Justia Insurance Law Opinion Summaries

The Supreme Court affirmed the decision of the court of appeals affirming the holding of the Workers' Compensation Board that the Administrative Law Judge properly found that Plaintiff's claim for workers' compensation benefits was barred by the applicable statute of limitations, holding that there was no error.Plaintiff received a workplace injury and filed a claim for benefits. Plaintiff never sought or received any temporary total disability benefits prior to the applicable statute of limitations expiring. The insurance adjuster for the employer's workers' compensation insurance carrier offered to settle Plaintiff's claim, but the parties never reached a settlement agreement. Plaintiff later filed an application for resolution of his claim, but the employer denied the claim on the grounds that it was time barred. The ALJ found that the claim was not timely under Ky. Rev. Stat. 342.185. The Board affirmed. The Supreme Court affirmed, holding that the ALJ properly determined that equitable principles did not warrant the tolling of the statute of limitations. View "Davis v. Blendex Co." on Justia Law

The plaintiffs retired from the Louisville Metropolitan police department and received free health insurance, administered by Kentucky Retirement Systems. Kentucky initially paid all of their healthcare costs. After the officers turned 65, Medicare became the primary payer, leaving Kentucky to cover secondary expenses. Each officer came out of retirement, joining county agencies different from the ones they served before retiring. They became eligible for healthcare benefits in their new positions. Kentucky notified them that federal law “mandate[d]” that it “cannot offer coverage secondary to Medicare” for retirees “eligible to be on [their] employer’s group health plan” as “active employees.” Some of the officers then paid for insurance through their new employers; others kept their retirement insurance by quitting or going part-time. The officers sued.The district court granted summary judgment to the officers, ordered Kentucky to reinstate their retirement health insurance, and awarded the officers some of the monetary damages requested. The Sixth Circuit affirmed. The officers have a cognizable breach-of-contract claim. Under Kentucky law, the Kentucky Retirement Systems formed an “inviolable contract” with the officers to provide free retirement health insurance and to refrain from reducing their benefits, then breached that contract. The Medicare Secondary Payer Act of 1980 did not bar Kentucky from providing Medicare-eligible police officers with state retirement insurance after they reentered the workforce and became eligible again for employer-based insurance coverage, 42 U.S.C. 1395y. View "River City Fraternal Order of Police v. Kentucky Retirement Systems" on Justia Law

The Supreme Court reversed the judgment of the trial court granting the state's motion to dismiss this tort action, holding that a state's waiver of sovereign immunity in Conn. Gen. Stat. 52-556 for claims arising from a state employee's negligent operation of a state-owned and -insured motor vehicle extends to litigants who are state employees.Plaintiff, a state employee, was a passenger in a motor vehicle owned and insured by the state and operated by another state employee, William Texidor, when another vehicle operated by Tyreke Brooks struck their vehicle. Brooks' vehicle was uninsured. Plaintiff, who applied for and received workers' compensation benefits, brought this action agains the state and Metropolitan Casualty Insurance Company alleging that Texidor's operation of the vehicle was negligent. The state filed a motion to dismiss for lack of subject matter jurisdiction on the ground of sovereign immunity. The trial court granted the motion to dismiss. The Supreme Court reversed, holding (1) the trial court had jurisdiction pursuant to the waiver of sovereign immunity in section 52-556; (2) Plaintiff's action against the state was barred by Conn. Gen. Stat. 31-284(a); and (3) therefore, the form of judgment was improper, and the case is remanded with direction to render judgment for the state. View "Feliciano v. State" on Justia Law

An Alaska State Commission for Human Rights (State) employee with preexisting medical conditions was involved in a work-related motor vehicle accident in January 2017. The employee consulted with Dr. Teresa Bormann two days after the accident; Dr. Bormann referred the employee to chiropractic treatment. After several month of treatment, Dr. Bormann referred the employee to physical therapy at United Physical Therapy (UPT) for chronic neck pain and headache. After an evaluation UPT recommended eight weeks of twice weekly physical therapy. Dr. Bormann endorsed the treatment plan, and the employee’s symptoms improved enough that she reduced her physical therapy visits to once a week beginning in mid-January. She saw UPT three times in February 2018. Payment for these February visits became the main dispute before the Board. The State arranged an employer’s medical evaluation (EME) with a neurologist and an orthopedist. The EME doctors diagnosed the employee with a cervical strain caused by the accident as well as several conditions they considered preexisting or unrelated to the work injury. After the State filed a retroactive controversion of medical treatment, the employee’s healthcare provider filed a workers’ compensation claim seeking payment for services it provided before the controversion was filed. The State disputed its liability for payment, and after several prehearing conferences, the Alaska Workers’ Compensation Board set a hearing on the merits of the provider’s claim. The Board ordered the State to pay the provider approximately $510.00 for the services. The State appealed, disputing several procedural aspects of the decision, and the Alaska Workers’ Compensation Appeals Commission affirmed the Board’s decision. Finding no reversible error, the Alaska Supreme Court affirmed the Commission’s decision. View "Alaska, Department of Health and Social Services v. Thomas et al." on Justia Law

