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Earlier this year, the Social Security Administration issued a Policy Interpretation Ruling for claimants seeking reconsideration of a decision made in the review process. The agency specifically addressed how the federal regulations for reopening a claim should be used when a decision hinges on a federal law that is later determined to be unconstitutional. The need for this Policy Interpretation came about following two Supreme Court decisions, Defense of Marriage Act in United States v. Windsor, 133 S. Ct. 2675 (2013) and Obergefell v. Hodges, 135 S. Ct. 2584 (2015). It may have an impact on Massachusetts Social Security claimants.

The two main programs of the Social Security Administration (SSA) are Title II and Title XVI. Title II benefits are ones from the Social Security Disability Insurance program, paid to individuals insured under the Social Security Act based on their payments into the system through the tax on their earnings. These payments can also be made to a particular set of disabled dependents. Title XVI benefits are better known as SSI, or Supplemental Security Income, and they are paid to disabled people who have limited income and resources. Much of the focus on whether an individual qualifies for Social Security benefits centers around whether or not she or he meets the medical criteria to be considered disabled. However, a claimant must also fall into the categories set by the SSA. The two Supreme Court cases above allow a greater amount of individuals to qualify as a disabled widow or widower, or as a dependent of a deceased insured parent.

Normally, if the claimant objects to the decision or determination of the agency, she or he can lose the right to another review if the appeal is not made within the listed time period. The decision or determination is then final. Exceptions to finality exist, and cases may be reopened under limited circumstances. The cases can be reopened for “good cause” at the agency’s initiative or by request of the party for revision. Agency regulations guide the grounds for reopening and whether or not there are deadlines to follow.

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The state allows employees to receive Massachusetts workers’ compensation benefits for both physical and psychological injuries. An employee is considered to be injured if the disability was predominantly caused by an accident that occurred while performing tasks for the employer. An injured employee can also recover for aggravated mental injuries that preceded the workplace accident if the workplace accident is a major, but not necessarily predominant, cause of the disability or need for treatment. In this instance, the injured employee does not have to provide as much medical proof to show she or he qualifies for benefits.

A recent Reviewing Board decision (Board No. 020182-15) looks at the difference between the burdens of proof. The self-insurer/employer sought to reverse a ruling awarding the employee total incapacity benefits. The employer argued several errors were made by the administrative judge. The board declined to dismiss the employee’s claim but did recommit the case for additional findings of fact.

In its decision, the board felt the nature of the dispute required a deeper scrutiny of the facts. The employee was a chaplain working at a hospital when a resident lunged from his wheelchair and hit the chaplain in the face. The employee maintained he sought workers’ compensation for his physical injury sustained from the incident as well as benefits for his pre-existing mental health issues. On appeal, the employer argued the employee was only attempting to seek benefits for a pure mental or emotional injury. The record indicated otherwise. The board noted the judge seemed to view the case as the injured employee presented it – a physical injury resulting in emotional sequela, or an aggravation of his previous injury. The employer felt it was deprived of due process by the judge’s treatment of the claim by allowing the lower burden of proof to prevail. The injured employee countered that there was no stipulation to the heightened standard of medical proof regarding causation.

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After a Massachusetts car accident, the costs can add up quickly. Even if the driver causing the accident has auto insurance, his policy limits can fall woefully short of covering medical bills stemming from the accident. Drivers and policy holders can then look to their own auto insurance policy for uninsured/underinsured coverage to make up the difference. Whether paying for an accident caused by an insured or paying for an injured party, insurers are ultimately interested in minimizing their costs and payouts. To mitigate this, the Commonwealth’s General Laws require an insurer to follow fair settlement practices. If an insurer fails to do so, the injured person can file suit, alleging the insurer committed an Unfair Claim Settlement Practice. A recent Appeals Court decision (16-P-509) addresses this type of lawsuit by assessing what an injured insured must produce for this claim to move forward against an auto insurer.

