Justia Public Benefits Opinion Summaries

After Insured sustained injuries in a car accident he sought MRIs from Virtual Imaging Services. Virtual Imaging obtained an assignment of personal injury protection (PIP) benefits under Insured's policy with GEICO and billed GEICO $3600 for the MRIs. GEICO paid the bill but limited its reimbursement to eighty percent of 200 percent of the applicable Medicare fee schedule in accordance with the formula described in Fla. Stat. 627.736(5)(a). This statutory provision became effective on January 1, 2008 as part of Florida's PIP statute. Virtual Imaging subsequently sued GEICO, alleging that GEICO's reimbursement was insufficient. The county court granted Virtual Imaging's motion for summary judgment. The court of appeal affirmed then certified a question of law to the Supreme Court, which answered by holding that GEICO was required to give notice to Insured by electing the permissive Medicare fee schedules in its policy before taking advantage of the Medicare fee schedule to limit reimbursements.View "Geico Gen. Ins. Co. v. Virtual Imaging Servs., Inc." on Justia Law

Holline and William Parsons (Plaintiffs) were enrolled in Today's Option, a Medicare Advantage Plan sponsored by the Pyramid Life Insurance Company (Pyramid). After Plaintiffs were each disenrolled from their respective plans, they brought suit against Pyramid, asserting numerous state law claims. The circuit court granted Plaintiffs' motion for summary judgment in part declaring that the Medicare Act did not provide the exclusive remedy for Plaintiffs' claims in this case. Pyramid then moved for Ark. R. Civ. P. 54(b) certification and a stay pending appeal, requesting permission to file an interlocutory appeal on the issues of whether Plaintiffs' state-law claims arose under the Medicare Act and whether their claims, to the extent they did not arise under the Act, were expressly preempted by the Act. The circuit court certified this appeal pursuant to Rule 54(b). The Supreme Court dismissed the appeal without prejudice, holding that the finding supporting Rule 54(b) certification was in error. View "Pyramid Life Ins. Co. v. Parsons" on Justia Law

This appeal by Dorothy Knight arose from a 2011 circuit court order. In it, the circuit court affirmed an administrative decision by the Public Employees Retirement System (PERS) denying disability benefits. Upon review, a majority of the Supreme Court concluded that Knight met her burden, and that PERS' decision to deny her claim was not supported by substantial evidence. Accordingly, the Court reversed the appellate and circuit courts' rulings and remanded the case for further proceedings. View "Knight v. Public Employees' Retirement System of Mississippi" on Justia Law

Petitioner Vincent James Hogg, Sr. sought review of a Workers' Compensation Court order which denied his workers' compensation benefits based upon the court's interpretation of 85 O.S. 2011, section 312 (3). Petitioner was employed by the Oklahoma County Juvenile Detention Center when in late 2011, he sustained an injury to his right shoulder and neck while subduing an unruly and combative juvenile. Petitioner was given a post-accident drug screen and a follow-up screen the next day. Both screens showed a "positive" result for the presence of marijuana in his system. Petitioner did not dispute the test results but Petitioner denied ever smoking marijuana. The trial court ultimately found there was no evidence presented to establish Petitioner was "high," nor was there any evidence to establish the marijuana in his system was the "major cause" of the accidental injury. The trial court did, however, deny Petitioner's eligibility for workers' compensation benefits by reason of its interpretation of the newly created 85 O.S. 2011, section 312 (3). The dispositive issue presented to the Supreme Court was whether the trial court erred in its interpretation of the statute. The trial court found the last sentence of paragraph 3 expressed the legislative intent of the entire paragraph without giving any weight to the other sentences in the same paragraph. In its order, the trial court indicated this sentence created an irrebuttable presumption. Upon review, the Supreme Court disagreed. The Court concluded that Petitioner overcame the rebuttable presumption of ineligibility for workers' compensation benefits. The case was reversed and remanded for further proceedings. View "Hogg v. Oklahoma Cty. Juvenile Bureau" on Justia Law

In this case the Supreme Court was asked to decide whether a charitable hospital may pursue payment for medical care provided to a Medicaid-eligible patient by filing a lien against a settlement between the patient and an insurance company covering the liability of a tortfeasor responsible for the patient's injuries. To answer the question, the Court balanced the complex state and federal legal framework surrounding Medicaid with Wis. Stat. 779.80 (hospital lien statute). The Court concluded that the soundest harmonization of the two permitted the liens at issue here. In so doing, the Court reversed the court of appeals, which reversed the circuit court's reasoning that the hospital was authorized to either file the liens or bill Medicaid.View "Gister v. Am. Family Mut. Ins. Co." on Justia Law

