Justia Government & Administrative Law Opinion Summaries

The Patient Protection and Affordable Care Act (42 U.S.C 18001) includes “guaranteed issue” and “community rating” requirements, which bar insurers from denying coverage or charging higher premiums based on health; requires individuals to maintain health insurance coverage or make a payment to the IRS, unless the cost of buying insurance would exceed eight percent of that individual’s income; and seeks to make insurance more affordable by giving refundable tax credits to individuals with household incomes between 100 per cent and 400 percent of the federal poverty line. The Act requires creation of an “Exchange” in each state— a marketplace to compare and purchase insurance plans; the federal government will establish “such Exchange” if the state does not. The Act provides that tax credits “shall be allowed” for any “applicable taxpayer,” only if the taxpayer has enrolled in an insurance plan through “an Exchange established by the State under [42 U.S.C. 18031],” An IRS regulation interprets that language as making credits available regardless of whether the exchange is established by a state or the federal government. Plaintiffs live in Virginia, which has a federal exchange. They argued Virginia’s Exchange does not qualify as “an Exchange established by the State,” so they should not receive any tax credits. That would make the cost of buying insurance more than eight percent of their income, exempting them from the coverage requirement. The district court dismissed their suit. The Fourth Circuit and Supreme Court affirmed. Tax credits are available to individuals in states that have a federal exchange. Given that the text is ambiguous, the Court looked to the broader structure of the Act and concluded that plaintiffs’ interpretation would destabilize the individual insurance market in any state with a federal exchange. It is implausible that Congress meant the Act to operate in that manner. Congress made the guaranteed issue and community rating requirements applicable in every state, but those requirements only work when combined with the coverage requirement and tax credits. View "King v. Burwell" on Justia Law

Candelario Lopez, who was hired by Interstate Treating to work on the installation of a gas processing plant, was transporting two other Interstate Treating employees to the job site when he died in an automobile accident. Lopez’s wife, Maximina Lopez, sought death benefits from Interstate Treating’s workers’ compensation insurance carrier, SeaBright Insurance Co. SeaBright denied coverage, concluding that Lopez was not acting in the course and scope of his employment at the time of the accident. A hearing officer, however, determined that Lopez was acting in the course and scope of his employment and ordered SeaBright to pay death benefits. The trial court affirmed the administrative decision. The court of appeals affirmed the trial court’s judgment. The Supreme Court affirmed, holding that Lopez was acting in the course and scope of his employment when he died, and Maximina was entitled to benefits. View "Seabright Ins. Co. v. Lopez" on Justia Law

Employee was injured when he ran from a co-worker on the job site after tricking that co-worker. Employee sought workers’ compensation benefits. Employer and Insurer denied workers’ compensation benefits, asserting that Employee’s injury did not “arise out of” or “in the course of” his employment because Employer specifically prohibited horseplay by its employees. Employee petitioned for a hearing. The Department of Labor concluded that Employee’s injury arose “out of” his employment because, but for his work with Employer” he would not have been at the job site where he was injured, but that the injury did not occur “in the course of” the employment. The circuit court affirmed. The Supreme Court reversed in part, affirmed in part, and remanded for an award of benefits, holding that the Department (1) correctly concluded that Employee’s injury arose “out of” the employment; and (2) erred when it did not consider the effect of the mandatory lull in Employee’s work when it determined that the injury did not occur “in the course of” his employment. Because Employee’s act of horseplay was not a substantial deviation from his employment, it occurred “in the course of the employment.” View "Petrik v. JJ Concrete, Inc." on Justia Law

At the time that Claimant suffered a compensable work-related injury to his left knee, Liberty Mutual Insurance Group (Liberty Mutual) was the workers’ compensation insurance carrier for Claimant’s employer (Employer). Claimant subsequently suffered a compensable work-related injury to his right knee. At the time, Chubb & Son (Chubb) was the workers’ compensation insurance carrier for Employer. Claimant was scheduled to have bilateral knee replacement surgery, but the two insurance carriers disagreed about who would pay for Claimant’s temporary total disability benefits. After a hearing, the Workers’ Compensation Commissioner required Liberty Mutual to reimburse Chubb for one half of Claimant’s temporary total disability benefits. The Workers’ Compensation Review Board and the Appellate Court affirmed. Liberty Mutual appealed, claiming that the Commissioner lacked the statutory authority to order the reimbursement to Chubb. The Supreme Court affirmed, holding that, given the unique factual circumstances of this case, the Commissioner had the authority to order the reimbursement pursuant to the relapse statute, Conn. Gen. Stat. 31-307b. View "Gill v. Brescome Barton, Inc." on Justia Law

