Justia Government & Administrative Law Opinion Summaries

A hotel housekeeper injured her back while lifting a pile of linens. Her employer challenged her application for benefits based on an examining doctor’s opinion that she was medically stable and that the job injury was no longer the substantial cause of any disability or need for medical treatment. After a hearing, the Alaska Workers’ Compensation Board decided that the woman was medically stable as of the date of the doctor’s opinion and therefore not entitled to further disability payments or to benefits for permanent partial impairment. The Board also denied further medical care after the date of medical stability. The Alaska Workers’ Compensation Appeals Commission affirmed the Board’s decision, and the woman appealed. Because the Board’s selected date of medical stability was not supported by substantial evidence in the record, the Alaska Supreme Court vacated the Commission’s decision and remanded the case to the Commission with instructions to remand the case to the Board for further proceedings. View "Tobar v. Remington Holdings LP" on Justia Law

This case arose from Hurricane Katrina insurance litigation. After the hurricane had destroyed many homes, policyholders and insurance companies began litigating whether the hurricane losses were caused by flood damage or wind damage. The distinction determined whether the insurance companies would pay claims on those polices that did not cover flood damage. This case is before the Court on interlocutory appeal. Safeco Insurance Company (Safeco) and Liberty Mutual Insurance Company individually challenged the circuit court’s reassignment of their respective cases and the appointment of a special master. The Mississippi Supreme Court found no abuse of discretion in reassigning judges, but vacated the order appointing the special master, finding an abuse of the trial court’s discretion. “The order itself acknowledged a blind-billing provision was “unusual.” But the Supreme Court found it was more than that: requiring both parties, one of which is the State of Mississippi, to pay an attorney in Louisiana to act as a judge, allowing either side to meet with him ex parte, and not requiring this special master to mention these meetings or even justify or detail his bill far exceeded the discretionary authority to appoint special masters.” View "Safeco Insurance Company of America v. Mississippi, ex rel. Hood" on Justia Law

Due to an unsafe condition on the premises, Osborne suffered a broken arm at the Center, which is owned and operated by Metro Nashville. Osborne obtained a state court judgment against Metro under the Tennessee Governmental Tort Liability Act; the damages included specific medical expenses related to the incident and found Osborne’s comparative fault to be 20 percent. Before the state court suit, Osborne incurred medical expenses for which Metro did not pay at the time. Medicare made conditional payments to Osborne totaling at least $9,453.09. Osborne claims he incurred—in addition to the costs of his state court litigation—the cost of his co-pays, deductibles, and co-insurance for treatments not covered through Medicare. Osborne alleged Metro is a primary payer who failed to pay under the Medicare Secondary Payer Act (MSPA), 42 U.S.C. 1395y(b), and was therefore liable for reimbursement of Medicare’s conditional payments and a double damages penalty under section 1395y(b)(3)(A). Metro claimed it paid the judgment in full, including discretionary costs. The Sixth Circuit affirmed that Osborne lacked statutory standing to sue for his individual losses and the conditional payments made by Medicare because the MSPA does not permit a private cause of action against tortfeasors. Because the MSPA is not a qui tam statute and financial injury suffered by Medicare is not attributed to Osborne, he also lacked Article III standing to sue for Medicare’s conditional payments. View "Osborne v. Metropolitan Government of Nashville and Davidson County" on Justia Law

The Supreme Court reversed the decision of the court of appeals reversing the judgment of the circuit court striking two insurance conditions from a conditional use permit (CUP) Dane County issued to Enbridge Energy Company as unenforceable under 2015 Wisconsin Act 55, holding that because Enbridge carried the requisite insurance, Act 55 rendered Dane County's extra insurance conditions unenforceable.The two conditions at issue required Enbridge to procure additional insurance prior to Enbridge expanding its pipeline pump station. Dane County approved the CUP with these insurance conditions. Thereafter, the Wisconsin Legislature passed Act 55, which prohibits counties from requiring an interstate pipeline operator to obtain additional insurance when the pipeline operating company carries comprehensive general liability insurance with coverage for "sudden and accidental" pollution liability. Dane County issued the CUP with the invalid insurance conditions. The circuit court struck the two conditions from the CUP as unenforceable under Act 55. The court of appeals reversed on the ground that Enbridge failed to show it carried the requisite coverage triggering the statutory prohibition barring the County from imposing additional insurance procurement requirements. The Supreme Court reversed, holding that Enbridge carried the requisite insurance, and therefore, Dane County's extra insurance conditions were unenforceable. View "Enbridge Energy Co. v. Dane County" on Justia Law

