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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. 03-05-00837-CV
Regular Panel Decision
Dec 23, 2008

Diana Foster v. Texas Retirement System, Trustee for Texas Public Retired School Employees Group Insurance Program Aetna Life Insurance Company And Aetna Health Management, LLC

Diana Foster, a retired teacher, sued the Teacher Retirement System of Texas (TRS) and its insurance administrators, Aetna, after her claim for intravenous immune globulin infusion therapy (IVIG) was denied. She asserted claims for breach of contract, breach of the duty of good faith and fair dealing, violations of the insurance code, and deceptive trade practices, along with a request for declaratory judgment. The trial court granted appellees' pleas to the jurisdiction, dismissing the lawsuit without prejudice, citing sovereign immunity. Foster appealed, arguing her declaratory judgment claim was not barred, legislative immunity was waived, the administrative procedures act provided for judicial review, and Aetna was not protected by sovereign immunity. The appellate court affirmed the trial court's dismissal, finding that sovereign immunity applied to TRS and, by extension, to Aetna as its agent, and that Foster's claims did not fall under any exceptions for judicial review or waiver of immunity.

Sovereign ImmunityGovernment AgencyInsurance DisputeDeclaratory JudgmentAdministrative Procedures ActAgency AdjudicationJudicial ReviewBreach of ContractDuty of Good Faith and Fair DealingDeceptive Trade Practices Act
References
26
Case No. MISSING
Regular Panel Decision

Bernhardt v. Tradition North America

Donald Bernhardt sued his former employers, Tradition North America Inc. and Tradition Asiel Securities, Inc., alleging breach of an implied employment contract. Bernhardt claimed he was wrongfully terminated after exposing illegal securities schemes and reporting them to the SEC, violating an implied agreement that the firm would operate lawfully. Defendants moved to dismiss the amended complaint under Rule 12(b)(6) and sought Rule 11 sanctions against Bernhardt's attorney. The court granted the motion to dismiss, ruling that Bernhardt failed to state a plausible claim for breach of an implied contract under New York's at-will employment doctrine. However, the court denied the request for Rule 11 sanctions, finding the lawsuit, while unsuccessful, did not constitute sanctionable conduct.

Implied contractEmployment at willWrongful terminationWhistleblowerSecurities law violationsMotion to dismissRule 12(b)(6)Rule 11 sanctionsFederal Rules of Civil ProcedureNew York employment law
References
18
Case No. MISSING
Regular Panel Decision

Aetna Casualty & Surety Co. v. Harjo

This case involves Aetna's appeal of an award of litigation expenses to the law firm Cherry and Morgan. James Har-jo suffered an on-the-job injury and received workers’ compensation from Aetna. Harjo, represented by Cherry and Morgan, filed a third-party action, which settled for $1,850,000. Aetna intervened to protect its subrogation interest and was awarded $296,566. Cherry and Morgan requested attorney’s fees and out-of-pocket litigation expenses from Aetna's award. The trial court awarded them attorney’s fees of $118,566 and half of the litigation expenses, amounting to $37,297, which Aetna appealed. The court, citing Standard Fire Ins. Co. v. Morgan and Jones v. Liberty Mutual Ins. Co., ruled that the Workers’ Compensation Act does not provide for the recovery or sharing of litigation costs, thus reversing the award of litigation expenses.

Workers' CompensationSubrogationAttorney's FeesLitigation ExpensesStatutory InterpretationAppellate ReviewPersonal InjuryTexas LawInsurance CarrierLaw Firm
References
2
Case No. MISSING
Regular Panel Decision

Hart v. Aetna Casualty & Surety Co.

Karen Hart, an emergency medical technician, was exposed to chlorine gas. Aetna Casualty and Surety Company's adjuster, Marianna Grimes, contacted the Harts, who subsequently signed a release of liability for $1,500. The Harts sued to set aside the release, alleging Grimes made material misrepresentations regarding Aetna's liability, the need for an attorney, and other parties' settlements. The trial court granted an instructed verdict for Aetna, finding no fiduciary duty existed between Aetna and the Harts as injured third parties, and that the alleged misrepresentations were either statements of opinion or immaterial to the Harts' decision to sign the release. The appellate court affirmed the trial court's judgment.

Instructed VerdictRelease of LiabilityFiduciary DutyMaterial MisrepresentationFraudUndue InfluenceInsurance AdjusterAppellate ReviewBreach of DutyCivil Procedure
References
7
Case No. MISSING
Regular Panel Decision

Aetna Casualty & Surety Co. v. State Board of Insurance

Aetna Casualty & Surety Company sought judicial review of an order from the State Board of Insurance, which denied Aetna's claim for a servicing carrier fee from the Texas Workers’ Compensation Insurance Facility. Aetna, acting as a servicing carrier, managed workers' compensation policies for the Facility, including for Tra-Jax, Inc. A dispute arose when Aetna claimed a servicing fee on $863,000 collected from Tra-Jax after a fraud investigation and settlement, despite previously marking the account as uncollectible. The Board concluded Aetna waived its right to the fee by declaring the account uncollectible and accepting reimbursement for legal and auditing fees, which were ordinarily the carrier's expense. The district court affirmed the Board’s decision, and this court upheld that judgment, finding substantial evidence supported the Board's conclusion.