When a fire caused by NSTAR Electric and Gas Company employees damaged a building owned by the Massachusetts Institute of Technology (MIT), two insurers paid the claims of the building’s tenants. The insurers then brought this complaint against NSTAR Electric Company and NSTAR Electric & Gas Company (collectively, NSTAR) seeking to recover for the claims paid. NSTAR moved for partial summary judgment, contending that, to the extent to which the insurers sought recovery for business interruption losses, the claims were barred by Massachusetts Department of Telecommunications and Energy Tariff No. 200A, filed with and approved by the Department of Public Utilities, and in effect when the explosion occurred. The tariff contained a limitation of liability clause that limited NSTAR from liability to nonresidential customers for special, indirect, or consequential damages resulting from the utility’s gross negligence. A judge of the superior court allowed NSTAR’s motion for partial summary judgment, concluding that a tariff filed with and approved by a regulatory agency may limit a public utility’s liability. The Supreme Judicial Court affirmed, holding that the limitation of liability clause in the tariff precluded Plaintiffs’ claims to recover for business interruption and other consequential or economic damages. View "Maryland Cas. Co. v. NSTAR Elec. Co." on Justia Law

Randy Ellington owned and operated R&J Cabinets as a sole proprietorship. When Ellington received a work-related injury, R&J had no employees. Kentucky Employers’ Mutual Insurance (KEMI) had previously issued a workers’ compensation policy to Ellington and R&J as “insureds.” At the same time, the policy included a specific exclusion from coverage of Ellington as the sole proprietor. KEMI denied Ellington’s claim for benefits, arguing that it was not covered because of the sole-proprietor exclusion endorsement. An administrative law judge concluded that Ellington was not covered by the policy. The Court of Appeals reversed, finding the policy was ambiguous and construing it in Ellington’s favor to provide coverage for his injuries. The Supreme Court reversed, holding that the policy, as issued, is not a personal policy but rather a business policy purchased by a sole proprietor, and Ellington, as the sole proprietor, was not entitled to benefits under the policy. View "Ky. Employers Mut. Ins. v. Ellington" on Justia Law

Illinois requires that motor carriers of property, conducting intrastate operations, obtain a license from the Illinois Commerce Commission, which requires appropriate insurance or surety coverage. A carrier complies by submitting proof of insurance or bond coverage and is then issued a public carrier certificate, stating that the holder “certifies to the Commission that it will perform transportation activities only with the lawful amount of liability insurance in accordance with 92 Ill. Admin. Code 1425.” Drivers must have a copy of the license with them at all times. It is a Class C misdemeanor offense for an operator not to produce proof of registration upon request. Three carriers were cited by the ICC police for conducting regulated activity without a license. During a follow-up investigation, the carriers refused to comply, reasoning that documents sought by the ICC would reveal their rates, routes, and services, so the requirement was preempted by the Federal Aviation Administration Authorization Act, 49 U.S.C. 14501(c). The ICC rejected the argument. The Seventh Circuit affirmed summary judgment in favor of the ICC, concluding that the document requests had no significant economic impact on rates, routes or services and, alternatively, that efforts to enforce the licensing requirement are exempted from preemption. View "Nationwide Freight Sys., Inc. v. Ill. Commerce Comm'n" on Justia Law

Most federal employees receive health benefits through the Federal Employee Health Benefits Program (FEHBP). Until the 2010 enactment of the Patient Protection and Affordable Care Act (ACA), members of the U.S. Senate and House of Representatives, and their staff members, were eligible for FEHBP insurance. The ACA limited their options to plans created under the ACA or offered through a health insurance exchange established under the ACA; they could no longer receive insurance through the FEHBP (42 U.S.C. 18032(d)(3)(D)). The Office of Personnel Management conducted notice-and-comment rulemaking and issued the final rule, 78 Fed. Reg. 60653-01. Senator Johnson and his legislative counsel sought to enjoin implementation of that rule, which, they claimed, was contrary to the ACA and other law because it allows the government to make pre-tax employer contributions to non-FEHBP plans and makes members of Congress and their staffs eligible for an ACA insurance exchange reserved for small businesses. The Seventh Circuit affirmed dismissal, finding that the plaintiffs had not identified a judicially cognizable injury that is traceable to aspects of the OPM regulation that they challenge. The court noted that the challenged regulation creates a benefit for Senator Johnson and that he is free to decline that benefit. View "Johnson v. United States Office of Pers. Mgmt." on Justia Law