An injured Massachusetts resident filed suit against her auto insurance company following an accident with another vehicle. Liability was undisputed, and the injured woman accepted the $25,000 limit of that driver’s policy as a settlement of her claim. The injured woman also filed an underinsurance claim with her auto insurer, but no settlement was offered by her insurer. The injured driver ultimately filed suit to compel her insurer to arbitrate the dispute about the amount of damages she suffered from the accident, in addition to a claim for unfair settlement practices, based on the absence of any settlement offer. The injured woman was allowed to go to arbitration regarding the accident-related damages, which were assessed to be $50,000. The amount was confirmed by the presiding judge, who allowed the injured person to pursue the unfair settlement practices claim.

The trial court judge made several findings at the jury-waived trial, pointing out that the injured person offered a lot of proof regarding the damages related to the injury, but no evidence about the insurer’s investigation, nor evidence about which type of settlement negotiations occurred between herself and her insurer. The trial court found the woman also failed to show which damages she suffered as a result of the insurer’s failure to offer a prompt settlement of the claim. The injured woman argued the judge erred by allowing the insurer’s motion to exclude three of her witnesses, who were all the defendant’s employees. The Appeals Court found no abuse of discretion and affirmed the trial court’s refusal, based on the injured person’s late disclosure of witnesses.

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Massachusetts statutes guide the responsibilities and expectations of a trustee as well as the parts of the process the trustee must use for distribution. A trustee has broad powers over the administration of an estate. If the trustee mishandles her or his duties, the beneficiaries can be shortchanged. A recent Massachusetts estate planning decision (16-P-1314) deals with a depleted trust account, reviewing when a trustee commits a breach of trust, how much discretion they have, the compensation they are entitled to receive, and how and when they should be removed.

In this case, the father of both the plaintiff and one of the defendants in the lawsuit was the settlor of the trust, executed in February 1999. His estate was divided into four equal shares, with one share distributed through a separate trust to the plaintiff daughter and two of her three children. The rest of the shares were to be distributed to the remaining beneficiaries “free of all trusts.” The trustees administered those assets after the settlor’s death in 2001, leaving the daughter and her designated children as the sole remaining beneficiaries by 2008. However, no distributions were made to the plaintiff or her children until ordered by the judge in 2016. In the interim, the trustees used assets designated to the plaintiffs to pay the storage fees for items belonging to the plaintiff daughter found in the settlor’s home. The plaintiff daughter was made aware that her items were in a storage facility and that it was her responsibility to move them, but the trustee refused to give her the address of the storage facility.

Nothing further was said of the property until 2008, when the same trustee sent a letter advising she could not “cherry pick” and must accept the items altogether. Once more, the trustee refused to give her the location of the storage unit. Two similar letters were sent out after this, but nothing was addressed until the daughter filed the underlying case in 2013. By then, $50,000 of the assets out of the plaintiffs’ trust had been used to pay the storage fee over the 15-year span. Trust assets were also used to pay trustees’ fees, attorneys’ fees, and litigation expenses. The balance of the trust was reduced from $542,042 to $463,719, absent any actual distribution by the time the lawsuit was filed. During the litigation, the defendants continued to use the trust’s assets, reducing the assets to $250,000.

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Whether state court or federal court, the civil justice system relies upon due process to ensure all parties are fairly heard and considered. Part of due process is the statute of limitations, which provides deadlines for parties for many parts of the litigation, including filing, responding, requesting evidence, and providing evidence. If deadlines are missed, the party missing the deadline can potentially be precluded from either moving forward with the litigation as the plaintiff, or maintaining an affirmative defense as the defendant. The First Circuit Court of Appeals addressed the effect of a missed deadline in a Massachusetts Social Security Disability appeal for benefits in a recent case (No. 16-2188).

The SSI claimant filed for Social Security Disability Insurance benefits (SSDI) in 2012, which were denied three months later and on reconsideration three months after that. A hearing was held 14 months later, ultimately concluding in an unfavorable decision for the claimant. The ALJ found he was not disabled and was ineligible for SSDI. The claimant then asked the agency’s Appeals Council to review the administrative law judge’s determination. The council denied the request, finalizing the ALJ’s denial of benefits.