The New York City Off-Track Betting Corporation (NYC OTB) was a public benefit corporation charged with operating an off-track pari-mutuel betting system within the City. Later, NYC OTB filed for bankruptcy and shut down. The City's Corporation Counsel then announced that NYC OTB retirees would lose coverage under the City's health insurance and welfare benefit plans because the Corporation was no longer able to reimburse the City. A union representing NYC OTB employees and retirees and others (collectively, Plaintiffs) brought suit against the State and City, seeking a judgment declaring that the failure of the State and City to fund, and the termination of retiree health insurance and supplemental benefits, violated the City Administrative Code and other express and implied obligations. Supreme Court rejected the four theories advanced by Plaintiffs to support State or City liability for NYC OTB retiree health benefits. The appellate division affirmed. The Court of Appeals affirmed, holding (1) Plaintiffs did not demonstrate a likelihood of success on the merits of their claim against the City; and (2) because NYC OTB had a legal identity separate from the State, Plaintiffs stated no viable theory under which the State could be held liable in this case.View "Roberts v. Paterson" on Justia Law

The State Department of Labor and Industry appealed a district court's order that reversed the Department's decision regarding Petitioner Sheila Callahan & Friends, Inc. (SC&F). SC&F, a radio broadcasting company entered into a one-year contract with Joni Mielke. During the term of employment, SC&F evaluated Mielke as being an excellent radio personality and announcer but as underperforming other responsibilities because she either did not want to do them or preferred announcing-related duties. Mielke elected not to renew her contract with SC&F, and on an exit interview form, Mielke indicated her reason for leaving was that she "quit." After Mielke left her employment with SC&F, she was hired by another radio station. After a brief employment with this subsequent employer, she was laid off and filed for unemployment benefits in October 2009. The Department of Labor sent a Notice of Chargeability Determination to SC&F assessing a pro rata share of the costs of Mielke’s unemployment insurance benefits to SC&F’s experience rating account. The Department administratively determined that Mielke was employed for SC&F on a contract basis during her base period of employment and that SC&F’s account was chargeable for a portion of benefits drawn by Mielke. SC&F requested a redetermination, arguing that Mielke had voluntarily left her employment. The Department issued a Redetermination affirming the initial Determination. An administrative hearing was then conducted by telephone; the hearing officer determined that Mielke neither voluntarily quit nor was discharged for misconduct and affirmed the decision to charge SC&F’s account. On appeal, the Department argued the District Court improperly failed to defer to the Board’s findings of facts. Upon review, the Supreme Court concluded that the error of the Board was primarily premised upon application of legal standards, in the nature of a conclusion of law. Given the inapplicability of the imputation rules to the situation here, the District Court properly concluded that the evidence did not support the Board’s determination that Mielke’s work separation was involuntary. View "Sheila Callahan & Friends, Inc. v. Montana" on Justia Law

Plaintiff's son, Hayden, was involved in a near-drowning accident in which he suffered severe permanent injuries. Plaintiff subsequently sought coverage for the cost of his treatment from Wasatch Crest Mutual Insurance, under which Hayden was insured. Wasatch Crest was later declared insolvent, and Plaintiff filed a claim against the Wasatch Crest estate. The liquidator of the estate denied Plaintiff's claim, concluding that Wasatch Crest had properly terminated coverage under the language of the plan. The Supreme Court reversed, interpreting the plan in favor of coverage. Plaintiff resubmitted her claim for medical expenses to the liquidator for payment under the Utah Insurers Rehabilitation and Liquidation Act. One year later, Plaintiff filed a motion for summary judgment with the district court. The liquidator subsequently issued a second amended notice of determination denying Plaintiff's claim on the merits. The district court then denied Plaintiff's motion for summary judgment, as Plaintiff had not yet challenged the second amended notice of determination and could do so under the Liquidation Act. Plaintiff appealed the district court's order. The Supreme Court dismissed the appeal because Plaintiff did not appeal from a final judgment and had not satisfied any of the exceptions to the final judgment rule.View "Mellor v. Wasatch Crest Mut. Ins." on Justia Law

The Employment Appeal Board (Board) denied Willie Hall's application for unemployment insurance benefits. Hall filed a petition for judicial review. The district court affirmed the decision of the Board and assessed costs against Hall. The court of appeals affirmed. The Supreme Court reversed the portion of the judgment as it related to court costs, holding (1) pursuant to Iowa Code 96.15(2), any individual claiming benefits shall not be charged fees of any kind, including court costs, in a proceeding under the statute by a court or an officer of the court; and (2) therefore, the district court erred by requiring that Hall pay court costs. View "Hall v. Employment Appeal Bd." on Justia Law

Plaintiff represented psychiatrists who treated patients eligible for both Medicare and Medicaid and defendants were responsible for administering Medicaid in New York and for implementing and enforcing medicaid reimbursement rates. At issue was whether the 2006 amendment to the Social Services law found in a budget bill implementing a coinsurance enhancement for the benefit of psychiatrists who treat patients eligible for both Medicare and Medicaid was intended to be permanent or whether the amendment was intended only to provide a limited one-year enhancement. The court concluded that the Legislature only intended to provide for a one-time coinsurance enhancement, limited to the 2006-2007 fiscal year.View "New York State Psychiatric Assn., Inc. v New York State Dept. of Health" on Justia Law