Justia Government & Administrative Law Opinion Summaries

Plaintiff Genworth Life Insurance Company challenged amended regulations promulgated by the New Hampshire Department of Insurance (Department) retroactively limiting rate increases for long-term care insurance (LTCI) policies. Plaintiff provided LTCI to over 6,000 New Hampshire residents. It appealed superior court orders dismissing its claim that the regulations violate the contract clauses of the State and Federal Constitutions, and entering summary judgment for the Department with respect to plaintiff’s claims that the regulations were ultra vires and violated the takings clauses of the State and Federal Constitutions. Because the New Hampshire Supreme Court concluded that the regulations were ultra vires, and, therefore, invalid, the Court reversed and remanded. View "Genworth Life Ins. Co. v. New Hampshire Dep't of Ins." on Justia Law

This appeal involved an insurance coverage dispute arising out of water damage caused by Superstorm Sandy to properties owned by plaintiff New Jersey Transit Corporation (NJ Transit). At the time Sandy struck in October 2012, NJ Transit carried a $400 million multi-layered property insurance policy program through eleven insurers. When NJ Transit sought coverage for the water damage to its properties brought about by the storm, certain of its insurers invoked the $100 million flood sublimit in NJ Transit’s policies and declined to provide coverage up to the policy limit. NJ Transit filed an action seeking a declaratory judgment against those insurers. The trial court found that the $100 million flood sublimit did not apply to NJ Transit’s claims; it also found that the insurers had not submitted sufficient evidence to support their claims for reformation of the policies. The court accordingly entered summary judgment in favor of NJ Transit and denied the insurers’ motions for summary judgment. The Appellate Division affirmed. Finding no reversible error in the Appellate Division's judgment, the New Jersey Supreme Court affirmed. View "New Jersey Transit Corporation v. Certain Underwriters at Lloyd's of London" on Justia Law

The Supreme Court reaffirmed in this case that undocumented aliens who are injured while working for a Nevada employer may be eligible for monetary disability benefits, holding that these monetary benefits, paid by the insurer, do not conflict with federal law or undermine the Legislature's intent.Respondent, an undocumented Nevadan, was severely injured while working for High Point Construction and applied for permanent total disability (PTD) status. Associated Risk Management (ARM), High Point's insurance administrator, denied the request. An appeals officer reversed and granted Respondent PTD status pursuant to the "odd-lot doctrine." ARM petitioned for judicial review, arguing that the appeals officer committed legal error by granting PTD to an undocumented alien. The Supreme Court affirmed, holding (1) undocumented aliens are not precluded from receiving disability benefits under Nevada's workers' compensation laws; (2) although federal law prohibits employers from knowingly employing an undocumented alien, it does not prohibit insurers from compensating undocumented aliens for injuries they sustain while working; and (3) the appeals officer's decision was based on substantial evidence. View "Associated Risk Management, Inc. v. Ibanez" on Justia Law

In a matter of first impression, the Pennsylvania Supreme Court granted review in this case to consider whether Section 310.74(a) of the Insurance Department Act of 1921 prohibited a licensed insurance producer from charging fees in addition to commissions in non-commercial, i.e. personal, insurance transactions. During its investigation, the Department discovered that, between March 2011 and October 2015, appellants charged a non-refundable $60- $70 fee to customers seeking to purchase personal insurance products. These fees were collected from the customers before appellants prepared the insurance policy applications. One consumer complaint indicated appellants kept an “un- refundable broker application fee” when the consumer declined to buy a policy. The Department’s investigation also revealed appellants paid a “one-time” $50 referral fee to car dealership sales personnel when they referred their customers in need of insurance. The Department concluded appellants’ fee practices included improper fees charged to consumers “for the completion of an application for a contract of insurance” and prohibited referral payments to the car dealerships. The Supreme Court held lower tribunals did not err when they determined Section 310.74(a) of the Act did not authorize appellants to charge the $60-$70 non-refundable fee to their customers seeking to purchase personal motor vehicle insurance. The Commonwealth Court’s decision upholding the Commissioner’s Adjudication and Order was affirmed. View "Woodford v. PA Insurance Dept." on Justia Law

The Supreme Court affirmed the circuit court's dismissal of West Virginia Counties Group Self-Insurance Risk Pool, Inc.'s (WVCoRP) claims against Great Cacapon Volunteer Fire Department, Inc. (VFD), holding that the circuit court did not err.When a fire destroyed the building where VFD was housed, the owner of the building, the Morgan County Commission, was reimbursed for the loss by WVCoRP. Seeking to recover the funds it expended, WVCoRP sued the VFD and other parties for negligence. In the process, WVCoRP invoked a contractual right to subrogation. The circuit court determined that the claims against VFD were barred by W. Va. Code 29-12A-13(c), which prohibits claims against political subdivisions made under a right of subrogation. The Supreme Court affirmed, holding (1) WVCoRP's claims spring from its coverage contract with the Commission and fall within any plain meaning of subrogation; and (2) section 29-12A-13(c) is not an insurance law of the State from which WVCoRP is exempt. View "West Virginia Counties Group v. Great Cacapon Volunteer Fire Department, Inc." on Justia Law

