Justia Government & Administrative Law Opinion Summaries

CareFirst, Inc., a nonstock, nonprofit Maryland corporation, is a holding company with two subsidiaries that provides health insurance for millions of Maryland residents. State law confers broad authority on the Maryland Insurance Commissioner to oversee its operation and adherence to its mission. This case arose from the termination of Leon Kaplan, a former executive of CareFirst. CareFirst declined to pay part of the post-termination compensation set forth in Kaplan's employment contract, reasoning that the compensation was not for "work actually performed," as that standard had been interpreted by the Commissioner. The Commissioner affirmed the decision not to pay the benefits, concluding that the payments would violate Md. Code Ann. Ins. 14-139. The Court of Appeals affirmed, holding (1) the Commissioner's determination was not preempted by ERISA; (2) the Commissioner's construction of the insurance code was legally correct; and (3) there was substantial evidence to support the Commissioner's determination in this case. View "Md. Ins. Comm'r. v. Kaplan" on Justia Law

Appellant was placed on disability leave from work. Appellant was covered under a long term disability (LTD) policy that her employer obtained from Medical Group Insurance Services (MGIS). The policy was written by Sun Life Assurance Company (Sun Life). After leaving her job, Appellant filed a claim with MGIS seeing long term disability benefits. Sun Life denied Appellant's request for benefits. Appellant filed an action against Sun Life, asserting various state law claims. The federal district court dismissed the action based on ERISA preemption. Appellant then amended her complaint to add ERISA claims and asked the district court to apply de novo review in its evaluation of her ERISA claims. The court denied the motion and granted summary judgment for Sun Life, concluding that Sun Life's decision to deny benefits was not arbitrary and capricious, and thus complied with ERISA's requirements. The First Circuit Court of Appeals vacated the judgment, holding (1) the safe harbor exception to ERISA did not apply to the policy covering Appellant, and therefore, Appellant's state law claims were preempted; but (2) the benefits denial was subject to a de novo review, rather than the highly deferential "arbitrary and capricious" review prescribed for certain ERISA benefits decisions. Remanded. View "Gross v. Sun Life Assurance Co. of Canada" on Justia Law

Petitioner Allen Davenport appealed a judgment affirming a Workforce Safety and Insurance ("WSI") decision to terminate benefits on his claim for treatment of his cervical spine and left shoulder and denying his claims for benefits for treatment of his anxiety and depression and lower back condition. He argued his anxiety and depression and his cervical spine, left shoulder and back conditions were "compensable injuries." Upon further review, the Supreme Court concluded Davenport failed to establish by a preponderance of the evidence that work incidents subject to this claim substantially accelerated the progression of, or substantially worsened the severity of, his existing conditions and that his physical injury caused at least 50 percent of his anxiety and depression. View "Davenport v. WSI" on Justia Law

Defendant City of Burlington Retirement System appealed a superior court judgment that reversed its decision to terminate the disability retirement of plaintiff, a former City firefighter. Upon review, the Supreme Court concluded the record fully supported the superior court's conclusion that there was no reasonable basis for the Board's decision to terminate plaintiff's disability retirement. View "Preston v. Burlington City Reitrement System" on Justia Law

After receiving a work-related injury during his employment by Employer, Employee applied for worker's compensation benefits. An ALJ ordered that further medical procedures were required to determine whether Employee was permanently and totally disabled, but the Labor and Industry Review Commission (LIRC) proceeded to award benefits to Employee for his permanent total disability. Employer filed a complaint seeking judicial review of LIRC's decision. The circuit court affirmed. The court of appeals reversed, concluding that the circuit court was required to dismiss Employer's complaint for lack of competency based on Employer's failure to name its insurer (Insurer) as an "adverse party" pursuant to Wis. Stat. 102.23(1)(a). The Supreme Court reversed and remanded with instructions to affirm LIRC's decision, holding (1) the circuit court had competency to adjudicate Employer's complaint notwithstanding Employer's omission of Insurer because Insurer was not an "adverse party" for purposes of section 102.23(1)(a); and (2) LIRC did not exceed its authority in awarding Employee permanent total disability benefits, and its finding that Employee was entitled to benefits on an odd-lot basis was supported by credible and substantial evidence. View "Xcel Energy Servs., Inc. v. Labor & Ind. Review Comm'n " on Justia Law