William Scholle worked for United Airlines, Inc., driving luggage tugs from the terminal to waiting planes, loading or unloading the bags, and returning to the terminal. In June 2012, Scholle was stopped at a stop sign on a return trip to the terminal when he was rear-ended by Daniel Moody, an employee of Delta Air Lines, Inc. Scholle applied for and received workers’ compensation insurance benefits from United, a self-insured employer. United covered all medical expenses resulting from Scholle’s on-the-job injuries, as well as a portion of his lost wages. Scholle’s medical providers produced bills for the services he received that reflected costs in excess of what is permitted by the workers’ compensation fee schedule, though they never tried to collect amounts beyond those permitted by statute. United exercised its subrogation right and sued Delta and Moody to recover the payments it made to and on behalf of Scholle. Scholle separately sued Delta and Moody for negligence, seeking to recover compensation for damages as a result of the collision. Eventually, Delta settled United’s subrogation claim; Scholle’s claims against Moody were later dismissed, leaving only Scholle and Delta as parties. Delta admitted liability for the accident, and the case went to trial on damages. In pretrial motions in limine, Scholle argued that the collateral source rule should preclude Delta from admitting evidence of the amount paid by Scholle’s workers’ compensation insurance to cover the medical expenses arising from his injuries. Instead, Scholle contended, the higher amounts billed by his medical providers reflected the true reasonable value of the medical services provided to him and should have been admissible at trial. The trial court disagreed, reasoning that when Delta settled with United, it effectively paid Scholle’s medical expenses, such that amounts paid for those expenses were no longer payments by a collateral source. The court further noted that, under the workers’ compensation statute, any amount billed for medical treatment in excess of the statutory fee schedule was “unlawful,” “void,” and “unenforceable.” The Colorado Supreme Court concluded that when, as here, a workers’ compensation insurer settles its subrogation claim for reimbursement of medical expenses with a third-party tortfeasor, the injured employee’s claim for past medical expenses is extinguished completely. "Because the injured employee need not present evidence of either billed or paid medical expenses in the absence of a viable claim for such expenses, the collateral source rule is not implicated under these circumstances. The court of appeals therefore erred in remanding for a new trial on medical expenses based on a perceived misapplication of that rule." View "Delta Air Lines, Inc. v. Scholle" on Justia Law

In December 2015, Joseph Gill was injured in an on-the-job car accident when he was struck by a truck owned by Swift Transportation Company, LLC (“Swift”), driven by Christopher Waltz. As a result of the injuries he suffered in the accident, Gill obtained workers’ compensation benefits through Pinnacol Assurance (“Pinnacol”) to cover his medical expenses. Gill’s medical providers produced bills totaling $627,809.76 for the services he received. However, because Colorado’s workers’ compensation scheme caps the amount that medical providers can charge, Pinnacol satisfied all of Gill’s past medical expenses for significantly less. Pinnacol then pursued, and ultimately settled, its subrogation claim with Swift. Gill and his wife subsequently sued Swift and Waltz for damages resulting from the accident, and the case was removed from state court to the U.S. District Court for the District of Colorado. Swift sought partial summary judgment , relying on case law which, in applying Colorado’s workers’ compensation law, concluded that an injured employee lacked standing to pursue damages for services that were covered by workers’ compensation after the insurer had settled its subrogated claims with the third-party tortfeasor. While the federal district court was considering Swift’s motion, the Colorado Court of Appeals issued its opinion in Scholle v. Delta Air Lines, Inc., 2019 COA 81M, in which a divided court disagreed with the case law. Instead, it determined that a plaintiff-employee could seek damages for medical services covered by workers’ compensation insurance if the billed amounts were higher than the paid amounts, even after the insurer had settled its subrogation claim. The Colorado Supreme Court reversed, finding that a settlement between a workers’ compensation insurer and a third-party tortfeasor for all past medical expenses paid as a result of an on-the-job injury extinguished the plaintiff-employee’s claim to recover damages for those past medical expenses from the third-party tortfeasor. "As a result, while Joseph Gill may still pursue his claims for noneconomic damages and any economic damages not covered by his workers’ compensation insurer, he no longer has any claim to recover economic damages based on services paid for by workers’ compensation. There is consequently no reason to present evidence of either the amounts billed or the amounts paid for those services, and the collateral source rule is not implicated in this case." View "Gill v. Waltz" on Justia Law

