Justia Insurance Law Opinion Summaries

Employee filed a claim for workers' compensation, alleging that he sustained injuries while working for Restaurant. Employee gained employment with Restaurant through a staff leasing company (Company). Employee agreed to a settlement of his claim. Later, Employee moved to re-open the workers' compensation award and to join the Uninsured Employers' Fund (UEF) as a party, asserting that Restaurant and Company were no longer available to pay for his continuing medical expenses. The ALJ subsequently joined the UEF. The ALJ found Employee's condition to have worsened so he was totally disabled and that the UEF was responsible for all benefits for which Employee was entitled. The Workers' Compensation Board vacated the portion of the ALJ's opinion regarding the amount of benefits Employee would receive and otherwise affirmed. The Supreme Court affirmed, holding (1) Employee's claim was properly reopened and the UEF joined as a party; (2) Employee presented sufficient evidence to show that his condition had worsened since the entry of his original workers' compensation award; and (3) although the original settlement agreement only listed Employee's lower back injury as compensable, Employee was not barred from raising a claim for his thoracic spine injury upon reopening. View "Commonwealth v. Allen" on Justia Law

Booker T. Washington, Jr. filed a claim against Porocel Corporation with the Workers' Compensation Commission, alleging exposure to asbestos and silica dust resulting in lung disease and silicosis. An ALJ found Washington's claim was barred by the statute of limitations. Washington subsequently filed suit against Porocel, alleging, inter alia, negligence and breach of implied warranty. Porocel moved to dismiss the complaint, contending that the Commission had exclusive jurisdiction of the claims alleged and that the Arkansas Workers Compensation Act (Act) was Washington's exclusive remedy. The circuit court denied Porocel's motion to dismiss, concluding that Washington's occupational disease was not one for which the Act provided coverage. Porocel then filed a petition for a writ of prohibition to prevent the circuit court from exercising jurisdiction over Washington's complaint. The Supreme Court granted the petition, holding that Washington's claim was covered by the Act. View "Porocel Corp. v. Circuit Court" on Justia Law

Beneficiaries of the deceased sued WSLAC after it denied life insurance benefits to the beneficiaries on the basis that the deceased had not disclosed her Hepatitis B on the application. A reasonable jury could conclude that the deceased gave truthful answers about her medical condition and that the agent recorded them incorrectly. It could also conclude that the deceased did not examine the application. The disputed facts were material because there was a genuine issue as to whether the deceased knew of misrepresentation in the application. Accordingly, the court reversed the district court's grant of summary judgment and remanded for further proceedings. View "Yang, et al v. Western-Southern Life Assurance Co." on Justia Law

"At its most basic level, this case presents a policy dispute: whose policy choice concerning health insurance premiums for State employees controls—the General Assembly's or the Budget and Control Board's?" The issue before the Supreme Court centered on "maintaining and enforcing the constitutional and statutory framework through which such issues must be resolved. " Upon review of the arguments of the parties and the applicable case law, the Supreme Court found that the General Assembly had and exercised the power to determine the contribution rates of enrollees for the State's health insurance plan in 2013. The Court held that the Budget and Control Board violated the separation of powers provision by substituting its own policy for that of the General Assembly, entered judgment for the petitioners, and directed the Board to use the appropriated funds for premium increases and return the premium increases previously collected from enrollees. View "Hampton v. Haley" on Justia Law

The Commissioner appealed the tax court's determination related to a deficiency in petitioners' federal income tax involving distributions from petitioners' variable universal life insurance policy. The Commissioner asserted that surrender charges could never be considered under I.R.C. 402(b)(2), and maintained that petitioners actually received the full stated policy values of their respective policies. The court affirmed the tax court's determination that the "amount actually distributed" when petitioners received ownership of the policies after their employer wound down their employees' benefit trust was "the fair market value of what was actually distributed." Further, the surrender charges associated with a variable universal life insurance policy could permissibly be considered as part of the general inquiry into a policy's fair market value. Accordingly, the court affirmed the decision. View "Schwab v. CIR" on Justia Law

Clarinet sued Essex alleging that Essex wrongfully refused to pay Clarinet under a commercial general liability insurance policy. Clarinet sought payment for expenses for stabilizing and demolishing a building that it owned, in accordance with Clarinet's interpretation of the policy. Essex denied coverage and refused payment. The insurance policy contained several conditions and exclusions, including the owned property exclusion. The court held that the district court properly granted summary judgment to Essex and denied relief to Clarinet because the owned property exclusion barred coverage. View "Clarinet v. Essex Ins. Co." on Justia Law

