Archbold v. Maxicare Health Plans, Inc.

722 So. 2d 1200, 98 La.App. 5 Cir. 531
CourtLouisiana Court of Appeal
DecidedDecember 16, 1998
Docket98-CA-531
StatusPublished
Cited by3 cases

This text of 722 So. 2d 1200 (Archbold v. Maxicare Health Plans, Inc.) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Archbold v. Maxicare Health Plans, Inc., 722 So. 2d 1200, 98 La.App. 5 Cir. 531 (La. Ct. App. 1998).

Opinion

722 So.2d 1200 (1998)

Diane ARCHBOLD
v.
MAXICARE HEALTH PLANS, INC. and ITT Hartford.

No. 98-CA-531

Court of Appeal of Louisiana, Fifth Circuit.

December 16, 1998.
Rehearing Denied January 19, 1999.

*1201 Pat M. Franz, Michael Baham, Metairie, Louisiana, Attorneys for Plaintiff/Appellant.

John J. Erny, III, Metairie, Louisiana, Attorney for Defendants/Appellees.

Panel composed of Judges EDWARD A. DUFRESNE, Jr., SOL GOTHARD, and MARION F. EDWARDS.

GOTHARD, Judge.

This appeal arises from the worker's compensation court. The worker's compensation judge ruled that the employer's insurer, ITT Hartford, was not arbitrary and capricious in reducing claimant's benefits, and therefore, claimant was not entitled to penalties and attorney's fees. For the following reasons, we reverse the decision of the worker's compensation judge.

Diane Archbold was injured and started receiving worker's compensation benefits in 1990. She is totally permanently disabled. She was found eligible for Social Security benefits; however, the amount of her Social Security benefits had been offset by the amount she was receiving as worker's compensation.

On March 25, 1997, ITT Hartford, the employer's worker's compensation insurance carrier, sought to obtain a "reverse offset" by the filing of a Motion for Recognition of the Right to a Social Security Offset with the Office of Workers' Compensation. The worker's compensation judge granted the motion on May 27, 1997. Ms. Archbold received notice of the motion and order on June 4,1997.

In July of 1997, ITT Hartford began applying the reverse offset, and it reduced the compensation benefits paid to Ms. Archbold. Ms. Archbold notified ITT Hartford that she had not received a corresponding increase in her Social Security benefits, and that she had contacted the Social Security Administration, who stated they had no knowledge of the order granting the reverse offset. Ms. Archbold requested that ITT Hartford reinstate her benefits pending Social Security action.

Because she was still receiving only the reduced benefits from ITT Hartford, Ms. Archbold filed a claim with the Office of Workers' Compensation on August 9, 1997, requesting that her benefits be reinstated and further alleging that ITT Hartford was arbitrary and capricious and therefore liable for attorney's fees and penalties. On August 28, 1997, ITT Hartford notified the Social Security Administration of the order granting the reverse offset.

In October, Hartford reinstated full benefits, pending action by the Social Security Administration. In February of 1998, the Social Security Administration began payment.

There were no facts in dispute and this matter was submitted to the hearing officer on memorandum and attached exhibits. On April 28, 1998, the worker's compensation judge rendered judgment finding that Hartford was reasonable in controverting the claim and Ms. Archbold was not entitled to attorney's fees and penalties. The hearing officer also found that WC-Form 1005 was the appropriate procedure for Hartford to follow in claiming the offset.

Ms. Archbold filed a motion for appeal on May 1, 1998. In this appeal she alleges that the insurer should not be allowed to reduce disability benefits until such time as benefits are increased by Social Security. She then argues that Hartford was in error because it failed to timely notify Social Security of the order allowing the reverse offset, and because it failed to reinstate plaintiff's benefits after it was informed that the Social Security Administration had no record of the order granting the reverse offset. Ms. Archbold argues that Hartford's continued reduction of benefits, prior to action by the Social Security Administration, and after Hartford was notified that Social Security had no knowledge *1202 of the reverse offset, constitutes arbitrary and capricious failure to pay.

ANALYSIS

In Garrett v. Seventh Ward General Hospital, 95-0017 (La.App.9/25/95), 660 So.2d 841, 843-844, the Louisiana Supreme Court provided a detailed history of wage-loss benefit coordination laws. The Court discussed the overlap between state workers' compensation benefits and federal Social Security disability benefits, stating:

Simply stated, the present federal statute requires that the amount of Social Security disability payments be reduced when the combined amount of such disability payments and the employee's workers' compensation benefits exceeds eighty percent of the employee's "average current earnings." 42 U.S.C. Sec. 424a(a) (1991). By adopting an offset in the form of an eighty percent federal ceiling, Congress "reduced the duplication inherent in the programs and at the same time allowed a supplement to workmen's compensation where the state payments were inadequate." Richardson v. Belcher, 404 U.S. [78] at 83, 92 S.Ct. [254] at 258 [30 L.Ed.2d 231 (1971) ].
The federal offset statute was modified for a period of time by a provision in Section 424a(d) that the federal offset did not apply if the state workers' compensation law itself provided for an offset of Social Security disability benefits against state workers' compensation benefits in the event of an overlap. By this "reverse offset" provision, Congress allowed the states to provide a benefit for local employers by enacting such a provision, with no reduction in the overall benefits received by employees. However, as part of a cost-cutting reform measure, Congress later imposed a cutoff date of February 18, 1981 for such state legislation. The effect of the cutoff date was to "grandfather in" existing state offset provisions enacted during the window period and to close the door to any subsequent state offset enactments. After the cutoff date, any legislation that added to or altered the scope of an existing state offset provision would not be recognized. 2 Social Security Law & Practice Sec. 26:69 (M. Rosenhouse ed.1987).

The Garrett Court then concluded that, in response to this federal legislation, the Louisiana Legislature enacted the reverse offset provision that is found in La. R.S. 23:1225 A, which reads as follows:

The benefits provided for in this Subpart for injuries producing permanent total disability shall be reduced when the person receiving benefits under this Chapter is entitled to and receiving benefits under 42 U.S.C. Chapter 7, Subchapter II, entitled Federal Old Age, Survivors, and Disability Insurance Benefits, on the basis of the wages and self-employment income of an individual entitled to and receiving benefits under 42 U.S.C. § 423; provided that this reduction shall be made only to the extent that the amount of the combined federal and worker's compensation benefits would otherwise cause or result in a reduction of the benefits payable under the Federal Old Age, Survivors, and Disability Insurance Act pursuant to 42 U.S.C. § 424a, and in no event will the benefits provided in this Subpart, together with those provided under the federal law, exceed those that would have been payable had the benefits provided under the federal law been subject to reduction under 42 U.S.C. § 424a.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Saragusa v. Auto Craft, Inc.
886 So. 2d 548 (Louisiana Court of Appeal, 2004)
Navarre v. K-Mart Corp.
807 So. 2d 893 (Louisiana Court of Appeal, 2002)
Price v. Universal Labor Services
769 So. 2d 745 (Louisiana Court of Appeal, 2000)

Cite This Page — Counsel Stack

Bluebook (online)
722 So. 2d 1200, 98 La.App. 5 Cir. 531, Counsel Stack Legal Research, https://law.counselstack.com/opinion/archbold-v-maxicare-health-plans-inc-lactapp-1998.