Dami Hospitality, LLC (“Dami”) was the owner-operator of a Denver motel that employed between four and ten people at any given time. As an employer of three or more persons, Dami was required by statute to maintain workers’ compensation insurance. Dami allowed its workers’ compensation coverage to lapse on in 2005. Upon receiving notification of the lapse from the Division of Workers’ Compensation (“DWC”), Dami conceded the violation and paid a corresponding settlement in June 2006. Dami again allowed its workers’ compensation coverage to lapse in 2006. From June 2007 to September 2010, Dami carried the proper insurance, but the company’s workers’ compensation coverage again lapsed on September 12, 2010 and went without insurance until July 9, 2014. On February 19, 2014, the DWC discovered that Dami had allowed its workers’ compensation insurance to lapse for these periods of time and issued a notice to Dami regarding this. Dami faxed a copy of workers' compensation insurance for the July 10, 2014 - July 10, 2015 period; Dami offered no such evidence for any other period, nor any explanation for the lapses. Fines accrued for noncompliance, totaling $841,200. The DWC ultimately issued an order upholding the fines. Dami appealed to the Industrial Claim Appeals Office (“ICAO”). The ICAO rejected all but Dami’s excessive fines argument. The ICAO remanded the matter to the DWC, directing it to review the constitutionality of the aggregated per diem fines assessed in accordance with the test established by the court of appeals in Associated Business Products v. Industrial Claim Appeals Office, 126 P.3d 323 (Colo. App. 2005). The ICAO would ultimately affirm the resulting fines, and Dami appealed to the Court of Appeals. The appellate court set aside the fines, assuming, without deciding, the Excessive Fines Clause could be applied to challenge regulatory fees imposed on a corporation. The Colorado Supreme Court concluded the proper test to assess the constitutionality of government fines under the Eighth Amendment required an assessment of whether the fine was grossly disproportional to the offense for which it was imposed. The Supreme Court thus reversed the court of appeals’ ruling and remanded to that court for return to the Division of Workers’ Compensation with instructions to, as appropriate and necessary, develop an evidentiary record sufficient to determine whether the $250–$500 fine that a business was required to pay for each day that it was out of compliance with Colorado’s workers’ compensation law is proportional to the harm or risk of harm caused by each day of noncompliance. View "Colo. Dept. of Labor & Emp. Div. of Workers' Comp. v. Dami Hosp." on Justia Law

Claimant Elvia Garcia-Solis was injured in a work-related accident. Farmers Insurance Company and Yeaun Corporation (collectively, “Insurer”) accepted a workers’ compensation claim and certain specified medical conditions associated with the accident. Because claimant also showed psychological symptoms, her doctor recommended a psychological referral to diagnose her for possible post-traumatic stress disorder (PTSD). Insurer argued, and the Court of Appeals agreed, that the cost of the psychological referral was not covered by workers’ compensation because claimant had failed to prove that it was related to any of the medical conditions that insurer had accepted. The Oregon Supreme Court reversed both the Court of Appeals and the Workers’ Compensation Board: “’injury’ means work accident is context-specific to exactly two uses in the first and second sentences of ORS 656.245(1)(a). It does not apply to the second use in the first sentence of ORS 656.245(1)(a). We do not decide or suggest that it applies to any other statute in the workers’ compensation system.” View "Garcia-Solis v. Farmers Ins. Co." on Justia Law

Defendant-appellant Ricardo Lara, the California Insurance Commissioner, filed a notice of noncompliance against plaintiffs-respondents Mercury Insurance Company, Mercury Casualty Company, and California Automobile Insurance Company (collectively Mercury) alleging Mercury charged rates not approved by the California Department of Insurance (CDI) and that the rates were unfairly discriminatory in violation of Insurance Code sections 1861.01 (c) and 1861.05 (b). The allegedly unapproved rates were in the form of broker fees charged by Mercury agents, which should have been disclosed as premium. After prevailing at an administrative hearing, the Commissioner imposed civil penalties against Mercury totaling $27,593,550 for almost 184,000 unlawful acts. Mercury filed a petition for writ of mandate, which the court granted, reversing the Commissioner’s decision. The court found the “broker fees” were not premium because they were charged for separate services. The court also rejected the Commissioner’s interpretation of the term premium under the Insurance Code and regulations. In addition, the court ruled Mercury did not have proper notice it was subject to penalties, in violation of due process, and the action was barred by laches because CDI had unduly delayed in bringing the action. Commissioner and intervener-appellant, Consumer Watchdog (CWD), appealed on several grounds, among them: (1) the trial court did not use the proper standard of review; (2) failed to give the Commissioner’s findings a strong presumption of correctness and failed to put the burden of proof on Mercury to show the findings were against the weight of the evidence; (3) the trial court’s finding the fees were charged for separate services was precluded by collateral estoppel; (4) Mercury received proper notice of the potential imposition of a penalty; and (5) laches did not bar the action. The Court of Appeal agreed with Commissioner and CWD the writ was issued in error and reversed the judgment. View "Mercury Insurance Co. v. Lara" on Justia Law