Defendant Daniel Clapp plead no contest to concealing the true extent of his physical activities and abilities from his employer, the Department of the California Highway Patrol (CHP), and the State Compensation Insurance Fund (SCIF). Consistent with a resolution negotiated by the parties, the trial court granted defendant three years’ probation, and as a condition of probation, ordered him to pay restitution. Following a hearing, defendant was ordered to pay $30,095.68 to SCIF for temporary disability benefits and $81,768.01 to CHP for benefits wrongfully obtained. He was also ordered to pay $1,350 and $70,159 to SCIF and CHP respectively for investigative costs. Defendant appealed the restitution award as to investigation costs contending that, as public investigative agencies, neither SCIF nor CHP was entitled to reimbursement for the costs of investigating his claim. After review, the Court of Appeal concluded that as direct victims of defendant’s fraud, both CHP and SCIF were indeed entitled to restitution for investigative costs incurred in an effort to justify discontinuance of payments and recoup money defendant fraudulently obtained. View "California v. Clapp" on Justia Law

The Louisiana Supreme Court granted certiorari review in this case to determine whether the court of appeal properly granted summary judgment in favor of defendant Louisiana Farm Bureau Casualty Insurance Company (“Farm Bureau”), where Farm Bureau argued that the “regular use” exclusion in its automobile insurance policy issued to plaintiff precluded uninsured motorist (“UM”) coverage, because plaintiff was operating a vehicle owned by his employer at the time of the accident. The plaintiff in this matter, Charles Higgins, was injured in an automobile accident while operating a truck owned by his employer, AT&T. The other driver in the accident was underinsured, and AT&T did not carry UM coverage on the truck. Higgins subsequently filed the instant suit against his personal UM insurer, Farm Bureau. Because the Supreme Court found the policy’s “regular use” exclusion impermissibly derogated from the requirements of the Louisiana uninsured motorist statute (the “UM statute”), La. R.S. 22:1295, the Court found this exclusion inapplicable and reversed the decision of the court of appeal. View "Higgins v. Louisiana Farm Bureau Casualty Ins. Co." on Justia Law

The issue this case presented for the Colorado Supreme Court's review centered on whether an injured passenger riding in a vehicle negligently driven by one co-worker and owned by another co-worker, when all three were acting within the course and scope of their employment, could recover UM/UIM benefits under the vehicle owner’s insurance policy. Although the parties disputed the meaning of the phrases “legally entitled to recover” and “legally entitled to collect” under section 10-4-609, C.R.S. (2020) the Court did not resolve that dispute here because, assuming without deciding that plaintiff Kent Ryser’s interpretation was correct, the Court concluded that he still could not prevail. Specifically, the Court found an injured co-worker was barred by operation of the Workers’ Compensation Act's (“WCA”) exclusivity and co-employee immunity principles from recovering UM/UIM benefits from a co-employee vehicle owner’s insurer for damages stemming from a work-related accident in which another co-employee negligently drove the owner’s vehicle and the injured party was an authorized passenger. Though the Court's reasoning differed from the appellate court's judgment, it affirmed the outcome: summary judgment was properly entered in favor of the insurance company. View "Ryser v. Shelter Mutual Insurance" on Justia Law

Cherokee Services Group, LLC; Cherokee Nation Government Solutions, LLC; Cherokee Medical Services, LLC; Cherokee Nation Technologies, LLC (collectively referred to as the “Cherokee Entities”); Steven Bilby; and Hudson Insurance Company (“Hudson Insurance”) appealed district court orders and a judgment reversing an administrative law judge’s (“ALJ”) order. The ALJ’s order concluded the Cherokee Entities and Bilby were protected by tribal sovereign immunity and Workforce Safety and Insurance (“WSI”) had no authority to issue a cease and desist order to Hudson Insurance. The district court reversed the ALJ’s determination. The Cherokee Entities were wholly owned by the Cherokee Nation; Bilby served as executive general manager of the Cherokee Entities. Hudson Insurance provided worldwide workers’ compensation coverage to Cherokee Nation, and the Cherokee Entities were named insureds on the policy. WSI initiated an administrative proceeding against the Cherokee Entities, Bilby, and Hudson Insurance. WSI determined the Cherokee Entities were employers subject to North Dakota’s workers’ compensation laws and were liable for unpaid workers’ compensation premiums. WSI also ruled that Bilby, as executive general manager, was personally liable for unpaid premiums. WSI ordered the Cherokee Entities to pay the unpaid premiums, and ordered Hudson Insurance to cease and desist from writing workers’ compensation coverage in North Dakota. The Cherokee Nation had no sovereign land in North Dakota, and the Cherokee Entities were operating within the state but not on any tribal lands. The North Dakota Supreme Court reversed the district court judgment, and reinstated and affirmed the ALJ’s order related to the cease and desist power of WSI, but the matter was remanded to the ALJ for further proceedings on the issue of sovereign immunity. View "WSI v. Cherokee Services Group, et al." on Justia Law