Justia Insurance Law Opinion Summaries

On April 1, 2005, Employee was injured during the course of his employment. Due to the injury, Employee never returned to work. Employee received workers' compensation benefits from April 2, 2005 through April 14, 2007. When the workers' compensation benefits ceased, Employee applied for unemployment insurance benefits. The Unemployment Insurance Commission based Employee's unemployment benefits on an extended base period comprised of the first three quarters of 2005 and the fourth quarter of 2006. Employee appealed, arguing that the extended base period should be based upon the four calendar quarters of the year 2004 because those were the most recent four quarters which fairly reflected the wages he earned prior to his injury. The circuit court reversed. The court of appeals affirmed. At issue on appeal was the proper interpretation of "extended base period" as defined in section 341.090(2). The Supreme Court reversed the court of appeals and reinstated the decision of the Commission, holding that the Commission properly applied the statute as written by the General Assembly in calculating Employee's unemployment benefits.

Petitioner Christopher Ruel, a licensed real estate appraiser, appealed a superior court order that remanded his case to the New Hampshire Real Estate Appraiser Board for a new disciplinary hearing. In the spring of 2007, Kenneth Frederick hired Petitioner to appraise his property in Kingston. The New Hampshire Department of Transportation (DOT) sought to take Frederick's property by eminent domain and Frederick used Petitioner's appraisal in negotiating a settlement with DOT. DOT performed its own appraisal and valued the property at approximately fifty thousand dollars less than did Petitioner. After finalizing the settlement, a DOT appraisal supervisor reviewed Petitioner's appraisal and filed a grievance against him with the Board. In April 2010, four members of the Board voted to order Petitioner to pay a $500 fine and attend two appraisal courses. On appeal, Petitioner argued that the superior court should have dismissed the Board proceedings against him because: (1) the DOT lacked standing to file the initial grievance and, therefore, the case should never have been heard; (2) the Board violated its governing statute by taking more than two years to dispose of his case; (3) the Board's delay materially prejudiced him; and (4) the Board's determination to continue with the hearing and render a final decision without a quorum violated his due process rights. Upon careful review of the Board's hearing record, the Supreme Court rejected Petitioner's arguments on appeal.

Exum, an employer of Elrac, served a notice of intention to arbitrate on Elrac, seeking uninsured motorist benefits. Elrace petitioned to stay the arbitration. Supreme Court granted the petition, but the Appellate Division reversed, permitting the arbitration to proceed. The court affirmed and held that a self-insured employer whose employee was involved in an automobile accident could not be liable to that employee for uninsured motorist benefits, notwithstanding the exclusivity provision of the Workers' Compensation Law.

Appellant appealed the district court's grant of summary judgment in favor of Zurich, SRS, and an insurance adjuster on his claim for wrongful denial and delay of workers' compensation benefits under Texas state and common law. At issue on appeal was whether appellees complied with the duty of good faith and fair dealing in resolving appellant's claim. The court affirmed summary judgment and held that appellant failed to raise a material fact issue with respect to his common-law bad faith cause of action.

Employee suffered an industrial injury and received surgery on his right shoulder, after which Employee returned to work for self-insured Employer. Employee experienced renewed shoulder complaints four years later and asked Employer to add new shoulder conditions to Employee's workers' compensation claim and authorize surgery to correct them. Employer and the Industrial Commission denied Employee's request after finding that the proposed procedure was unrelated to the conditions allowed in Employee's workers' compensation claim. At issue on appeal was a doctor's report upon which the Commission based its decision. The court of appeals granted a limited writ in mandamus that ordered the Commission to reconsider the application after finding inconsistencies within the report. The Supreme Court reversed, concluding that none of the alleged inconsistencies noted in the doctor's report affected the viability of the doctor's opinion that further surgery was not reasonably related to the allowed conditions, and therefore, the report was evidence supporting the Commission's decision.

In previous workers' compensation cases, the Montana Supreme Court had determined that its decisions apply retroactively to claims that are not "final" or "settled" at the time the decision was issued. Under statute, two types of claims fall under the definition of "settled," (1) claims where there has been a formal settlement agreement, and (2) claims that are "paid in full." In this case, the workers' compensation court (WCC) defined "paid in full" to mean that an injured worker received all the applicable benefits prior to a new judicial decision and had not received subsequent benefits on his or her pre-judicial decision claim. The Supreme Court affirmed, holding that the WCC properly applied retroactivity law in formulating its definition of "paid in full."

