Justia Government & Administrative Law Opinion Summaries

In two consolidated cases, Liberty Mutual Fire Insurance Company denied personal injury protection (PIP) benefits to Chung Ahn and Kee Kim (collectively, Insureds) for treatments after motor vehicle accidents. Insureds each sought administrative reviews with the Insurance Division of the Department of Commerce and Consumer Affairs (DCCA). The DCCA granted summary judgment to Liberty Mutual based on the holding in Wilson v. AIG Hawaii Insurance Company, which stated that unless an insurer's non-payment of PIP benefits jeopardizes an insured's ability to reach the minimum amount of medical expenses required to file a tort lawsuit, insureds are not real parties in interest allowed to pursue lawsuits seeking payment of PIP benefits to providers. The circuit court reversed, concluding that Act 198 of 2006 had legislatively overruled Wilson. The intermediate court of appeals (ICA) upheld the circuit court. On appeal, the Supreme Court (1) overruled Wilson, holding that insureds are real parties in interest in actions against insurers regarding PIP benefits; and (2) vacated the ICA and circuit court judgments because at the time of judgment, Act 198 of 2006 was not retrospective, and the real party in interest holding of Wilson was still in effect. Remanded.

Defendant-Appellant Alan Tukes appealed his federal conviction for bank robbery, arguing that the governmentâs evidence was insufficient to prove that the bank was insured by the Federal Deposit Insurance Corporation (âFDICâ) at the time of the crime. At trial, a prosecutor asked the bankâs branch manager: âNow, the Compass Bank, is that a bank that is federally insured by the [FDIC]?â She responded: âYes, it is.â When asked whether the bank âhasâ any documentation proving its insured status, she replied: âYes. We have a certificate.â When asked whether the certificate âhangsâ in the branch, the manager replied in the affirmative. The district court admitted the certificate, dated November 8, 1993, into evidence. The government offered no additional evidence of the bankâs insured status. At summation, Defendant argued that the government had not proven that the bank was FDIC insured at the time of the robbery. The jury returned a guilty verdict. Viewing the evidence in the light most favorable to the government, the Tenth Circuit concluded "it is clear that a rational juror could have concluded beyond a reasonable doubt that the bank was insured at the time of the robbery." The Court affirmed Defendant's conviction.

Appellant appealed the district court's grant of summary judgment in favor of Sun Life in an Employee Retirement Income Security Act (ERISA), 29 U.S.C. 1001 et seq., benefits case. At issue was whether Sun Life was entitled to offset from appellant's employer-provided long-term disability benefits the amount that appellant received in Department of Veterans Affairs (VA) benefits each month. The court held that VA benefits, for a wartime service-related disability, as a matter of statutory construction, did not derive from an act that was "similar to" the SSA or RRA, which were both federal insurance programs based upon employment and the amount of an award under their terms depended upon how much had been paid in. Accordingly, the court reversed and remanded to the district court with directions to enter judgment in favor of appellant.

Mallory Warburton was working for the City of North Las Vegas when she was involved in a car accident and suffered numerous injuries. The City started paying workers' compensation benefits to Warburton at a rate of $10 an hour. At the time of the accident, Warburton was expected to make $12 an hour because of a promotion to manager of one of the City's pools. After an administrative appeal, a hearing officer instructed the City to redetermine Warburton's benefits using the $12-an-hour rate of pay for a pool manager. An appeals officer reversed, concluding Warburton's benefits should be based on the $10-an-hour rate of pay she was actually receiving at the time of the accident. The district court reversed the appeals officer's decision. The Supreme Court affirmed, holding that the appeals officer's conclusion was not supported by substantial evidence and that substantial evidence supported the district court's determination that (1) Warburton's primary job at the time of the accident was that of pool manager, and (2) Warburton's workers' compensation benefits must be determined using an average monthly wage calculation at the $12-an-hour rate of pay.

In 1970, while working for Employer, Employee was injured. In 1989, Employee retired. In 2008, Employee applied for permanent total disability (PTD) compensation. The Industrial Commission of Ohio concluded that Employee was permanently and totally disabled without ruling on the credibility of the assertion that Employee retired because of his injury or determining whether his retirement was voluntary or involuntary. The court of appeals granted Employer a limited writ of mandamus that vacated the Commission's order and ordered the Commission to reconsider the matter. The Supreme Court affirmed the court of appeals, holding that because a voluntary retirement from the work force prior to asserting PTD precludes the payment of compensation for that disability, the court of appeals was correct in ordering further consideration of whether Employee retired because of his injury and whether his retirement was voluntary.

