Justia Insurance Law Opinion Summaries

Employee was injured in a work-related accident in Minnesota and then moved to Wyoming where she received medical treatment. The Wyoming medical providers submitted their charges to Employer's workers' compensation insurer. Relying on Minn. Stat. 176.136, subd. 1b(d), the insurer made payments in the amount provided under the workers' compensation benefit structure in Wyoming. Employee filed a workers' compensation medical request for the unpaid balance, arguing that Minn. Stat. 176.135, subd. 1 was controlling. The workers' compensation judge agreed and found for Employee. The workers' compensation court of appeals reversed. The Supreme Court affirmed, holding (1) Minn. Stat. 176.136, subd. 1b(d) limits a Minnesota employer's workers' compensation liability to an out-of-state medical provider to the amounts provided in the workers' compensation schedule of benefits in the state where the provider is located; and (2) section 16.136, subd. 1b(d) was not unconstitutional as applied.

Appellant Beverly Fetzer appealed a district court judgment that affirmed a Workforce Safety and Insurance (WSI) order denying her request for benefits. While walking down a hallway on her employer's premises and during work hours, Appellant thought she heard someone call her name. Turning in response, she caught her foot and fell, fracturing her left hip and wrist. No cause of the fall was apparent. Appellant filed a claim for workers' compensation benefits with WSI, and WSI denied her claim. Appellant submitted a request for reconsideration; WSI issued an order consistent with its prior decision, determining Appellant’s injury "occurred in the course of, but did not arise out of" her employment. WSI added, "Mere walking, without more, is not an activity that is sufficiently linked to Claimant's employment so that the injury can be deemed to have arisen from employment." Upon review, the Supreme Court affirmed: “If merely being at work was sufficient to show causation, the legislature need not have required the 'arising out of' test." Appellant was unable to prove a causal connection between her employment and injury.

Claimant Carl Wynne was a truck driver. While he was in Tennessee driving a truck for his former employer, he heard that Triad Transport, Inc. was hiring. Claimant called Triad’s headquarters in McAlester and spoke to a recruiter who had hiring authority. Claimant requested that an application be sent by fax to Odessa, Texas, where he lived. He completed the application and sent it by fax to McAlester. A week or so later, the recruiter phoned while Claimant was driving somewhere between Georgia and Arizona that his application had been approved. Claimant agreed to travel to McAlester for orientation. He returned his prior employer's truck to a terminal in Tuscon, Arizona, and a Triad employee gave him a ride to a Triad satellite terminal in Laveen, Arizona. There, he passed a drug test, was provided a fuel card, and dispatched to Rockwall, Texas with a load. In 2010, Claimant was injured in a motor vehicle accident in Colorado while he was driving Triad’s truck. He filed a Form 3 claim for benefits in the Oklahoma Workers' Compensation Court which Triad opposed. The trial tribunal conducted a hearing solely on the issue of the court's jurisdiction. Two witnesses were presented, Claimant and the President of Employer. Claimant testified concerning when and where he was actually hired, and Employer's President testified to the general hiring practices of his company. The recruiter was not called to testify. The trial tribunal made several findings of fact and concluded that it had jurisdiction to hear the case of Claimant's subsequent injury as Claimant's hiring and final assent to permanent employment relationship between claimant and respondent occurred in Oklahoma. A three-judge panel of the Workers' Compensation Court unanimously affirmed the decision. The Supreme Court’s de novo review of the record, the testimony of the witnesses, and the arguments of the parties lead to the conclusion that Claimant's final assent to employment did not occur until he attended the orientation in Oklahoma, “[t]hat process began when Claimant first made contact with [Triad’s] recruiter, but it did not end until Claimant gave his final assent to employment during the orientation in Oklahoma. The Workers' Compensation Court did not err in determining that it has jurisdiction to hear the claim.”

Plaintiff James Casale was employed by Defendant City of Cranston when he was injured. During his incapacity, Plaintiff received injured-on-duty (IOD) benefits from the City. In accordance with its policy with Plaintiff, Plaintiff's insurer, Amica Mutual Insurance Company, tendered $100,000 in uninsured motorist benefits to Plaintiff minus the amount that the City paid to Plaintiff for IOD benefits. Plaintiff subsequently initiated this declaratory judgment action seeking a judicial determination that R.I. Gen. Laws 45-19-1.1, which requires that an employer be reimbursed out of the proceeds received from the third party, was inapplicable to his case and that the City was not entitled to reimbursement from uninsured motorist benefits Plaintiff recovered under the policy. The trial justice concluded that the City was not entitled to reimbursement. The Supreme Court affirmed, holding (1) the trial justice correctly held that Defendant was not entitled to reimbursement for the IOD payments paid to Plaintiff; and (2) because Plaintiff did not collect any money from the tortfeasor, section 45-19-1.1 was inapplicable to this case.