Central States is a multiemployer pension plan for members of the Teamsters union in the eastern half of the U.S. Ready Mix employed Teamsters labor and participated in the Central States plan. In 2007 Ready Mix ceased employing covered workers and incurred $3.6 million in withdrawal liability to fully fund its pension obligations. Two affiliated companies under common control by Nagy, the owner of Ready Mix, conceded liability for the shortfall under the Employee Retirement Income Security Act, as amended by the Multiemployer Pension Plan Amendments Act of 1980, 29 U.S.C. 1301(b)(1). The district court concluded that Nagy held and leased property to Ready Mix as a passive investment, not a trade or business, so the leasing activity did not trigger personal liability, but that Nagy’s work as a manager for a country club was as an independent contractor, not an employee, and this activity qualified as a trade or business under section 1301(b)(1), which was enough for personal liability. The Seventh Circuit affirmed, holding that Nagy’s leasing activity is categorically a trade or business for purposes of personal liability under 1301(b)(1). View "Cent. States SE & SW Areas Pension Fund v. Nagy" on Justia Law

In 2007, Employers Mutual Casualty Company (EMC) brought a declaratory judgment action against the Donnellys and Rimar Construction, Inc. (RMI) to establish that under its policy of insurance with RCI, EMC had no duty or responsibility to pay damages claimed by the Donnellys in litigation between the Donnellys and RCI. The declaratory judgment action was stayed until a verdict was reached in the underlying action. In the underlying action, the Donnellys were awarded damages, costs and attorney fees against RCI. Subsequently the district court entered summary judgment in the declaratory action, finding that there was no insurance coverage for the damages the Donnellys incurred, but that there was coverage for costs and attorney fees. On appeal, EMC argued that the district court erred in its determination that it had a duty to pay attorney fees and costs when there were no damages awarded to the plaintiff subject to the policy coverage. The Donnellys cross appealed, arguing the district court erred in its conclusion that EMC did not have a duty to cover the damages in this case, and that the Donnellys were entitled to attorney fees. Upon review, the Supreme Court affirmed the district court's decision. View "Employers Mutual Casualty Co v. Donnelly" on Justia Law

Plaintiff filed a claim with his Insurer under his policy for stolen tools and equipment, which Insurer denied. Plaintiff sued. The district court granted summary judgment for Insurer. The court of appeals reversed and remanded for entry of judgment for Plaintiff. On remand, Plaintiff requested and received attorney fees related to both the district court and the appellate proceedings. The court of appeals reversed the award of appellate attorney fees, concluding Plaintiff had waived his right to appellate fees by not filing a motion for attorney fees with the court of appeals in the prior appeal. Petitioner filed a motion requesting appellate attorney fees for his second appeal in Snider II. The court of appeals awarded additional appellate attorney fees. Plaintiff appealed, requesting a judgment for the appellate attorney fees incurred in Snider I and an award of additional fees for the appeal in Snider II. The Supreme Court affirmed, holding that the court of appeals (1) correctly applied Supreme Court Rule 7.07(b), Evans v. Provident Life & Accident Ins. Co., and Kan. Stat. Ann. 40-908; and (2) did not err in determining the amount of reasonable attorney fees related this current appeal. View "Snider v. Am. Family Mut. Ins. Co." on Justia Law

Plaintiffs claimed that PacifiCare was not entitled to any reimbursement payments out of the wrongful death benefits paid by an insurance policy to them. PacifiCare counterclaimed, arguing that it was entitled to reimbursement under both the terms of its contract with the deceased (Count I) and directly under the Medicare Act (Count 11), 42 U.S.C. 1395. At issue was whether a private Medicare Advantage Organization (MAO) plan could sue a plan participant's survivors, seeking reimbursement for advanced medical expenses out of the proceeds of an automobile insurance policy. Because interpretation of the federal Medicare Act presented a federal question, the district court had subject matter jurisdiction to determine whether that act created a cause of action in favor of PacifiCare against plaintiffs. The district court properly dismissed the causes of action arising under the Medicare Act for failure to state a claim where section 1395y(b)(2) did not create a federal cause of action in favor of a MAO and where, under section 1395y(b)(3)(A), the Private Cause of Action applied in the case of a primary plan which failed to provide for primary payment, which was not applicable in this instance. The court affirmed the district court's dismissal of Count II for failure to state a claim as well as its decision to decline to exercise supplemental jurisdiction over Count 1. View "Parra v. Pacificare of Arizona" on Justia Law