Franklin Electric formed two new subsidiaries and started new unemployment experience accounts with a low introductory contribution rate for each one, which equaled about half the experience rating of Franklin Electric. The Department of Workforce Development later canceled the subsidiaries' experience accounts, and all experience balances and liabilities reverted to Franklin Electric. The Department also demanded back payments, interest, and a ten percent penalty. A liability administrative law judge (LALJ) affirmed the Department's determination that the three entities were a single employer but waived the penalty imposed by the Department. The court of appeals affirmed. The Supreme Court granted transfer and vacated the opinion of the court of appeals and affirmed the determination of the LALJ, holding (1) the new subsidiaries were not new employers because they were not distinct and segregable from Franklin Electric; (2) Franklin Electric's experience rating should have applied to contributions made by the subsidiaries; and (3) because there was no evidence suggesting improper conduct on the part of Franklin Electric, the penalty was not appropriate.

Appellant Thomas Pearson was struck by a forklift and was later determined to have been injured in the course of his employment with Archer-Daniels-Midland Milling Company (ADM). The workers' compensation court entered an award granting Pearson, among other benefits, certain future medical expenses. Pearson subsequently had a total knee replacement and sought reimbursement from ADM for those expenses as well as for expenses relating to a back injury. After ADM declined to pay the expenses, Pearson filed a motion to compel payment. A further award was entered (1) denying Pearson's motion with respect to the knee replacement but ordering ADM to pay expenses relating to the treatment of the back injury, and (2) applying the workers' compensation court's fee schedule to payments for the back injury, which had previously been paid by Pearson's health insurer. The workers' compensation court review panel affirmed. The Supreme Court affirmed in part and reversed in part, holding (1) the trial court incorrectly found that the original order denied knee replacement, and (2) the trial court did not err in applying the fee schedule to any reimbursement to a third party. Remanded.

An elderly woman requiring long-term medical care gave $120,000 to her son in February 2007. The mother believed that the gift would not prevent her from receiving Medicaid coverage if she lived long enough to exhaust her remaining assets. She relied on a provision in Alaska's Medicaid eligibility manual that suggested prospective Medicaid beneficiaries could give away a portion of their assets while retaining sufficient assets to pay for their medical care during the period of ineligibility that Medicaid imposes as a penalty for such gifts. But by the time the mother applied for Medicaid in September 2008, the Alaska legislature had enacted legislation with the retroactive effect of preventing the kind of estate planning the mother had attempted through her gift. The State temporarily denied the mother's application. The son appealed pro se on behalf of his mother, who died in 2009. Upon review, the Supreme Court found that the Alaska legislature's retroactive change to the Medicaid eligibility rules was valid. The Court thus affirmed the State's temporary denial of the mother's application.

Thomas Skinner received an award of benefits from the Workers' Compensation Commission for asbestosis under the scheduled loss provisions of Section 42-9-30 of the South Carolina Code.  Westinghouse Electric Corporation, Skinner's former employer, appealed that decision, arguing Skinner could not recover for a scheduled loss and must proceed under the "general disability" statutes found in Sections 42-9-10 and 42-9-20 of the South Carolina Code. Westinghouse's arguments on appeal concerned the impact of section 42-11-60 on Skinner's right to recover for his pulmonary disease.  In particular, it argued Skinner could only recover for total or partial disability under sections 42-9-10 and 42-9-20, respectively.  The Supreme Court agreed with Westinghouse and reversed the special referee's affirmation of Skinner's award based upon the clear language of section 42-11-60: "[i]n that section, the General Assembly specified that recovery for a pulmonary disease such as Skinner's hinges upon a showing of lost wages under section 42-9-10 and 42-9-20.  Because our resolution of this issue is dispositive of the appeal, it is not necessary for us to address the remaining issues raised by the parties."

Shannon Cave suffered a work-related injury and was awarded temporary total disability (TTD) benefits during her recovery. After Cave rejected an offer of temporary light duty work from her employer, the Wyoming Workers' Safety and Compensation Division (Division) reduced Cave's TTD benefits to one-third of the previously authorized amount in accordance with Wyo. Stat. Ann. 27-14-404(j). The Office of Administrative Hearings (OAH) upheld the reduction of TTD benefits. The district court reversed the OAH decision. The Supreme Court reversed the district court's order, holding that the OAH decision was supported by substantial evidence and was not contrary to law as the hearing examiner properly determined that the offer of light duty employment tendered to Cave was bona fide, and therefore, the OAH was obligated to reduce Cave's TTD benefits.