Justia Government & Administrative Law Opinion Summaries

Anthem Health Plans of Maine appealed from a judgment entered in the Business and Consumer Docket affirming a decision by the Superintendent of Insurance (1) determining that Anthem's proposed rate increase for its individual health insurance products was excessive and unfairly discriminatory, and (2) indicating that an average rate increase with a lower profit margin for those products would be approved. Anthem appealed, contending that the Superintendent's decision violated Me. Rev. Stat. Ann. 24-A, 2736 (the statute) and the state and federal Constitutions because the approved rate increase eliminated Anthem's opportunity to earn a reasonable profit on its line of individual health insurance products. The Supreme Court affirmed, holding (1) the Superintendent properly balanced the competing interests within the statutory framework of the statute in arriving at its approved rate increase; and (2) because the approved rate provided a built-in risk and profit margin, Anthem's argument that the Superintendent improperly cross-subsidized between Anthem's regulated and unregulated product lines, and the corollary argument that the approved rate resulted in an unconstitutional confiscatory taking, necessarily failed as a matter of law.

In 2005, pursuant to the Black Lung Benefits Act's administrative provisions, an Administrative Law Judge (ALJ) awarded lifetime benefits to Merrill Lambright and survivor benefits to his widow, Delores Ashmore. Lambright's claims arose out of his employment with Petitioner Bridger Coal Company. In 2006, a three-member panel of the U.S. Department of Labor Benefits Review Board vacated the ALJ's decision and remanded to the ALJ for reconsideration. In 2008, the ALJ denied benefits on both the lifetime and survivor claims. In 2009, a three-member panel of the Board reversed this decision and reinstated the 2005 award of benefits. The issue on appeal was the characterization of Ms. Ashmore's 2002 request for a modification in her survivor benefits: "it appears the director interpreted Ashmore's motion as a motion for modification based on change in conditions, but only to the extent Ashmore alleged she was entitled to additional (survivor) benefits due to Lambright's death. To the extent the order granting modification was based on a change in conditions, the ruling only implicated the claim for survivor benefits, not Lambright's original claim for lifetime benefits." On reconsideration en banc, the full five-member Board was unable to reach a disposition in which at least three permanent members concurred. As a result, the 2009 panel decision stood. Petitioner appealed, challenging the scope of the 2009 panel's authority to review the 2008 ALJ decision, the standard used in determining whether to award benefits, and the onset-date determination. Upon review, the Tenth Circuit affirmed the 2009 panel decision.

In this appeal the Supreme Court was asked to determine whether the parties' indemnity agreement clearly and unequivocally indemnified the Snohomish County Public Transportation Benefit Area Corporation (doing business as Community Transit) for losses resulting from its own negligence. Upon review, the Court concluded that the language of the agreement, and in particular language providing that indemnity would not be triggered if losses resulted from the sole negligence of Community Transit, clearly and unequivocally evidenced the parties' intent that the indemnitor, FirstGroup America, Inc. (doing business as First Transit) indemnify Community Transit for losses that resulted from Community Transit's own negligence. The Court reversed the Court of Appeals' decision to the contrary and remanded the case to the trial court for further proceedings.

The issue on appeal to the Supreme Court was whether the circuit court erred in granting summary judgment for the Mississippi Insurance Guaranty Association (MIGA), and in denying a cross-motion for summary judgment for nursing homes and nursing-home residents. The circuit court found that MIGA was entitled to a credit, which would reduce the amount MIGA must pay to indemnify nursing-home owners and operators for damage claims of two nursing-home residents that were allegedly caused by a series of negligent acts and omissions over the course of many years. Upon review, the Court found "the factual and legal predicates necessary to formulate an opinion on coverage issues are lacking, which would preclude any court from rendering a valid ruling on coverage." The Court reversed the circuit court's judgment that granted MIGA's motion for summary judgment and that denied the cross-motions for summary judgment.

In July 2006, Respondent Paul Cook's workers' compensation claim was dismissed for failure to file a properly completed prehearing statement. In December 2006, his "Motion for an Order Re-Instating Claim" was denied for failing to "attach a properly completed prehearing statement . . . ." In August 2008, Respondent's "Amended Motion to Reinstate" was dismissed as barred under a one-year statute of limitations. The full Commission affirmed the dismissal, as did the circuit court and a unanimous Mississippi Court of Appeals. The Supreme Court granted Respondent's petition for certiorari and affirmed: "Cook's claim was properly dismissed. To hold otherwise would eviscerate the Commission's rules and rulings of their statutorily intended effect, since '[a] rule which is not enforced is no rule at all.'"