Petitioner was traveling home from work in his personal vehicle when he sustained back injuries in a car accident. Petitioner applied for workers' compensation benefits, but his application was denied under the "going and coming rule," which deems injuries occurring during a work commute outside the course of employment and thus not compensable. Petitioner appealed, arguing that in light of the benefits his employer received through various work-related uses of his vehicle, he was "in the course of employment" during the accident. The labor commission and court of appeals rejected Petitioner's claim that he qualified under the "instrumentality" exception of the going and coming rule. The Supreme Court affirmed, holding that Petitioner fell within the rule and not the exception. View "Jex v. Utah Labor Comm'n" on Justia Law

States participating in Medicaid in a managed care environment are required to make, at least every fourth month, supplemental “wraparound” payments to federally-qualified health centers (FQHCs) equal to the difference between a rate set by statute multiplied by the number of Medicaid patient encounters, and the amount paid to FQHCs by managed care organizations (MCOs) for all Medicaid-covered patient encounters, 42 U.S.C.1396. Concerned that gaps in FQHC claim verification led to overpayments, the New Jersey Department of Human Services changed its calculation: instead of basing wraparound payments solely on the number of Medicaid encounters and total MCO receipts as self-reported by FQHCs, the state would rely on data reported by MCOs absent receipt of certain additional data from the FQHCs. Because MCOs report only encounters that they have approved and paid, prior MCO payment would be a prerequisite to wraparound reimbursement under the new system. An association of FQHCs sued, claiming that the change violated their due process rights as well as state and federal law, resulting in budget shortfalls. The district court granted the association summary judgment and a preliminary injunction. The Third Circuit affirmed the holding that the requirement that wraparound payments be contingent on prior MCO payment violated the Medicaid statute’s requirement that FQHCs receive timely full wraparound payment for all Medicaid-eligible claims. View "NJ Primary Care Assoc. v. NJ Dep't of Human Servs." on Justia Law

Plaintiff-Appellant Cynthia Pfeifer filed suit against Defendant-Appellee Federal Express Corporation in the District of Kansas, alleging that the company fired her in retaliation for receiving workers' compensation benefits. Plaintiff filed suit fifteen months following the termination within the applicable state statute of limitations, but outside the limit of six months enumerated in her employment agreement. The district court granted Defendant's motion for summary judgment, concluding that the contract clause was reasonable and was not a violation of public policy. Because no Kansas law appeared to control the outcome of the case, the Tenth Circuit certified two questions to the Kansas Supreme Court regarding the ability of parties to shorten the applicable statute of limitations by contract, and if not, then was the six-month limitation unreasonable in this case? The Kansas Court responded that the contract clause in question here did violate public policy. Because of that answer, the Court did not respond to the Tenth Circuit's second question. In light of these answers, the federal district court was reversed and the case remanded for further proceedings. View "Pfeifer v. Federal Express Corporation" on Justia Law

A staffing services company (Company) furnished workers for the City, including Respondent. During the course of his employment, Employee lost an arm working on a garbage truck driven by an employee of the City. Respondent sued the City and its employee (collectively, Petitioners). Petitioners filed a motion for summary judgment, asserting governmental immunity based in part on the exclusive remedy under the Texas Labor Code, which provides that recovery of workers' compensation benefits is the exclusive remedy of an employee covered by workers' compensation insurance. The trial court dismissed the case. The court of appeals reversed, holding that a fact question remained whether Respondent, who was paid by Company, was within the specific terms of the City's workers' compensation coverage. The Supreme Court reversed and dismissed the case, holding that, as a matter of law, the City provided Respondent's workers' compensation coverage, and therefore, Respondent's exclusive remedy was the compensation benefits to which he was entitled. View "City of Bellaire v. Johnson" on Justia Law

Employee was employer at Employer's aluminum-processing plant from 1957 to 1989. In 2009, Employee filed an occupational-disease claim for benefits with the Arkansas Workers' Compensation Commission, alleging that he suffered from cancer caused by his exposure to asbestos while working for Employer. A law judge found Employee's complaint was time barred. Rather than appeal the decision to the full Commission, Employee filed suit against Employer in circuit court. Employer filed a motion to dismiss based on the exclusive remedy afforded by the Workers' Compensation Act. The circuit court denied the motion, concluding that, where a plaintiff's disease manifests after the statute of limitations has expired, a circuit court has authority to exercise jurisdiction over the plaintiff's claims. The Supreme Court granted Employer's requested writ of prohibition, holding that the Commission had exclusive jurisdiction to decide the issue in the first instance, and because Employee's claim was not submitted to the Commission, the circuit court lacked jurisdiction to decide the case. View "Reynolds Metal Co. v. Circuit Court" on Justia Law