Justia Insurance Law Opinion Summaries

Petitioner Toni Weeks appealed a district court judgment that affirmed a decision by Workforce Safety and Insurance (WSI) that reduced her disability benefits. Petitioner was injured at work after being exposed to anhydrous ammonia while employed by Dakota Gasification Company, in Beulah, North Dakota. In 2009, WSI received confirmation that on November 1, 2009, Weeks' social security disability benefits would convert to social security retirement benefits. WSI issued a notice of intention to discontinue or reduce benefits, in which Petitioner was informed that her permanent total disability benefits would end on October 31, 2009, and she would receive an "additional benefit payable" beginning November 1, 2009. Petitioner requested reconsideration. In November 2009, WSI issued an order denying Petitioner further disability benefits after October 31, 2009. Upon review, the Supreme Court found that because Petitioner failed to adequately brief her argument that WSI's reduction of her wage loss benefits violated equal protection under the federal and state constitutions, the Supreme Court declined to address her argument and otherwise affirmed the judgment.

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

Plaintiffs, a class of economically vulnerable Arizonians who receive public health care benefits through the state's Medicaid agency, sued the U.S. Secretary of Health and Human Services (Secretary) and the Director of Arizona's medicaid agency (director)(collectively, defendants), alleging that the heightened mandatory co-payments violated Medicaid Act, 42 U.S.C. 1396a, cost sharing restrictions, that the waiver exceeded the Secretary's authority, and that the notices they received about the change in their health coverage was statutorily and constitutionally inadequate. The court affirmed the district court's conclusion that Medicaid cost sharing restrictions did not apply to plaintiffs and that Arizona's cost sharing did not violate the human participants statute. The court reversed the district court insofar as it determined that the Secretary's approval of Arizona's cost sharing satisfied the requirements of 42 U.S.C. 1315. The court remanded this claim with directions to vacate the Secretary's decision and remanded to the Secretary for further consideration. Finally, the court remanded plaintiffs' notice claims for further consideration in light of intervening events.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660â61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

Plaintiff Melissa Qualls appealed a district Court's order that affirmed the Social Security Administration's decision to deny her application for disability insurance benefits. Plaintiff alleged she became disabled in 2004. Her "date last insured" was December 31, 2008, "thus she had the burden of proving that she was totally disabled on that date or before." Though Plaintiff suffered from multiple sclerosis, the Administrative Law Judge (ALJ) found that she was not disabled because "she could make a successful adjustment to other light and sedentary work that exists in significant numbers in the national economy." On appeal, Plaintiff argued that the ALJ failed to perform a proper credibility determination prior to rendering his judgment. Upon review of the Administration's record, the Tenth Circuit found that the Commissioner's decision was supported by substantial evidence, and the the law was properly applied. The Court affirmed the Commission's decision to deny Plaintiff further insurance benefits.

Plaintiff Geral Brown appealed a district court's order that granted summary judgment to Defendant Hartford Insurance Company (Hartford). Plaintiff sued Hartford under the Employee Retirement Income Security Act (ERISA) for the company's termination of his long-term disability benefits. Following his injury, Plaintiff filed for Social Security Disability benefits as required by his benefit plan, and the Social Security Administration awarded him benefits. The plan then offset the monthly benefit it paid to Plaintiff by the amount of the Social Security benefit. The Hartford denied Plaintiff's administrative appeal. After examining and weighing the evidence, the trial court granted summary judgment to the Hartford. The Tenth Circuit concluded that the plan administrator's decision was supported by substantial evidence. Accordingly, the Court affirmed the decision of the district court.

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.

Petitioner Hartford Insurance Company (Hartford) appealed orders of the Compensation Appeals Board (CAB) that denied it recovery from the State Special Fund for Second Injuries for injuries to Claire Hamel and John Rygiel. Ms. Hamel worked as an assembly person for a motor manufacturing company. She was temporarily disabled for psychiatric reasons. She continued to work until her second injury for degenerative disc disease. Mr. Rygiel worked as a truck driver for a mobile MRI unit. Mr. Rygiel had Type II diabetes that required medication. Mr. Rygiel sustained an employment-related injury to his wrist. In both Ms. Hamel and Mr. Rygiel's cases, Hartford applied for and was denied reimbursement from the second injury fund. Hartford appealed both the Hamel and Rygiel decisions by CAB. The issue from both cases centered on whether state law allowed the CAB to consider an employee's past job performance as evidence that his or her preexisting impairment would not be a hindrance to obtaining employment if that employee became unemployed. The Supreme Court concluded that the employee's ability to perform his or her existing job is not determinative of whether the preexisting impairment was a hindrance to obtaining employment. The Court found that the CAB erroneously relied on the employee's ability when it denied Hartford's claims for reimbursement. Accordingly, the Court vacated the CAB's decisions in both the Hamel and Rygiel cases and remanded the cases for further proceedings.

To provide relief in the aftermath of Hurricanes Katrina and Rita, Congress appropriated funds to Louisiana which distributed some of those funds through the "Road Home" program. The State required more than 150,000 Road Home grant recipients to execute a "Limited Subrogation/Assignment Agreement." The Road Home program created "perverse incentives" for insurance companies and their insured homeowners: some insurers inadequately adjusted and paid grant-eligible claims, and some grant-eligible homeowners had little motivation for file insurance claims. As a result, Road Home applications skyrocketed and created a $1 billion shortfall in the program. The State filed suit against more than 200 insurance companies, seeking to recover the funds spent and yet to be spent on claims under the Road Home program. The Insurance Companies successfully removed the case to the federal district court. The Insurance Companies then sought to dismiss the State's case, arguing that as a matter of law, anti-assignment clauses in the homeowners' policies invalidated the subrogation/assignment to the State. The federal district court denied the Companies' motion to dismiss. The Companies appealed to the Fifth Circuit. Because interpretation of the policy provisions at issue was a matter of State law, the Court certified interpretation to the Louisiana Supreme Court. The Supreme Court found that there is no public policy in Louisiana that precludes anti-assignment claims from applying to post-loss assignments. The Court commented that the language of the anti-assignment clause must clearly and unambiguously express that it applies to post-loss assignments, and as such must be evaluated on a policy-by-policy basis.

Plaintiff sought disability insurance benefits under the Social Security Act, alleging that migraine headaches, affective mood disorder, and mayofascial back pain left her unable to work. At issue was whether the administrative law judge's ("ALJ") decision was supported by substantial evidence and whether the ALJ properly weighed physicians' opinions in determining plaintiff's residual functional capacity. The court concluded that substantial evidence supported the ALJ's decision to discredit plaintiff's subjective complaints where none of her doctors reported functional or work related limitations due to her headaches and where there was no basis for her creditability. The court also held that the ALJ properly weighed the physicians' opinions in determining plaintiff's residual functional capacity.