Justia Insurance Law Opinion Summaries

The company previously gave retirees credit toward their share of health care costs, based on unused sick-leave. Union workers could take that sum in cash or put it toward the premium. Executives who quit before retirement, or decided not to participate in the plan, did not receive any other form of compensation for unused leave. It had value only as a credit toward retirement health-care costs. In 2008 the company amended the plan and stopped paying any part of retirees' health-care costs. Money for employees who could have taken their balances in cash is put in an account administered by the health-care plan. Retirees, including executives who never had an option to take balances in cash, plus one who had that option but elected to leave the money on deposit, filed suit under the Employee Retirement and Income Security Act, 29 U.S.C. 1081. The district court granted judgment on the pleadings to the company. The Seventh Circuit affirmed. The company, which did not take anything out of the plan, but simply reduced the amount it would pay in, reserved the right to amend its health-care plan. It is a business decision, not a legal question, whether to use that authority to retireesâ detriment.

Employee was injured while working in Minnesota for Wisconsin-based Employer. Employee applied for Wisconsin and Minnesota workers' compensation benefits. Employer's insurance company, Travelers Insurance, covered the Wisconsin benefits but denied the claim for Minnesota benefits based on an exclusion of Minnesota coverage in Employee's policy. Employee then filed a claim for Minnesota benefits with the Minnesota Department of Labor and Industry. After settling the claim, the Department pursued a petition for reimbursement it had filed against Employer. A compensation judge found that Employer was not insured for Minnesota workers' compensation liability and ordered Employer to reimburse the Department. The Workers' Compensation Court of Appeals (WCCA) reversed, concluding that Employer was entitled to coverage from Travelers under the reasonable expectations doctrine. On review, the Supreme Court reversed and remanded for reconsideration in light of a recent Court decision clarifying that the doctrine should not be used to provide coverage in contravention of unambiguous policy terms. On remand, the WCCA again reversed the compensation judge. On review, the Supreme Court reversed, holding that the WCCA had no authority to declare unambiguous language of an insurance contract to be invalid and unenforceable because the exclusion conflicted with Wisconsin statutory provisions and public policy.

While Timothy Allen worked as a sales associate for respondent Burnet Realty, he executed agreements to participate in respondent's legal administration program (LA Program). Under the LA Program contracts, Allen and respondent agreed to an allocation of expenses should a dispute arise related to Allen's work for respondent. In litigation commenced after he stopped working for respondent, Allen claimed that respondent violated Minn. Stat. 60K.47 because the LA Program contracts were insurance, and, as a result, respondent was required to be, but was not, authorized to engage in the business of insurance in Minnesota. Allen also claimed other relief on the basis that the contracts were insurance. The district court granted summary judgment in favor of respondent, concluding that the contracts were not contracts of insurance. The court of appeals affirmed. The Supreme Court affirmed the grant of summary judgment to respondent, holding that the LA Program was not "insurance" under statutory definitions on statute or case law.

Plaintiff was employed full time with Able Body Temporary Services, Inc. (Able Body), a labor broker in the business of furnishing its day-laborer employees to clients on a temporary basis. Able Body supplied its client, Federal Marine Terminals, Inc. (FMT), with day-laborers, including plaintiff, for longshore services. Plaintiff was subsequently injured on the job and received benefits under the Longshore and Harbor Workers' Compensation Act (LHWCA), 33 U.S.C. 901 et seq. Plaintiff, seeking to supplement his workers' compensation benefits, brought this negligence action against FMT, claiming that the negligence of FMT's employees caused his injury. At issue was whether the district court erred in holding that FMT was plaintiff's employer and that section 905(a) of the LHWCA precluded his negligence claim. The court held that because all the elements necessary for a borrowed-employment relationship were satisfied in light of the undisputed evidence, FMT was plaintiff's borrowing employer for purposes of the LHWCA and consequently, plaintiff's negligence claim was barred by section 905(a). Therefore, the judgment of the district court was affirmed.

Plaintiff appealed from the district court's dismissal of his claim for benefits under ERISA, 29 U.S.C. 1001 et seq., where the district court held that he failed to exhaust his administrative remedies. The court held that because plaintiff sought either current or future benefits, the plan provided an administrative procedure for his claim. The facts alleged in plaintiff's complaint showed neither futility nor the lack of an administrative remedy and therefore, the court concluded that he was required to exhaust his administrative remedies under the plan before he could bring a civil action in federal court.

