Justia Insurance Law Opinion Summaries

Carlin Jewett was employed as a welder by Real Tuff where Jewett often worked on his knees. In 2006, Jewett suffered a right knee injury. Jewett received arthroscopic surgery, during which the surgeon found pre-existing bilateral osteoarthritis in Jewett's knee. Jewett subsequently filed a petition with the state Department of Labor, seeking workers' compensation for a right knee replacement. Two years later, Jewett suffered a second work-related injury to his left knee. Jewett added a workers' compensation claim for diagnostic treatment of his left knee. The Department and the circuit court ruled that Jewell failed to sustain his burden of proof on the alternate theories that (1) work-related injuries to both knees were a major contributing cause of the need for medical treatment, and (2) the cumulative effect of Jewett's work-related activities was a major contributing cause of the osteoarthritis. On appeal, the Supreme Court affirmed, holding the Department and circuit court did not err in finding (1) Jewett's first injury was not a major contributing cause of Jewett's need for a right knee replacement, and (2) Jewett did not prove that working on his knees was a major contributing cause of his osteoarthritis.

Plaintiff filed an action against defendants (collectively, the Plan) for refusing to pay certain long-term disability benefits. At issue was whether the district court erred in granting summary judgment for defendants and dismissed plaintiff's claims without prejudice due to his failure to exhaust available administrative remedies under the Plan. The court held that the district court adopted the Plan's reading of ERISA, 29 C.F.R. 250.503-1(i) without the benefit of the Secretary of Labor's interpretation of that provision. Therefore, deferring to the Secretary's plausible approach, the court held that where a claimant sought review of his or her disability claims, the quarterly meeting rule was restricted to multiemployer plans. Accordingly, the Plan was required to render a decision within 90 days of plaintiff's administrative appeal and failed to do so. Consequently, plaintiff's claims must be deemed exhausted and the judgment was reversed and remanded.

Plaintiff challenged the denial of his claims for long-term disability benefits by defendant, who served as both the administrator of claims and the payor of benefits in the long-term disability plan in which defendant participated. At issue was whether there was a conflict of interest where defendant was both administrator and payor of benefits of the plan governed by ERISA, 29 U.S.C. 1001-1461. The court found that defendant considered the medical information submitted by plaintiff's doctors and relied upon the advice of several independent medical professionals to conclude that plaintiff failed to make a sufficient showing of disability under the plan and, even where plaintiff's own doctors offered different medical opinions than defendant's independent doctors, the plan administrator could give different weight to those opinions without acting arbitrarily or capriciously. Therefore, the court held that a reasonable basis supported defendant's benefits decisions and that the conflict of interest did not render the decisions arbitrary or capricious.

Plaintiff Scott Hackett aggravated a pre-existing low back injury while working as a long distance truck driver for Western Express. After Hackett was terminated for reasons unconnected to his injury, Hackett filed a petition for award to the Workers' Compensation Board and was awarded ongoing partial incapacity benefits for a gradual injury to his lower back. When calculating Hackett's weekly wage, the hearing officer (1) excluded the nine cents per mile Hackett received as per diem pay, concluding that it was paid to cover special expenses, and (2) concluded that the per diem payments were not a fringe benefit that could be included to a limited extent in average weekly wage. Hackett appealed. The Supreme Court affirmed the hearing officer's decision but remanded for a recalculation of Hackett's fringe benefits pursuant to Me. W.C.B. R. ch. 1, 5(1).

Appellant, who had been on a medical leave of absence from appellee for nearly four months, sued appellee alleging violations of the Family and Medical Leave Act ("FMLA"), 29 U.S.C. 2612(a)(1), and the benefits-termination notice provisions of the Consolidated Omnibus Budget Reconciliation Act ("COBRA"), 29 U.S.C. 1166(a)(4)(A), when appellee fired him for job abandonment. Appellant appealed the district court's grant of summary judgment in favor of appellee on each of his claims. The court held that the district court properly granted summary judgment to appellee on appellant's interference claim under the FMLA where appellant failed to demonstrate any prejudice as a result of his firing on May 1, 2007. The court also held that the district court properly granted summary judgment to appellee on appellant's claim that appellee failed to provide him with notice of the termination of his benefits as required by COBRA where appellant failed to show that a genuine factual dispute existed regarding the means used by appellee to send the notice and where the undisputed facts showed that appellee used a notice method "reasonably calculated to reach" appellant.

