Legal News

Case Summaries

Insurance Law

[07/03] State Comp. Ins. Fund v. WCAB
The California Supreme Court finds that the Legislature intended to require employers to conduct utilization review when considering requests for medical treatment, and employers may not use Labor Code section 4062 as an alternative method for disputing employees' treatment requests.

[07/02] Sgro v. Danone Waters of N. Am., Inc.
In an ERISA action arising from a denial of plaintiff's claim for disability benefits, dismissal of plaintiffs' claims is affirmed in part and vacated in part where: 1) dismissal of state law claims was proper as defendant's disability plan is governed by ERISA, but the dismissal should have been without prejudice; 2) a California insurance regulation does not require defendants to reimburse plaintiff for the cost of copying the medical records that defendant-insurer/administrator requested, as that regulation is preempted by ERISA; 3) defendants did not violate ERISA's regulation on "claims procedures" by requiring documentation from plaintiff regarding his claim; and 4) a remand was required in part as to dismissal of a claim that defendants violated ERISA section 1132(c)(1) for failing to turn over certain documents.

[07/02] Wakkinen v. UNUM Life Ins. Co. of Am.
In an ERISA action, summary judgment for defendant upholding its denial of long-term disability benefits under an employer-offered plan is affirmed where substantial evidence supported plan administrator's finding that claimant was not "continuously disabled" through the 180 days of his elimination period as defined within the policy in dispute.

[06/30] Stamp v. Metropolitan Life Ins. Co.
Plan administrators of an employee benefits plan governed under ERISA may reasonably conclude that an insured, killed in a one-car collision with a tree while driving with BAC of 3 times the legal limit, did not die as a result of an "accident" for purposes of his Accidental Death and Dismemberment life insurance policies.

[06/27] Assoc. Indus. of Kentucky, Inc. v. U.S. Liab. Ins. Group
In an action for declaratory judgment as to whether defendant had a duty to defend plaintiff against several lawsuits in state court and a duty to cover any liabilities that might arise from the lawsuits, summary judgment for defendant is affirmed where defendant had not duty to defend any lawsuits arising from the offering of an insurance program due to an exclusion in the contract between the parties.

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Workers' Comp

[07/03] State Comp. Ins. Fund v. WCAB
The California Supreme Court finds that the Legislature intended to require employers to conduct utilization review when considering requests for medical treatment, and employers may not use Labor Code section 4062 as an alternative method for disputing employees' treatment requests.

[07/03] BNSF Ry. Co. v. Swanson
Provisions of Minnesota Statute sections 609.849(a)(1) and (a)(2), governing a railroad's treatment of injured workers, are both preempted by the Internal Control Plans regulations adopted by the Federal Railroad Administration pursuant to the Federal Railroad Safety Act.

[07/02] Anderson v. Commerce Construction Services, Inc.
In an action for negligence arising out of a Nebraska subcontractor's employee's injuries while performing demolition work in Kansas, summary judgment for defendant is affirmed where: 1) Kansas courts would have applied the lex loci delicti choice of law rule whereby the state where the tort occurred governs the merits of the litigation; 2) Kansas courts have only applied section 185 of the Restatement (Second) of Conflict of Laws to cases dealing with subrogation; and 3) application of section 184's most significant relationship test would result in defendant prevailing.

[07/02] Wakkinen v. UNUM Life Ins. Co. of Am.
In an ERISA action, summary judgment for defendant upholding its denial of long-term disability benefits under an employer-offered plan is affirmed where substantial evidence supported plan administrator's finding that claimant was not "continuously disabled" through the 180 days of his elimination period as defined within the policy in dispute.

[06/23] Barr v. WCAB
The Workers' Compensation Appeals Board has the discretion to award costs for preparing a vocational rehabilitation consultant's report, regardless of whether or not the report itself is admissible as evidence under Labor Code section 5703.

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