The council’s denial included a notice that the claimant has 60 days to file a civil action or ask a federal court for a review. The notice specifically stated that the 60 days start the day after the claimant receives the letter and that it is assumed the letter was received within five days after the date stamped on the Notice, unless the claimant can show otherwise. The notice also advises that if the claimant is unable to file for a review within 60 days, an extension is available as long as there is a good reason for waiting more than 60 days to ask for a court review. This request for an extension must be in writing.

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Massachusetts workers’ compensation offers benefits for both physical and psychological injuries an employee suffers after an accident. By their nature, physical injuries are easier to connect to a workplace accident. Detailed proof and testimony must be offered by an injured person to show the workplace accident was the major factor in the psychological injury. A recent Massachusetts workers’ compensation action (Bd. No. 031456-05) offers a glimpse into which proof can be offered in a successful bid for workers’ compensation for a psychiatric injury.

In this lawsuit, the Reviewing Board assessed whether or not an employee should have been awarded both §§ 34 and 34A benefits. The employee suffered multiple fractures in her left foot after she slipped and fell in an industrial accident. Her employer agreed the foot injury was caused by a workplace accident and agreed to cover the initial costs related to her psychiatric issues stemming from the injury. The employee exhausted her § 35 and § 34 benefits after a fusion in 2006, followed by another in 2012 and a third in 2013. The second surgery seemed to provide some relief to her condition but did not resolve her pain or her difficulties walking on uneven surfaces. The third surgery did not do much to alleviate pain in her heel or the pain that had since developed in her knee. Since the accident, the injured person could not leave the house on cold days because it took her foot hours to feel warm, which then resulted in additional psychological tension. Because of the constant pain and inability to perform typical daily functions, the employee often felt sad, cried, and had fits of anger.

At the hearing, the administrative judge found the employee was permanently and totally disabled due to both the orthopedic and the psychological conditions. The employee was awarded § 34 and § 34A permanent and total incapacity benefits. The employer/self-insurer appealed the ruling, alleging the psychiatric disability should not have been tried at the hearing, since the issue had not been raised at the pre-trial conference. The Reviewing Board disagreed, pointing to the submissions and transcript of discussions before the hearing.

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In a recent Massachusetts workers’ compensation case, the Reviewing Board analyzed an appeal by an insurer dissatisfied with a hearing decision. The insurer alleged the judge incorrectly used the wage amount of $1,726.37 to calculate the weekly wage paid to the injured carpenter. The insurer argued the employee was not entitled to the award, since there was no appeal of the conference order.  The insurer felt the employee could only use the maximum amount of $1,490.33 to calculate his entitled average weekly wage.

The injured carpenter was hurt in an industrial accident while moving a piece of machinery. The machinery began to tip, he grabbed it, and he caught his ring on the machine. The employer didn’t dispute liability and agreed to initially pay an average weekly wage of $800 a week. The injured employee eventually sought an adjustment, which was at the center of this action. The carpenter initially asked for an average wage of $1,505.09 a week, and he submitted an IRS Form 1099 for checks from his employer, payable to him for 35 out of 52 weeks prior to the injury, as proof. The claim was then withdrawn in October 2012.

In November 2012, the injured man refiled a claim for an adjustment, this time requesting an average weekly wage of $1,490.22 per week. As proof, the employee submitted the same 35 weeks’ worth of checks. This claim was also withdrawn, but he eventually refiled a year later. This third attempt at a readjustment claim was for the same amount, and this was accompanied by medical reports and a 2011 tax return. This amount was sent to a conference. After the conference, the administrative judge ordered $1,490.33 to be used as the weekly wage amount. The insurer appealed, but the employee did not.

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Any award of damages in a Massachusetts injury case, whether through a plaintiff’s verdict or settlement agreement, can still present challenges if the defendants either fail to pay or cannot pay the ordered amount.  The federal First Circuit Court of of Appeals addresses this in Vargas-Colon v. Foundation Damas, Inc. (Nos. 16-1213 and 16-1620).  The underlying injury happened to a child who was born by cesarean section after the mother had been in the hospital for several hours.  Because of this delay, the child did not receive enough oxygen and suffered permanent neurological defects.