Defendant appealed from the district court's grant of summary judgment in favor of plaintiff, compelling arbitration of a dispute related to healthcare benefits under an expired collective bargaining agreement. At issue was whether the district court erred in granting plaintiff's motion for summary judgment and issuing an order compelling the arbitration. The court reversed and held that the district court erred in granting summary judgment and compelling arbitration where both parties vigorously disputed issues of both law and fact, including whether the 1994 agreement was ambiguous and whether the summary plan descriptions constituted an intrinsic or extrinsic evidence of the parties' intent. The parties also point to various other extrinsic evidence and vehemently disagree as to whether the bargained for fully-paid health insurance premiums for life or just for the term of the agreement. Under these circumstances, the court held that the question of whether the right to fully-paid premiums vested under the 1994 agreement was best decided in the first instance by the district court and therefore, remanded for further proceedings.

Plaintiffs sued defendants, former directors of a retirees association of former unionized transportation workers, alleging, among other things, that defendants breached their fiduciary duty to the retirees association and its members by buying and maintaining a health insurance policy with premiums that far outstripped the benefits received by members. When defendants prevailed on all counts, defendants appealed the district court's denial of their fees motion. At issue was whether the district court erred in denying the fees motion in light of the recent Supreme Court decision, Hardt v. Reliance Standard Life Insurance Co. The court affirmed and held that the district court did not abuse its discretion in denying fees where, although the district court did not have the benefit of Hardt in reaching its decision, nothing in the district court's opinion contradicted Hardt or suggested that the district court would have decided the matter differently in light of Hardt. Accordingly, Hardt did not require the court to reverse or remand. The court also held that, when determining whether attorney's fees should be awarded to defendants, the court focused on whether plaintiffs brought the complaint in good faith.

New York Marine & General Insurance Company ("NYMAGIC") and Union Fire Insurance Company of Pittsburgh, Pennsylvania ("NUFIC-PA") were both insuring Bayou Steel Corporation ("Bayou") when an employee of Bayou's Illinois stevedoring contractor, Kindra Marine Terminal ("Kindra"), was injured during Kindra's unloading of Bayou's steel bundles from a vessel belonging to Memco Barge Lines ("Memco"). Memco had contracted with Bayou to haul the cargo for Bayou by barge from Louisiana to Illinois. At issue was whether Kindra was Bayou's contractor or subcontractor for purposes of the provision in NYMAGIC's policy that excluded coverage of Bayou's liability for bodily injury incurred by employees of Bayou's subcontractors but did not exclude coverage of such injuries incurred by Bayou's contractors. The court held that, because Bayou was the principal party, paying party, and not the prime contractor, performance party, under both its barge transportation agreement with Memco and its offloading agreement with Kindra, there was no way for Kindra to have been a subcontractor of Bayou within the intendment of NYMAGIC's policy's exclusion of coverage. Kindra contracted directly with Bayou, not with some contractor of Bayou, to offload Bayou's cargo, so Kindra was Bayou's contractor. Accordingly, NYMAGIC's coverage exclusion did not apply to the employee's injuries because he was the employee of a contractor of Bayou.

The Commonwealth Court declined to issue a writ of mandamus to Appellant Crozer Chester Medical Center (Crozer) in its attempt to force the Department of Labor and Industry (Department) to reimburse it for medical fees. Claimant William Radel suffered a work-related injury while lifting a bundle of rebar for his employer. The claimant underwent surgery at Crozer, and Crozer sent claimant's records and the bill to claimant's insurance company, Zurich North American Insurance (Zurich). Zurich did not pay, nor did it deny the claim. Crozer then turned to the State for reimbursement. The Department rejected the application as "premature," because Zurich's non-payment made an "outstanding issue of liability/compensability for the alleged injury." Crozer then petitioned the Commonwealth Court to force the Department to pay. The Supreme Court agreed that Crozer's application for reimbursement was premature. The Court found that Crozer did not try to resolve Zurich's nonpayment before petitioning the State or the Commonwealth Court. The Court affirmed the decision of the Department and the lower court, and dismissed Crozer's petition for a writ of mandamus.

Plaintiff sued defendant, a general contractor at a residential construction site, alleging claims of negligence, cross negligence and/or willful, wanton, or reckless conduct which resulted in the deaths of two employees hired by the subcontractor that was hired by defendant. At issue was whether, pursuant to G.L. c. 152, 23, a general contractor that paid workers' compensation benefits to an employee of an uninsured subcontractor, was immune from liability for common law claims the employee could have against that general contractor. The court held that the plain language of section 23 did not release a general contractor that paid workers' compensation benefits to its uninsured subcontractor's employee and that G.L. c. 152, 18 made clear that suits were not barred against general contractors that were obligated to pay workers' compensation benefits to the uninsured subcontractor's employees. Accordingly, the immunity provided under section 23 did not apply to defendant and therefore, the court vacated summary judgment in favor of defendant and remanded for further proceedings.