Justia Government & Administrative Law Opinion Summaries

In December 2008, Appellee was performing his duties as an outdoor parking lot attendant when he developed frostbite. Appellee’s employer and its insurance company (Appellants) voluntarily paid for the medical treatment of Appellee’s frostbite injury and paid temporary total disability benefits through mid-2009. In September 2012, a partial amputation of the fifth metatarsal in Appellee’s right foot was performed. In January 2013, Appellee sought additional benefits for his work-related injury. The Workers’ Compensation Court awarded benefits. On appeal, Appellants argued that the Workers’ Compensation Court erred in finding that Appellee’s claim was not barred by the two-year statute of limitations. The Supreme Court affirmed, holding that the partial amputation of Appellee’s foot was a material change in condition and substantial increase in disability that would permit Appellee to seek benefits more than two years after Appellants’ last voluntary payment. View "Lenz v. Cent. Parking Sys. of Neb., Inc." on Justia Law

The South Carolina Supreme Court answered certified two questions from the U.S. District Court for the District of South Carolina. The case concerned supplemental health insurance policies, which differ from ordinary health insurance policies in both purpose and operation. The questions were: (1) whether the definition of "actual charges" contained within S.C. Code Ann. 38-71-242 be applied to insurance contracts executed prior to the statute's effective date; and (2) whether the South Carolina Department of Insurance could mandate the application of "actual charges" to policies already inexistence on the statute's effective dates by prohibiting an insurance company from paying claims absent the application of that definition. The South Carolina Supreme Court answered both questions "no." View "Kirven v. Central States" on Justia Law

In this insurance coverage dispute, the driver involved in an accident filed a claim with the Insurer of the other vehicle involved in the accident. The Insurer denied the claim. The Office of the Insurance Commissioner reviewed the denial and ordered the Insurer to adjust and resolve the claim. The Insurer did not file an appeal and instead filed a complaint for declaratory and injunctive relief in the federal district court. The district court dismissed the federal court action on res judicata grounds. The First Circuit Court of Appeals affirmed, holding that res judicata barred this action and no exceptions to res judicata applied. View "Universal Ins. Co. v. Office of the Ins. Comm'r" on Justia Law

This case involved a petition for injunctive and declaratory relief brought by plaintiffs Harbor Homes, Inc. and Gary Dube, Thomas Taylor, Cynthia Washington, and Arthur Furber against defendants the New Hampshire Department of Health and Human Services (DHHS), the Commissioner of DHHS, the Associate Commissioner of DHHS, and the Administrator of the Bureau of Behavioral Health seeking, in part, to enjoin DHHS from denying the individual plaintiffs the right to obtain Medicaid-funded services from their chosen provider, Harbor Homes. The individual plaintiffs received Medicaid-funded rehabilitative services from Harbor Homes. Since 1991, Harbor Homes participated in New Hampshire's Medicaid program pursuant to a Medicaid Provider Enrollment Agreement. On June 23, 2008, Harbor Homes entered into an interagency agreement (IAA) with a community mental health program, Community Council of Nashua, NH, now known as Greater Nashua Mental Health Center (GNMHC), which authorized Harbor Homes to provide certain Medicaid-funded rehabilitative services to GNMHC patients. In February 2011, Harbor Homes learned that GNMHC did not intend to renew its IAA and that the Medicaid reimbursable services provided by Harbor Homes would be transitioned to GNMHC. This was done pursuant to Administrative Rule He-M 426.04(a)(2), which meant that Harbor Homes would no longer have an IAA with a community mental health provider, and it would no longer be permitted to provide Medicaid funded mental health services to approximately one hundred and forty of its clients, including the individual plaintiffs in this case. Plaintiffs filed a petition for injunctive and declaratory relief, seeking a court order enjoining DHHS from "terminating or limiting Harbor Homes' status as a qualified Medicaid provider" and to direct the State to allow the individual plaintiffs to obtain community mental health services from Harbor Homes, the provider of their choice. Following two hearings, the court denied the plaintiffs' request for a preliminary injunction. Thereafter, all parties moved for partial summary judgment on the plaintiffs' claim that DHHS's reliance upon the IAA requirement as a reason to terminate Harbor Homes' status as a qualified Medicaid provider was improper because the requirement was invalid both on its face and as applied in this case. Plaintiffs appealed rulings of the Superior Court that denied their summary judgment motions and granting the defendants' cross-motions for summary judgment on two counts in the plaintiffs' petition. Upon review of the matter, the Supreme Court reversed the Superior Court's ruling that New Hampshire Administrative Rules, He-M 426.04(a)(2) did not violate the federal Medicaid Act. The case was remanded for further proceedings. View "Dube v. New Hampshire Dept. of Health & Human Svcs." on Justia Law

