheme as a whole, however, and employing the principle of liberal construction in furtherance of the Act’s remedial purposes, [the Court found] it to be plain enough that the Legislature meant to require persons (including entities) contracting with others to perform work which is a regular or recurrent part of their businesses to assure that the employees of those others are covered by workers’ compensation insurance, on pain of assuming secondary liability for benefits payment upon a default."

The issue before the Supreme Court was the proper method of calculating an hourly-wage claimant's average weekly wage under Section 309 of the Workers’ Compensation Act where the specific loss claimant suffered an initial incident, changed employers, and later suffered a work-related injury caused by the initial incident. Claimant Janice Weber-Brown worked for Appellant Lancaster General Hospital as a licensed practical nurse. In 1980, while cleaning the tracheotomy of a patient who was infected with the herpes simplex virus (HSV), the patient coughed, causing sputum to spray in Claimant’s left eye. Approximately two weeks after the incident, Claimant’s eye became swollen and infected, and Claimant believed she contracted HSV. Claimant left the employ of Lancaster General in 1985 for reasons unrelated to the eye incident. At that time, she earned $8 per hour and worked full-time. In the years following her departure from the hospital, Claimant’s eye became infected several more times. Each time, her symptoms subsided with treatment, and Claimant did not miss any work with her other employers due to her eye infections. In October 2006, however, Claimant’s eye again became infected and, this time, her infection did not respond to treatment. By February 2007, Claimant lost the vision in her left eye, and, in May 2007, she underwent a cornea transplant. The transplant did not improve her vision, and, as a result of her blindness, she was not able to return to work. At that time, Claimant earned $21 per hour. Lancaster General denied Claimant's allegations that she contracted HSV while working for the hospital, and challenged her claim that she be paid based on her then-current wage with her new employer. The WCJ determined Claimant suffered a work-related injury and held that the hospital pay Claimant's wage set at $21 per hour. Lancaster General appealed. Upon review, the Supreme Court concluded that the WCJ correctly held that the Claimant's weekly wage should have been based on her 2007 wages with her new employer, as those wages were earned with that employer at the time Claimant suffered her work-related injury.

The parties to the appeal disagreed about whether an employer who self funded a health-benefit plan for its employees was an "insurer" under the Texas Insurance Code, and therefore should be treated as a reinsurer when purchasing stop-loss insurance. The court of appeals concluded that an employer's self-funded plan was clearly an insurer under the Code and that a plan's purchase of stop-loss insurance was also clearly reinsurance beyond the regulatory scope of the Texas Department of Insurance. The court accordingly reversed the trial court's judgment, which held that the agency's regulation of the stop-loss policies at issue as direct insurance. Because the regulatory agency did not clearly err in its regulation of these stop-loss policies, however, the court reversed the court of appeals' judgment and rendered judgment for the agency.

At issue in this appeal was whether Ky. Rev. Stat. 342.730(6) entitled UPS Airlines to receive credit against its liability under section 342.730(1) for the payment of loss of license benefits that were the product of a collective bargaining agreement between UPS Airlines and the Independent Pilots Association (IPA), of which Claimant was a member. Claimant, a UPS pilot, sustained a work-related injury and underwent surgery. UPS paid the entire premium for the loss of license insurance plan. UPS subsequently sought leave to credit Claimant's loss of license benefits against its liability for income benefits. Reversing an ALJ's decision, the workers' compensation board found that section 342.730(6) did not entitle UPS to a dollar-for-dollar credit against Claimant's past due and future income benefits for all benefits paid under the loss of license plan. The Supreme Court (1) affirmed to the extent that UPS was not entitled to a dollar-for-dollar credit; but (2) reversed with respect to the conclusion that loss of license benefits were not funded exclusively by the employer for the purposes of section 342.730(6) because they were bargained-for benefits, holding that section 342.730(6) does not entitle UPS to credit the overpayment of voluntary benefits against future income benefits. Remanded.