Workers' CompensationInsurance LawServicing CarrierPremium CollectionAdministrative ReviewSubstantial EvidenceArbitrary and CapriciousWaiverLegal FeesAuditing Fees
References
13
Case No. MISSING
Regular Panel Decision

Aetna Life Insurance Co. v. Wells

Homer Baxter Wells obtained a judgment against Aetna Life Insurance Company for medical expenses related to a heart attack, based on a jury finding that the heart attack was not an accidental injury. This meant it was not covered by worker's compensation. However, Wells had previously settled a worker's compensation claim with Highlands Insurance Company, asserting the heart attack *was* an accidental injury, leading to a double recovery for the same medical expenses. Aetna argued that Wells was estopped or barred from asserting the heart attack was not an accidental injury due to his prior successful claim. The Supreme Court of Texas found that Aetna's arguments regarding judicial admissions or judicial estoppel were not sufficiently established and were not properly urged in the lower court. Consequently, the writ of error sought by Aetna was refused, with no reversible error.

Double RecoveryJudicial EstoppelWorker's Compensation ClaimMedical ExpensesWrit of ErrorTexas Civil ProcedureInconsistent Legal PositionsHeart Attack InjuryInsurance Dispute
References
8
Case No. MISSING
Regular Panel Decision

Aetna Casualty & Surety Co. v. Moseley

James B. Moseley, an employee of Hall Real Estate Company, suffered an inner ear injury in 1989 and underwent multiple surgeries. His worker's compensation carrier, Aetna Casualty & Surety Company, settled his claim based on medical reports suggesting a good prognosis. However, Moseley's symptoms persisted and were later determined to be permanent. He sued to set aside the settlement, alleging misrepresentation by Aetna and its doctors. The trial court sided with Moseley, finding that Aetna's representatives and doctors misrepresented the extent of his injuries, and Moseley relied on these misrepresentations. Aetna appealed, but the appellate court affirmed the trial court's decision, allowing the Compromise Settlement Agreement to be set aside without Moseley having to return the received benefits.

Compromise Settlement AgreementMisrepresentationAppellate ReviewLegal SufficiencyFactual SufficiencyTexas LawIndustrial Accident BoardPermanent DisabilityTinnitusVertigo
References
14
Case No. 03-97-00285-CV
Regular Panel Decision
Apr 02, 1998

the Aetna Casualty & Surety Company v. Texas Workers' Compensation Insurance Facility

The Aetna Casualty & Surety Company appealed a declaratory judgment that found an indemnification provision in its servicing agreement with the Texas Workers' Compensation Insurance Facility unenforceable. Aetna had sought indemnification for sums paid to defend and settle claims by Jane Craft, alleging Aetna mishandled her workers' compensation claim with bad faith and gross negligence. The trial court's ruling, affirmed by the appellate court, determined that the indemnification clause did not expressly cover Aetna's own misdeeds. The court applied the "express negligence rule" and extended it to bad faith, gross negligence, and other alleged statutory violations, emphasizing that such liabilities must be explicitly stated in indemnity clauses. The court also addressed and rejected Aetna's arguments regarding agency, res judicata, and vested rights.

Indemnification ClauseExpress Negligence RuleBad Faith ClaimGross NegligenceDeclaratory JudgmentWorkers' Compensation InsuranceServicing AgreementInsurance Code ViolationsDeceptive Trade Practices ActContract Interpretation
References
8
Case No. MISSING
Regular Panel Decision

Texas Workers' Compensation Insurance Facility v. Aetna Casualty & Surety Co.

The Texas Workers’ Compensation Insurance Facility (TWCIF) appealed a take-nothing judgment in its suit against Aetna Casualty & Surety Company (Aetna). TWCIF, a workers' compensation carrier, paid benefits to an employee injured in a car accident and sought to assert its subrogation right against Aetna, the employer’s uninsured/underinsured motorist insurance carrier, after Aetna settled with the employee. The trial court ruled against TWCIF, stating it had no viable claim. On appeal, the court determined that TWCIF’s statutory subrogation right extends to claims against an uninsured/underinsured motorist insurance carrier, rejecting Aetna’s arguments regarding the scope of 'third party' and contractual limitations. Consequently, the appellate court reversed the trial court's judgment and remanded the case, holding that TWCIF is entitled to recover stipulated damages and interest.

Workers' CompensationSubrogationUninsured MotoristUnderinsured MotoristInsurance CarrierStatutory InterpretationTexas LawAppellate ReviewReimbursementDamages
References
4
Case No. 03-93-00541-CV
Regular Panel Decision
May 03, 1995

Aetna Casualty and Surety Company v. State

Aetna Casualty & Surety Company (Appellant) sought judicial review of an order by the State Board of Insurance and Texas Workers' Compensation Insurance Facility (Appellees) denying its claim for a servicing carrier fee. Aetna, as a servicing carrier, collected premiums for Tra-Jax, Inc., but a dispute arose over its entitlement to a 26.5% servicing fee on collected premiums totaling $863,000. The Facility denied the fee, arguing Aetna waived its right by declaring the account uncollectible and accepting reimbursement for legal and auditing expenses, which were ordinarily the servicing carrier's responsibility. The Board affirmed this decision, and the district court upheld the Board's order. The Court of Appeals affirmed the lower court's judgment, finding substantial evidence to support the Board's conclusion that Aetna waived its servicing fee.

Insurance DisputeServicing Carrier FeePremium CollectionWaiver of FeeSubstantial Evidence ReviewAdministrative Procedure ActTexas Workers' CompensationFraud InvestigationJudicial ReviewAgency Decision
References
10
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