Plaintiff, a maintenance director, had a stroke and began leave under the Family and Medical Leave Act, 29 U.S.C. 612(a)(1) in January 2008. He received disability benefits from Unum. The doctor cleared him to return to work starting on May 1, with conditions that he not work more than four hours per day or lift loads in excess of 20 pounds. The administrator notified plaintiff that part-time work was not available. The doctor cleared him to work full-time, but did not change the lifting restriction. On April 20, the employer terminated plaintiff's employment and notified him that he would not be rehired with lifting restrictions. Until July 2008, when the restrictions were lifted, he received benefits from Unum. The district court rejected claims under the Americans with Disabilities Act, the Pennsylvania Human Relations Act, and the FMLA. The Third Circuit affirmed. The FMLA does not require an employer to provide reasonable accommodation to facilitate return to an equivalent position following leave. Entitlement to restoration requires that the employee be able to perform essential job functions without accommodation. Having represented to Unum that he was disabled, plaintiff was estopped from claiming that he was able to perform all essential functions.

Plaintiff sued her employer and its workers' compensation insurer for intentional obstruction of workers' compensation in violation of Minnesota statute 176.82. The employer and insurer moved for summary judgment, which the district court granted. The court held that there were genuine issues of material fact as to whether the employer intentionally obstructed her receipt of workers' compensation benefits through her manager's fabrications and its 17-month delay in payment. The court also held that genuine issues of material fact remained as to whether the insurer intentionally obstructed her receipt of workers' compensation benefits by concealing the manager's first statement about the purpose of the meeting at issue, filing a factually-inaccurate claim denial, and continuing to deny the claim through trial. Accordingly, the court reversed the judgment of the district court and remanded for further proceedings.

Employee, a truck driver, resigned from his employment with Employer after he developed arthritis. Employee later filed an occupational disease claim, which the Montana State Fund (MSF) denied. The Workers' Compensation Court (WCC) concluded that Employee's job duties were the major contributing cause of his arthritic condition, and therefore, Employee was suffering from an occupational disease. The Supreme Court affirmed, holding that the WCC did not err in concluding that Grande was suffering from a compensable occupational disease arising out of and in the course and scope of his employment, as the WCC's findings of fact were supported by substantial, credible evidence, and its conclusions of law were correct.

An insurer appealed from a decision related to an employee's injury in a metal rolling machine accident. The court concluded that the board was not arbitrary or capricious in deciding that there was insufficient evidence to find that the employee was entitled under G.L.c. 152, section 51 to compensation based on an amount greater than his average weekly wage. But the court concluded that the board erred in finding that the employee's compensation should be based on the average weekly wage he earned when injured in 1980 rather than the out-of-state average weekly wage he earned when that injury recurred in 2003. The court also affirmed the board's decision to vacate the denial of recoupment for the insurer's overpayment of temporary total disability benefits between 1985 and 1988, but noted that, should the insurer decide to renew its claim for recoupment in a separate complaint filed with the department, its claim could prevail only if recoupment was equitable in the circumstances.

Appellant Valerie Joy Tronnes appealed a judgment that affirmed the Job Service of North Dakota's decision to deny her claim for unemployment benefits. In 2002, Appellant began working part-time at the Wal-Mart Vision Center. In 2010, Appellant received her paycheck (via a debit-card style card), and purchased a few items at Wal-Mart's customer service center. The amount of the purchase was mistakenly credited to Appellant's account by a different employee rather than deducted, which resulted in a substantial benefit to Appellant. Appellant met with the vision center manager about the extra money on her card, but later testified she believed the amount to be correct. The store gave Appellant the option of resigning as a result of her spending the extra money, but believed the paid time off she was given ( a "D-day"-- so named to give Appellant a day to decide whether to remain employed at Wal-Mart) meant she would be fired soon. Store management negotiated a payment plan for Appellant to repay the amount she was credited and allowed her to return to work. Ultimately the "repayment plan" took the form of the store withholding Appellant's subsequent paychecks to cover the indebtedness. Appellant did not report to work after that payday, and subsequently filed for unemployment benefits. The Job Service determined Appellant was ineligible for benefits because she voluntarily quit her job. Upon review, the Supreme Court concluded the evidence in the record supported the Job Service's denial of benefits to Appellant.

Appellant Michael Beall received preauthorization from the Wyoming Workers' Safety and Compensation Division for an orchiectomy, a procedure to remove his left testicle, which he claimed was related to a workplace injury. Beall's employer, Sky Blue Enterprises, objected to the preauthorization and the matter was referred to the Medical Commission Hearing Panel for a contested case hearing. Beall elected to undergo the surgery prior to the scheduled hearing. The Commission denied Beall's claim for reimbursement of medical expenses on the basis that the surgery was not reasonable or necessary medical care resulting from his workplace injury. The district court affirmed. The Supreme Court affirmed, holding (1) the burden of proving that the orchiectomy was reasonable and necessary medical care as related to Beall's alleged workplace injury rested with Beall; and (2) substantial evidence supported the Commission's determination that Beall failed to meet this burden.