A highly paid worker suffered a debilitating stroke while traveling for his employer. The employer did not think the stroke was work related, but it later accepted the claim and paid workers' compensation benefits. The statutory maximum compensation rate at the time of the injury was $700 a week. A little more than five months after the employee's stroke, an amended version of the Alaska Workers' Compensation Act took effect. Instead of an absolute maximum compensation rate, the amended statute set a variable rate indexed to the statewide average weekly wage. The employee asked for an increased rate of compensation, arguing that the law in effect at the time he was recognized as being permanently and totally disabled should govern his benefit amount. The Alaska Workers' Compensation Board, with one panel member dissenting, decided that the version of the statute in effect at the time of the injury was the applicable statute and consequently capped the employee's benefits at $700 a week for life. The dissenting panel member would have construed the statute as permitting increased benefits. The Alaska Workers' Compensation Appeals Commission affirmed the Board's decision. The employee appealed, arguing that the amount of his benefits did not fairly compensate him for lost wages during the period of his disability so that the date of his disability, rather than the date of his injury, should have been used to determine the version of the statute governing his claim. Finding no reversible error, the Supreme Court affirmed the Commission's decision.View "Louie v. BP Exploration (Alaska), Inc." on Justia Law

Plaintiff injured his shoulder while working for Employer. Plaintiff was terminated later that year for “reduction of staff due to lack of work.” Employer accepted Plaintiff’s injury as compensable. In January 2009, Plaintiff began to receive unemployment benefits from Employer and Insurer (together, Defendants). In December 2010, Defendants sought to terminate payment of compensation, alleging that Plaintiff could no longer show he was disabled. The Industrial Commission concluded that Plaintiff was not entitled to disability payments made after December 2010 and that Defendants were entitled to a credit for any payments they had made after that date, finding that Plaintiff’s inability to find work was not due to his injury but to large-scale economic factors. The Supreme Court affirmed, holding that the Commission properly concluded that Plaintiff failed to prove that his inability to earn the same wages as before his injury resulted from his work-related injury. View "Medlin v. Weaver Cooke Constr., LLC" on Justia Law

While working for Vista Care (Employer), appellant Sherrie Fowler suffered a back injury. Appellant began receiving TTD and subsequently underwent back surgery. Several years later, a physician determined that appellant reached maximum medical improvement (MMI). This case began when appellant filed a complaint with the Workers' Compensation Act (WCA) in 2010, for reinstatement of her TTD benefits and for an increase in her PPD rating. The Court of Appeals held that the Act limited appellant's eligibility for TTD benefits to 700 weeks of benefits and reversed a contrary decision of the Workers’ Compensation Administration judge. Upon review of the matter, the Supreme Court concluded that the Act imposed no such limitation; TTD benefits are payable during any period of total disability for the remainder of a worker’s life. View "Fowler v. Vista Care" on Justia Law

Paul Lightner filed a consumer complaint on behalf of himself and other policyholders before the Insurance Commissioner against CitiFinancial and Triton Insurance Company challenging the rates for certain insurance products. Following the Commissioner’s investigation and consideration of Lightner’s complaint, the Commissioner denied Lightner’s request for a hearing and found the challenged rates were reasonable. Lightner filed a petition appealing the Commissioner’s order denying his request for a hearing. The circuit court affirmed. The Supreme Court affirmed, holding that the circuit court (1) did not err in upholding the Commissioner’s order denying a hearing because this case did not present any factual disputes warranting a hearing in this case; and (2) properly concluded that the Commissioner’s handling of the rate issues raised in Lightner’s complaint met statutory, regulatory, and constitutional standards. View "Lightner v. Riley" on Justia Law

Appellant, an over-the-road truck driver, filed a claim for workers’ compensation benefits, alleging that he sustained injuries in the form of deep vein thrombosis and pulmonary embolism in an accident that occurred during the course and scope of his employment. The compensation court applied a split test of causation used in heart attack cases, which requires proof of both legal and medical causation. The court then dismissed Appellant’s claim for failure to establish the medical cause prong. The Supreme Court affirmed the dismissal of Appellant’s claim, holding (1) the split test was properly applied to Appellant’s injuries in this case, as deep vein thrombosis and pulmonary embolism present the same difficulties in attributing the cause of a heart attack to a claimant’s work and are similar in origin to a heart attack; and (2) the compensation court’s finding as to causation was not clearly wrong. View "Wingfield v. Hill Bros. Transp., Inc." on Justia Law

In 2004, Appellant fell while working and strained her back. Appellant was awarded worker’s compensation benefits. In 2009, Appellant slipped and fell at work and injured her ankle. In 2010, Appellant sought temporary total disability and medical pay benefits from the Workers Compensation Division, which denied Appellant’s requests. After a contested case hearing, the Office of Administrative Hearings (OAH) upheld the Division’s denial of Appellant’s request for benefits, concluding Appellant did not meet her burden of proving that she suffered aggravation of a preexisting back condition as a result of a work related injury or that she suffered a second compensable injury. The district court affirmed. The Supreme Court affirmed, holding that the OAH did not err by failing to find a causal connection between the 2009 workplace incident and Appellant’s delayed back pain. View "Hirsch v. State ex rel. Wyo. Workers' Safety & Comp. Div." on Justia Law