Matter of Empire Mutual Insurance Company, 27 N.Y.2d 146 (1970)
An insurance carrier that waives its lien on a third-party settlement as part of its contribution to the settlement cannot then seek reimbursement from the Special Disability Fund for payments made beyond the statutory retention period.
Summary
Empire Mutual, acting as both the workmen’s compensation carrier and the employer’s liability carrier, sought reimbursement from the Special Disability Fund for payments made to a claimant beyond 104 weeks after the claimant settled a third-party action. Empire Mutual had waived its compensation lien and contributed $29,000 towards the settlement. The court held that because Empire Mutual effectively received reimbursement for its compensation payments by reducing its liability carrier contribution, it was not entitled to reimbursement from the Special Disability Fund. Allowing such reimbursement would constitute a windfall.
Facts
In 1960, a claimant sustained severe injuries. The claimant had a pre-existing physical handicap due to a prior injury while working for the same employer. Empire Mutual Insurance Company was the workmen’s compensation carrier for the employer. Empire Mutual made compensation payments to the claimant for 186-4/5 weeks.
Procedural History
The Workmen’s Compensation Board directed the Special Fund to reimburse Empire Mutual for payments made beyond 104 weeks. The Appellate Division affirmed the Board’s decision. The Special Fund appealed to the New York Court of Appeals.
Issue(s)
Whether an insurance carrier, acting as both compensation and liability carrier, is entitled to reimbursement from the Special Disability Fund for payments made to a claimant beyond the statutory retention period, when the carrier waived its lien on the proceeds of a third-party settlement and contributed to the settlement as the employer’s liability carrier.
Holding
No, because the insurance carrier, in voluntarily waiving its lien for the total amount of the compensation paid to the claimant and contributing to the settlement, is effectively reimbursed for its compensation payments, making it ineligible for further reimbursement from the Special Disability Fund.
Court’s Reasoning
The court reasoned that generally, a carrier can exercise its statutory rights as a lienor to recover payments made to the claimant from a third-party recovery, and then turn to the Special Fund for any deficiency arising after the 104th week. However, in this case, Empire Mutual acted in dual capacities: as the workmen’s compensation carrier and as the employer’s liability carrier. Empire Mutual actively participated in the third-party settlement by contributing $29,000 and waiving its lien for compensation payments.
The court found that Empire Mutual’s cash settlement as liability carrier was reduced by the amount of payments made previously as compensation carrier. If two separate carriers had been involved, the liability carrier would have had to contribute a greater amount to satisfy the compensation carrier’s lien. In effect, Empire Mutual was already reimbursed for its compensation payments by having its payments as liability carrier reduced.
The court emphasized that allowing further reimbursement from the Special Disability Fund would constitute a windfall for Empire Mutual. The court stated, “Here, Empire Mutual, acting in dual capacities, was fully reimbursed for its compensation payments to claimant by having its payments as liability Carrier correspondingly reduced. To allow Empire Mutual reimbursement under such circumstances would be, in effect, a windfall.”
The court reversed the Appellate Division’s order and dismissed the claim for reimbursement from the Special Disability Fund.