Justia Insurance Law Opinion Summaries

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.

This case stemmed from the collective bargaining agreement (CBA) between Volvo Group North America, LLC (Volvo) and the union representing workers at Volvo's New River Valley assembly plant (NRV). At issue was whether the CBA permitted Volvo to make unilateral changes to the health benefits of retirees from its NRV assembly plant after the agreement expired. The court held that Volvo was not permitted to make unilateral modifications to the retirees' health benefits after the expiration of the CBA unless it followed the mechanism agreed to by both parties in that agreement. Therefore, the court affirmed the judgment of the district court where Volvo could not employ that mechanism in this case.

After being diagnosed with fibromyalgia, chronic pain, anxiety, and depression, plaintiff was awarded long-term disability benefits under an employee benefit plan issued and administered by defendant. Benefits were discontinued about 24 months later, when defendant determined that plaintiff had received all to which she was entitled under the planâs self-reported symptoms limitation. Because plaintiff had retroactively received social security benefits, defendant also sought to recoup equivalent overpayments as provided by the plan. The district court dismissed. The Seventh Circuit reversed in part and remanded for reinstatement. The self-reported symptom limitation violates ERISA, 29 U.S.C., 1022; the policy sets out that long-term benefits will be discontinued after 24 months if disability is due to mental illness or substance abuse, but does not mention that the time limitation applies if a participantâs disability is based primarily on self-reported symptoms. The Social Security Act does not bar recovery of overpayments occasioned by receipt of social security benefits.

Appellees brought this declaratory judgment action seeking a determination that there was no coverage for an accident involving a company car driven by Daniel Brandt and injuring Donald Bunch. At issue was whether liability coverage extended to Brandt and whether Donald Bunch was entitled to uninsured and underinsured motorist coverage because the policy at issue was ambiguous. The court concluded that the Bunches conceded that Brandt did not have express or implied permission from his employer to drive the car and that Patricia Bunch lacked the authority to give Brandt permission to use the vehicle as either a named insured or as a second permitee. Therefore, the district court did not err in concluding that liability coverage did not extend to Brandt. The court also concluded that there was no indication that the term "vehicle" was ambiguous or that a person reading the policy would not understand that the vehicle referred to in the exclusion would have included the car involved in the accident. Therefore, the district court did not err in determining that Donald Bunch did not qualify for uninsured or underinsured motorist coverage.