After defendant denied plaintiff's claim for long-term disability benefits (LTD benefits), where plaintiff suffered from fibromyalgia, plaintiff filed a complaint against defendant pursuant to ERISA, 29 U.S.C. 1000 et seq. At issue was whether the district court properly granted summary judgment in plaintiff's favor finding that defendant had abused its discretion in denying benefits to plaintiff. The court held that the district court improperly determined that defendant abused its discretion when it ultimately denied the LTD benefits claim. Based on the record, there was more than a scintilla of evidence supporting defendant's conclusion that plaintiff's condition did not render him "disabled" under the policy's any occupation definition and defendant's decision was supported by substantial evidence, where a reasonable person could have reached a similar decision. The court also held that the fact that defendant operated under a structural conflict of interest, as both plan administrator and insurer, did not warrant a finding that defendant abused its discretion in denying plaintiff's claim. Accordingly, the court reversed summary judgment and remanded for further proceedings.

After injuring her back in a car accident, plaintiff filed for and received long-term disability benefits from the insurance plan sponsored by her employer. Plaintiff brought suit pursuant to the Employee Retirement Income Security Act of 1974 (ERISA), 42 U.S. C. 29 U.S.C. 1001 et seq., against her employer and the administrators and underwriters of her employer-sponsored long-term benefit disability insurance policy after the claims administrator of that plan determined that she no longer qualified for benefits. At issue was whether the district court properly granted defendants' motion for summary judgment, finding no violation of law. The court held that because defendants acted reasonably, the court concluded that defendants' termination of plaintiff's benefits complied with federal law. The court found none of plaintiff's procedural claims persuasive and held that the district court did not err when it held that defendants did not violate plaintiff's right to a full and fair review of her adverse eligibility determination. The court also rejected plaintiff's argument that the district court violated local rule 7(h) where plaintiff failed to make this argument before the district court. Accordingly, the court affirmed the judgment of the district court.

Plaintiffs, retired U.S. Airways pilots, each received pensions from the U.S. Airways pension plan (the plan) and each opted to receive his pension in a single lump sum rather than as an annuity. Plaintiffs subsequently sued U.S. Airways claiming that the plan owed them interest for its 45-day delay. The court reversed the judgment of the district court with respect to plaintiffs' actuarial equivalence claim where the amount of plaintiffs' lump sum benefit was equal to the actuarial present value of the annuity payments plaintiffs would have received under the plan's default payment option. Even so, U.S. Airway's 45-day delay in paying plaintiffs was unrelated to the calculation of plaintiffs' benefits and therefore, not reasonable under existing IRS regulations. The court remanded to the district court to calculate the appropriate amounts due to plaintiffs and affirmed the judgment of the district court that plaintiffs were not entitled to attorney's fees.

Plaintiff, a workers' compensation claimant, brought suit against defendant regarding the company's conduct in referring his claim to the insurance fraud bureau (IFB), communicating with fraud investigators and prosecutors regarding his activity and claim, and using criminal processes to gain leverage in dealings with him. At issue was whether summary judgment in favor of defendant was properly denied. The court held that defendant enjoyed qualified immunity regarding its reporting of potentially fraudulent activity but that summary judgment was inappropriate because all of plaintiff's claims rely, at least in part, on conduct falling outside the scope of the immunity. The court also held that portions of plaintiff's claims could be barred by workers' compensation exclusivity under G.L.c. 152, but that not one of plaintiff's counts was barred entirely such that the Superior Court would be without subject matter jurisdiction. Accordingly, the court affirmed the order of the Superior Court denying summary judgment and remanded the case for further proceedings.

Plaintiff, employed by a company contracted to do grounds maintenance, was injured while mowing grass at an Army base. A deteriorating steam pipe fell, striking him in the head. The district court granted summary judgment to the United States, reasoning that under the Kentucky Workers' Compensation Law, the United States was an up-the-ladder contractor, or statutory employer, so that plaintiff's only remedy was the workers' compensation benefits he received from his direct employer. The Sixth Circuit affirmed, holding that the U.S. government is a "person" entitled to the up-the-ladder defense and that the waiver of immunity under the Federal Torts Claims Act, 28 U.S.C. 1346, provides for claims in the same manner and to the same extent as a private individual. The government "secured the payment of compensation" by hiring a contractor and, therefore, cannot be treated as an employer that did not secure benefits. The work performed by plaintiff was a "regular and recurrent" part of work at the facility and the government was entitled to contractor immunity.