Tony Kourianos worked as a coal miner for more than 27 years before filing a claim for benefits under the Black Lung Benefits Act (“BLBA”). His claim was reviewed through a three-tiered administrative process. Ultimately, the Benefits Review Board (“BRB”) found that he was entitled to benefits. The BRB also found that Kourianos’s last employer, Hidden Splendor Resources, Inc., was the “responsible operator” liable for paying those benefits. Hidden Splendor’s insurer, Rockwood Casualty Insurance Company, petitioned the Tent Circuit Court of Appeal for review of the BRB’s decision: (1) challenging the administrative law judge’s (“ALJ”) decision prohibiting Hidden Splendor from withdrawing its responsible operator stipulation; and (2) contending the BRB incorrectly found that Kourianos was totally disabled and entitled to benefits. Finding no abuse of discretion in the BRB decision, the Tenth Circuit denied Rockwood's petition. View "Rockwood Casualty Insurance v. Director, OWCP" on Justia Law

Winter wheat farmers could purchase insurance to protect against below-average harvests. The policies at issue here offered yield protection. On July 1, 2014, the Federal Crop Insurance Corporation (“FCIC”) published an interim rule to implement the 2014 Farm Bill. In that interim rule, the FCIC warned that the APH yield exclusion “may not be implemented upon publication” because “[p]roduction data availability and intensive data analysis may limit FCIC’s ability to authorize exclusions of yields for all APH crops in all counties.” Therefore, the FCIC amended the Common Crop Insurance Policy (CCIP) Basic Provisions (the actual terms of the insurance policy offered for sale) “to allow the actuarial documents to specify when insureds may elect to exclude any recorded or appraised yield.” The revised CCIP Basic Provisions stated that farmers “may elect” the APH yield exclusion “[i]f provided in the actuarial documents.” The deadline for winter wheat farmers to purchase insurance for the 2015 crop year was September 30, 2014. When Plaintiffs purchased insurance, they elected to use the APH yield exclusion. But in a letter dated October 31, 2014, the USDA notified insurance providers that the APH Yield Exclusion would not be available for winter wheat for the 2015 crop year. The letter stated that insurance providers could respond to farmers’ elections by pointing them to the USDA’s “actuarial documents,” which did not yet “reflect that such an election is available.” Plaintiffs sought review of this denial through the USDA’s administrative appeals process. An administrative judge determined that she lacked jurisdiction over Plaintiffs’ challenge because the October 2014 letter to insurance providers was not an adverse agency decision. Plaintiffs then appealed to the Director of the National Appeals Division. The Director found that the October 2014 letter was an adverse agency decision, but affirmed the FCIC’s decision not to make the APH yield exclusion available to winter wheat farmers for the 2015 crop year. Plaintiffs appealed the Director’s decision to the United States District Court for the District of Colorado. The district court reversed the Director’s decision and remanded the case to the FCIC with instructions to retroactively apply the APH yield exclusion to Plaintiffs’ 2015 crop year insurance policies, reasoning the applicable statute unambiguously made the APH yield exclusion available to all farmers on the day the 2014 Farm Bill was enacted. Finding no reversible error in the district court’s judgment, the Tenth Circuit affirmed. View "Ausmus v. Perdue" on Justia Law

The Affordable Care Act’s three premium‐stabilization programs were designed to redistribute money among insurance companies and mitigate each company’s exposure to market risks, 42 U.S.C. 18061–18063. The Department of Health and Human Service (HHS) intended to implement these programs in a budget‐neutral way paying out only the funds that each program had taken in from other insurance companies. Land of Lincoln participated in these premium‐stabilization programs and incurred a debt of roughly $32 million but HHS owed Land of Lincoln over $70 million. HHS was not able to pay what it owed because it was taking in far less money than expected, and it refused to dip into its discretionary funds. Like other insurance companies, Land of Lincoln sought the overdue payments in an unsuccessful suit. Land of Lincoln became insolvent and began liquidation. Despite an Illinois court order, HHS began to offset its overdue payments against Land of Lincoln’s debt, as its own regulations permitted. The Director of the Illinois Department of Insurance, Land of Lincoln’s appointed liquidator, asked the state court for a declaration that HHS violated the order, but HHS removed the motion to federal district court arguing that the federal government was not subject to state court jurisdiction. The district court remanded the case back to state court relying on a narrow reading of 28 U.S.C. 1442, and principles of abstention. The Seventh Circuit reversed on both grounds and remanded to the district court. View "Hammer v. United States Department of Health and Human Services" on Justia Law