The parents initiated a medical malpractice action in the federal district court, alleging the doctor and hospital were negligent in the care and delivery of the child.  The parties reached a settlement agreement with the defendants paying $1.5 million in eight installments.  This was entered into a judgment, and the district court retained jurisdiction over the terms of the settlement.  After the first payment of $400,000, the hospital failed to make the scheduled payments.  Instead, the hospital filed for bankruptcy.  The plaintiffs moved to dismiss the hospital’s bankruptcy petition alleging several claims including fraud and bad faith.

The bankruptcy case proceeded, and a reorganization plan was confirmed for the hospital for the court.  Within the plan was a supplement that assured any medical malpractice claimant that they could still file a motion or legal action against the hospital in the pursuit of an action or collection of funds.  The plan also did not preclude medical malpractice claimants from pursuing actions against third parties.  At this point the plaintiffs only received a little under $645,000 – less than half of the $1.5 million agreed upon in the settlement agreement. 

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Injured Massachusetts employees may be surprised to learn that workers’ compensation includes benefits for psychiatric injuries. Compensable psychiatric injuries can be caused by hostile supervisors, bullying by coworkers, or traumatic events. Anxiety and depression stemming from a physical injury can also be compensated. Claims for psychiatric benefits are discussed in a recently issued Reviewing Board decision (Bd No. 0061111-12), which looked at whether or not the administrative judge erred by ceasing all claims for benefits after May 2013.  The injured worker was a court officer whose duties included transporting prisoners and providing security in the courtroom. In 2012, the employee was injured by a prisoner and taken to the hospital to care for harm to his ribs, right arm, and wrist. The officer also experienced headaches and vertigo months after the incident.

The self-insurer accepted liability for the physical injuries. Benefits for those were resolved in 2013. At this conference, the employee added claims for psychiatric counseling, PTSD, and further indemnity benefits. The insurer objected, disputing the liability for the neurological injury and PTSD claim. The insurer asserted there was no causal relationship between the psychiatric injury and the workplace.

In his decision and denial of benefits, the administrative judge adopted the expert testimony opinion the employee did not have an objective neurological impairment related to the inmate altercation in 2012, as well as the opinion of another expert who determined the injured employee did not have a psychiatric condition limiting his ability to work. The judge found that the employee’s physical injuries had resolved by May 2, 2013 and that he was able to perform the full range of activities consistent with employment.

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As a responsible Massachusetts driver or homeowner, one obtains an insurance policy in the event of an accident or emergency. If someone else is injured in a policy holder’s home or vehicle, the insured relies on the insurance company to help defend against personal injury claims. This also applies to corporate policies. In a recent case, the Massachusetts Supreme Court examined whether an insurer’s duty to defend extends to a counterclaim brought by the insured. Counterclaims are actions filed by the defendant against the plaintiff, alleging the plaintiff was negligent and liable for damages.  As an example, one could look at someone injured in a car accident.  The defendant party could choose to claim the plaintiff was independently liable for her or his negligence. If the duty to indemnify extended to counterclaims, an injured party may be subject to additional litigation backed by the pockets and experience of attorneys working for the defendant’s insurance company.

In this lawsuit, the Commonwealth’s Supreme Court declined to expand the duty to include counterclaims. The insurance policy in this action provided liability coverage for employment practices. The Eye Safety and Cleaning Product Company sought indemnification from its insurer for the wrongful termination claims brought against it during a period of time from 2011 to 2012. The policy stated the insurer was required to defend the claim and pay 100% of the defense costs for the claim up to the policy limit. The company discovered what appeared to be a large misappropriation of company funds. The company terminated an employee, who then began an action for wrongful termination, alleging age discrimination. The insurer provided an attorney who addressed three nondiscriminatory reasons for the employee’s termination:  poor job performance, insubordination, and suspected misappropriation of funds.

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