The Patient Protection and Affordable Care Act (ACA) creates “navigators,” to assist consumers in purchasing health insurance from exchanges, 42 U.S.C. 18031(i), and authorizes the Department of Health and Human Services to establish standards for navigators and exchanges. HHS regulations recognize: federal navigators, certified application counselors (CACs), and non-navigator assistance personnel. They conduct many of the same activities, but federal navigators have more extensive duties. Plaintiffs, federally-certified counselor designated organizations, employ CACs. The federal government established a Missouri Federally Facilitated Exchange. The Health Insurance Marketplace Innovation Act (HIMIA), Mo. Rev. Stat. 376.2000, regulates “person[s] that, for compensation, provide[] information or services in connection with eligibility, enrollment, or program specifications of any health benefit exchange.” Regulatory provisions dictate what state navigators and cannot do. Plaintiffs challenged: the definition of state navigators; three substantive provisions; and penalty provisions. The district court granted a preliminary injunction, finding that the ACA preempted HIMIA. The Eighth Circuit affirmed in part, finding likelihood of success in challenges to HIMIA requirements that: state navigators refrain from providing information about health insurance plans not offered by the exchange; that in some circumstances, the navigator must advise consultation with a licensed insurance producer regarding private coverage; and that CACs provide information about different health insurance plans and clarify the distinctions. The court vacated the preliminary injunction, holding that ACA does not entirely preempt HIMIA. View "St. Louis Effort For AIDS v. Huff" on Justia Law

Defendant "L.A." was employed by the Trenton Board of Education as an elementary school security guard. While at work, L.A. allegedly had unlawful sexual contact with two minor students, N.F. and K.O. The allegations were referred to the Institutional Abuse Investigation Unit (IAIU) of the Department of Children and Families (DCF) and defendant was subsequently indicted. In the N.F. indictment, L.A. was charged with third-degree aggravated criminal sexual contact and second-degree endangering the welfare of a minor. In the K.O. indictment, L.A. was charged with two counts of second-degree sexual assault and one count of second-degree endangering the welfare of a minor. L.A. pled guilty to one count of second-degree endangering the welfare of a minor (N.F.) in exchange for dismissal of the remaining charges regarding N.F. and complete dismissal of the K.O. indictment. K.O. s guardian ad litem subsequently filed a civil complaint alleging that L.A. sexually assaulted K.O. and that the Board negligently hired L.A. The Board answered the complaint, taking no position with regard to the allegations against L.A. However, L.A. was assigned counsel by the Horace Mann Insurance Agency, pursuant to a private insurance policy maintained by the New Jersey Education Association. Ultimately, K.O.'s civil action was settled without any admission of wrongdoing by L.A. or the Board. After the settlement, L.A., through counsel provided by Horace Mann, filed a verified petition against the Commissioner of Education seeking reimbursement for the attorney's fees and costs incurred in defending against K.O.'s civil action. The matter was transferred to the Office of Administrative Law and L.A.'s counsel and the Board filed cross motions for summary judgment. The Administrative Law Judge (ALJ) granted L.A.'s motion, denied the Board's, and awarded L.A. attorney's fees and costs pursuant to N.J.S.A.18A:16-6, the statute that addressed the right to indemnification for officers and employees of boards of education in civil actions. The issue this case presented for the Supreme Court's review centered on whether N.J.S.A. 18A:16-6 entitled a school board employee to indemnification for attorney's fees and costs spent in defense of a civil action arising from the same allegations contained in a dismissed criminal indictment. The Court concluded that in such circumstances N.J.S.A. 18A:16-6 requires indemnification unless there was proof by a preponderance of the evidence that the employee's conduct fell outside the course of performance of his or her employment duties. Here, rather than conducting an evidentiary hearing, the ALJ disposed of the matter by way of summary judgment. Because there are disputed issues of material fact regarding whether L.A. was acting within the scope of the responsibilities of his employment, the judgment of the Appellate Division was reversed. The matter was remanded to the Commissioner of Education for a hearing to determine whether L.A.'s conduct fell outside the course of performance of his employment duties. View "L.A. v. Board of Education of the City of Trenton" on Justia Law