Respondents New Hampshire Department of Corrections and Liberty Mutual Insurance Copmany (Insurer) appealed the decision of the New Hampshire Compensation Appeals Board (CAB) that Petitioner Michael Whitaker (Claimant) was entitled to ongoing temporary total disability indemnity benefits. Claimant first filed a workers’ compensation claim in January 2008, alleging that he suffered emotional injuries in 2007 because of harassment and retaliation at his DOC job. The insurer denied the claim on the ground that Claimant’s injuries were not causally related to his employment. In 2009, the CAB ruled in Claimant’s favor, awarding him benefits from the date he was deemed unable to work, through "at least" October 20, 2008, the date of the initial hearing before a department of labor hearing officer. The insurer did not appeal the CAB’s decision. In late 2009, Claimant sought to have his benefits increased to the higher temporary total disability rate when he was hospitalized for "[m]ajor depressive disorder, recurrent, severe, with psychotic features." The insurer denied this request on the ground that Claimant had failed to demonstrate that his hospitalization was related to his 2007 work injury. A department of labor hearing officer ruled in the insurer’s favor in January 2010; Claimant appealed to the CAB. The insurer argued that because Claimant had filed a claim with the New Hampshire Commission for Human Rights seeking damages for his allegedly wrongful discharge from the DOC, he waived his claim for increased benefits. The CAB was unpersuaded by Insurer's argument, and approved Claimant's claim. After unsuccessfully moving for reconsideration, Insurer appealed to the Supreme Court. Upon careful review of the CAB record, the Supreme Court affirmed, finding all of the issues the Insurer's raised on appeal unsupported by legal authority.

Doctors' Associates, Inc. (DAI) owns the "Subway" trademark and franchises the right to operate Subway sandwich shops nationwide. A claimant sought workers' compensation benefits for a work-related injury sustained while working for an uninsured Subway franchisee. The DAI and Uninsured Employers' Fund (UEF) were later joined as parties. The sole issue submitted for a decision by the ALJ was whether DAI was a contractor and, thus, liable to the employee of its uninsured subcontractor. The ALJ dismissed the UEF's claim against DAI, ruling that Ky. Rev. Stat. 342.610, which provides that a contractor can be liable to the employee of its uninsured subcontractor, imposed no liability on DAI because the statute did not encompass franchise relationships. The workers' compensation board affirmed. The court of appeals reversed, holding that the ALJ committed by legal error by concluding that the legislature did not intend for section 34.610 to encompass the franchisor-franchisee relationship simply because the statute failed to mention the relationship. The Supreme Court reversed, holding (1) the ALJ erroneously interpreted section 342.610, but (2) the error did not require reversal of the ALJ's ruling because the ALJ properly analyzed the facts of the case under the statute.

Employee suffered a work-related injury to his back in 2004. Employee had also suffered previous accidents resulting in injuries to his lower back. A rating physician determined that Employee's permanent partial disability (PPD) benefits for the 2004 injury should be calculated using a net twenty-six percent impairment rating. Employer's Insurer offered an award to Employee based on a net seventeen percent impairment rating. An appeals officer ordered Insurer to offer Employee a PPD award based on the original impairment rating. The district court affirmed, concluding that Employee's prior impairment rating, which was calculated using an older version of the AMA Guides, should be deducted from his current impairment rating, which was calculated using the current edition of the AMA Guides. The Supreme Court reversed, holding (1) the governing statute required the rating physician to reconcile the different editions of the AMA Guides by first recalculating the percentage of the previous impairment rating using the current edition and then subtracting that recalculated percentage from the current level of impairment; and (2) the district court and appeals officer erred in determining the amount due, and therefore, the PPD award based on the seventeen percent impairment rating for the current injury was proper.

At issue in this case was the interpretation of approximately sixty collective bargaining agreements (CBAs) between the City of Duluth and its employees. Subject to certain conditions and exceptions, the CBAs guaranteed retired City employees health insurance benefits "to the same extent as active employees." The dispute in this case centered on the meaning of that phrase, specifically, whether the phrase guaranteed health insurance benefits to retirees to the same extent as employees who were active at the time of a retiree's departure, or to the same extent as current City employees. Several retired City employees filed a lawsuit, alleging that the City had wrongfully changed or threatened to change their health insurance benefits and claiming that CBAs guaranteed that health insurance benefits for retirees would be frozen as of the time of retirement. The district court held for the City. The court of appeals affirmed the district court's interpretation of the active-employees clause. The Supreme Court affirmed, holding that the CBAs unambiguously guaranteed health insurance benefits to retirees to the same extent as current City employees.