ESBC, billing agent for the Fire Department, determined that each of the individual defendants owned a vehicle involved in a collision to which the Fire Department responded and each had insurance coverage, and billed response costs incurred for each collision. The defendants refused to pay and ESBC sought a declaration that defendants were liable under the Comprehensive Environmental Response, Compensation, and Liability Act, 42 U.S.C. 9601. Under CERCLA, the owner of a “facility” from which hazardous substances have been released is responsible for response costs that result from the release. Insurer-defendants counterclaimed for injunctive relief from ESBC’s billing practices and alleging violation of the Fair Debt Collection Practices Act, 15 U.S.C. 1692, unjust enrichment, unlawful fee collection, fraud, constructive fraud, and insurance fraud. The district court granted defendants judgment on the pleadings and dismissed counterclaims without prejudice. The Seventh Circuit affirmed. Motor vehicles for personal use fall under the "consumer product in consumer use” exception to CERCLA’s definition of facility

Alohacare, a health maintenance organization (HMO), submitted a proposal to the Department of Human Services to bid for a Quest Expanded Access contract to provide healthcare services for participants in the state's Medicaid program. The Department of Human Services awarded Quest contracts to United HealthCare Insurance (United) and WellCare Health Insurance (Ohana) but not to Alohacare. Alohacare petitioned the Insurance Commissioner of the Department of Commerce and Consumer Affairs for declaratory relief that the Quest contracts required the accident and health insurers to carry an HMO license. The Commissioner concluded that the license was not required to offer the Quest managed care product because the services required under the contracts were not services that could be provided only by an HMO. The circuit court affirmed. The Supreme Court affirmed, holding (1) AlohaCare had standing to appeal the Commissioner's decision; (2) both accident and health insurers and HMOs were authorized to offer the model of care required by the Quest contracts; and (3) this holding did not nullify the Health Maintenance Organization Act.

Plaintiffs-Appellants Randolph Farber, Scott Becker, and Critter Clinic (Farber) alleged that the Manager of the Defendant-Respondent State Insurance Fund (SIF or "the Fund") failed to comply with I.C. 72-915, which provides the means by which the SIF Manager may distribute a dividend to policyholders. The district court determined that the gravamen of Farber's claim implicated the statute and held that the three-year statute of limitation provided by I.C. 5-218(1) barred all claims that accrued prior to July 21, 2003. Farber timely appealed. Upon review, the Supreme Court held that the five-year statute of limitation in I.C. 5-216 applied to Farber's claim. Therefore, the Court reversed the trial court's decision and remanded the case for further proceedings.

The Maryland Insurance Commissioner approved a filing by Allstate Insurance Company and Allstate Indemnity Company (collectively, Allstate) giving notice of its intent to cease writing new property insurance policies in certain geographic areas of the state. The Commissioner concluded that the filing was subject to administrative review under Md. Code Ann. 19-107(a) and Md. Code Ann. Ins. 27-501(a) and that it satisfied the pertinent criteria under both statutes. The circuit court affirmed both aspects of the Commissioner's ruling. The court of special appeals affirmed but on alternative grounds, holding that section 27-501(a) did not apply to the filing and that, even if it did, the statute was not violated. The Court of Appeals affirmed but, again, on different grounds, holding (1) the Commissioner did not err in finding that section 27-501 did apply to the Allstate filing, and (2) the evidence was sufficient to support the Commissioner's decision.

Claimant Jerry Benoit worked for Turner Industries for twenty-seven years. For ten of those years he worked as a general laborer for a Lake Charles Citgo refinery, where Turner was contracted to perform general maintenance. Claimant's duties included cleaning chemical discharges and oily waste which collected in the drainage ditches, sewers, and processing units at the refinery. In the course of this work, he was exposed to any number of potentially dangerous or carcinogenic chemicals, including high levels of benzene. In July 2006, Claimant fell ill. He was diagnosed with acute myeloid leukemia (AML), known to be linked to high levels of benzene exposure. Despite the medical evidence linking Claimant's cancer to the chemicals he was exposed to at work, his claim for medical benefits was denied. The eventual medical bills totaled over $625,000. Medicaid paid for $203,124.68. The remaining $422,043.59 was "written off" by the medical care providers. Turner paid nothing. Claimant's family filed suit in 2007. The Office of Workers' Compensation (OWC) awarded Claimant total medical expenses and attorney fees. Turner appealed, and the court of appeals affirmed the OWC judgment in its entirety. Upon review of the correctness of the OWC award of medical expenses, the Supreme Court concluded the OWC erred in awarding the "written off" medical expenses: "Claimant would receive an improper windfall if he was allowed to recover for medical expenses which have been reduced by health care providers as a result of their contractual arrangements with Medicaid." The Court reversed the appellate court's decision and remanded the case for further proceedings.