The Supreme Court reversed the court of appeals' decision affirming the North Carolina Industrial Commission's finding that the uninsured/underinsured motorist (UIM) proceeds that Plaintiff received on behalf of her husband's estate through the settlement of a wrongful death lawsuit were subject to Defendants' subrogation lien under N.C. Gen. Stat. 97-10.2, holding that the UIM proceeds recovered from the wrongful death lawsuit may not be used to satisfy Defendants' workers' compensation lien.The decedent, Plaintiff's husband and an employee of Employer, was involved in a fatal motor vehicle accident with a third party in South Carolina. The Commission ordered Defendants to pay workers' compensation benefits to Plaintiff. Plaintiff then filed a wrongful death case seeking damages from the third party driver. The parties reached a settlement agreement that included recovery in the form of UIM proceeds. The workers' compensation insurance carrier for Employer subsequently claimed a lien on the UIM proceeds that Plaintiff recovered from the wrongful death settlement. The Commission ordered the distribution of Plaintiff's entire recovery from the South Carolina wrongful death settlement, concluding that Defendants were entitled to subrogation under section 97-10.2. The Supreme Court reversed, holding that Defendants may not satisfy their workers' compensation lien by collecting from Plaintiff's recovery of UIM proceeds in her South Carolina wrongful death settlement. View "Walker v. K&W Cafeterias" on Justia Law

In the Patient Protection and Affordable Care Act (ACA), Congress directed each state to establish an online exchange through which insurers may sell health plans if the plans meet certain requirements. One requirement is that insurers must reduce the “cost-sharing” burdens—such as the burdens of making co-payments and meeting deductibles—of certain customers. When insurers meet that requirement, the Secretary of Health and Human Services shall reimburse them for those cost-sharing reductions, 42 U.S.C. 18071(c)(3)(A). In October 2017, the Secretary stopped making reimbursement payments, due to determinations that such payments were not within the congressional appropriation that the Secretary had, until then, invoked to pay the reimbursements. Sanford, a seller of insurance through the North Dakota, South Dakota, and Iowa exchanges, and Montana Health, a seller through the Montana and Idaho exchanges, sued.The trial courts granted the insurers summary judgment, reasoning that the ACA reimbursement provision is “money-mandating” and that the government is liable for damages for its failure to make reimbursements for the 2017 reductions. The court did not reach the contract claim in either case. The Federal Circuit affirmed, citing the Supreme Court’s 2020 “Maine Community,” addressing a different payment-obligation ACA provision. Maine Community indicates that the cost-sharing-reduction reimbursement provision imposes an unambiguous obligation on the government to pay money; that obligation is enforceable in the Claims Court under the Tucker Act, 28 U.S.C. 1491(a)(1). View "Sanford Health Plan v. United States" on Justia Law

The Patient Protection and Affordable Care Act (ACA), 124 Stat. 119, directed each state to establish an online exchange through which insurers may sell health plans that meet certain requirements. Insurers must reduce the “cost-sharing” burdens, such as co-payments and deductibles, of certain customers. When insurers meet that requirement, the Secretary of Health and Human Services (HHS) shall reimburse them for the required cost-sharing reductions, 42 U.S.C. 18071(c)(3)(A). In October 2017, the Secretary stopped making reimbursement payments, due to determinations that such payments were not within the congressional appropriation that the Secretary had invoked to pay the reimbursements. Insurers sued.The Federal Circuit affirmed summary judgment in favor of the insurers on liability, reasoning that the ACA reimbursement provision is “money-mandating” and that the government is liable for damages. The court cited the Supreme Court’s 2020 “Maine Community,” addressing a different ACA payment-obligation as indicating that the cost-sharing-reduction reimbursement provision imposes an unambiguous obligation on the government to pay money; that obligation is enforceable through a damages action under the Tucker Act, 28 U.S.C. 1491(a)(1). The court remanded the issue of damages. The government is not entitled to a reduction in damages with respect to cost-sharing reductions not paid in 2017. As to 2018, the Claims Court must reduce the insurers’ damages by the amount of additional premium tax credit payments that each insurer received as a result of the government’s termination of cost-sharing reduction payments. View "Community Health Choice, Inc. v. United States" on Justia Law

After claimant Danny Arvidson received an award of permanent total disability, insurer Liberty Northwest Insurance Corporation requested a hearing before an administrative law judge (ALJ) to review the award. The ALJ dismissed insurer’s hearing request as time-barred. The question on review before the Oregon Supreme Court was whether that dismissal entitled claimant to attorney fees under ORS 656.382(2), which provided that, if an insurer initiates review of a compensation award and the reviewing body “finds that ... all or part of the compensation awarded ... should not be reduced or disallowed,” the insurer shall pay the claimant’s attorney a “reasonable attorney fee.” The ALJ determined that the statute applied to the dismissal of insurer’s claim and awarded fees to claimant. The Workers’ Compensation Board reached a different conclusion and reversed that decision. The Court of Appeals affirmed without opinion. The Oregon Supreme Court reversed, finding the ALJ correctly determined that his dismissal of insurer’s request for hearing entitled claimant to attorney fees. The board erred in concluding otherwise. View "Arvidson v. Liberty Northwest Ins. Corp." on Justia Law

The Third Circuit Court of Appeals certified a question of law to the New Jersey Supreme Court. The matter before the federal court involved a dispute between a workers' compensation insurance carrier and its insured, a public employer. Both plaintiff, the City of Asbury Park (the City), and its insurance carrier, defendant Star Insurance Company (Star), sought reimbursement of monies paid toward an injured firefighter’s workers’ compensation claim from funds he recouped through settlement with a third-party tortfeasor. The funds available for reimbursement will not cover the full amount paid collectively by the City and Star. The question was whether, under the equitable “made-whole” or “make-whole” doctrine, the City had priority to recover what it paid before Star could recover any of its losses. The Supreme Court answered the certified question in the negative. Under equitable principles of New Jersey law, the made-whole doctrine did not apply to first-dollar risk, such as a self-insured retention or deductible, that is allocated to an insured under an insurance policy. View "City of Asbury Park v. Star Insurance Company" on Justia Law