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

Case No. MISSING
Regular Panel Decision

Dorato v. Blue Cross of Western New York, Inc.

George Dorato (plaintiff) sued Blue Cross of Western New York (defendant), also known as HealthNow, Inc., doing business as Blue Cross & Blue Shield of Western New York, after his health insurance benefits for a herniated disk were denied. Dorato's workers' compensation claim, which alleged a work-related injury, resulted in a $80,000 Section 32 settlement agreement, although his claim was officially 'disallowed' by the Workers' Compensation Board. HealthNow denied benefits citing a contract exclusion for injuries where payment is available under Workers' Compensation Law, arguing the settlement constituted such payment. Dorato moved for summary judgment, seeking a de novo review and asserting collateral estoppel, and also moved to amend his complaint to recharacterize his claims under ERISA. The court applied an 'arbitrary and capricious' standard of review to HealthNow's decision, noting the contract's discretionary authority. The court found that collateral estoppel did not apply due to lack of identical issues and HealthNow's inability to participate in the WCB proceedings. Ultimately, the court granted HealthNow's motion for summary judgment, ruling that their interpretation of the contract's exclusion was rational and not arbitrary or capricious. Dorato's motions were consequently denied as futile.

ERISAWorkers' CompensationHealth InsuranceSummary JudgmentCollateral EstoppelArbitrary and Capricious StandardDe Novo ReviewBenefit DenialContract ExclusionEmployee Welfare Benefit Plan
References
29
Case No. MISSING
Regular Panel Decision

Memorial Hospital System v. Blue Cross & Blue Shield of Arkansas

Plaintiff Memorial Hospital System, a Texas-based healthcare provider, initiated this action against Defendant Blue Cross and Blue Shield of Arkansas, an Arkansas insurance company. Memorial alleged jurisdiction based on a single long-distance phone call from its employee in Texas to Blue Cross in Arkansas, during which an agent allegedly misrepresented insurance coverage for a patient. In reliance on these representations, Memorial treated the patient and subsequently filed a claim for $10,070, which Blue Cross refused to pay. The court evaluated whether this unsolicited telephone contact constituted sufficient minimum contacts to establish *in personam* jurisdiction over Blue Cross in Texas under federal due process. Citing relevant case law, the court concluded that such a fortuitous or unsolicited contact did not demonstrate purposeful availment by Blue Cross of the benefits and protections of Texas law, thus failing to satisfy due process requirements. Consequently, the court granted Blue Cross's motion to dismiss for lack of personal jurisdiction.

Personal jurisdictionMinimum contactsDue processLong-arm statuteNegligent misrepresentationERISAInsurance coverage disputeInterstate commerceTexas lawArkansas corporation
References
35
Case No. MISSING
Regular Panel Decision

Blankenship v. Estate of Bain

The Tennessee Supreme Court addressed whether TennCare, administered by Blue Cross/Blue Shield, has subrogation rights for medical expenses paid on behalf of a recipient without the recipient first being 'made whole' for their loss. Benny and Sheila Blankenship, TennCare enrollees, were injured in a car accident and settled their claim for less than their total damages. Blue Cross/Blue Shield sought to intervene for subrogation. The trial court denied this, citing the 'made whole' doctrine, but the Court of Appeals reversed. The Supreme Court reversed the Court of Appeals, holding that TennCare's subrogation rights under Tenn.Code Ann. § 71-5-117(a) are subject to the equitable 'made whole' doctrine, as the statute does not explicitly waive this requirement. It also clarified that federal law does not mandate full subrogation regardless of the 'made whole' doctrine.

SubrogationMade Whole DoctrineTennCareMedical Assistance ProgramEquitable PrinciplesStatutory InterpretationHealth InsuranceThird-Party LiabilityWorkers' CompensationMedicaid
References
23
Case No. MISSING
Regular Panel Decision

Blue Cross of Western Pennsylvania v. LTV Steel Co. (In re Chateaugay Corp.)

Appellant Blue Cross of Western Pennsylvania (BCWP) appealed a Bankruptcy Court decision that denied its request for relief from an automatic stay in the Chapter 11 bankruptcy of LTV Steel Company, Inc. BCWP, an insurance provider for LTV Steel's former constituent companies (J&L and Republic), sought to set off a $2.88 million refund it owed LTV/J&L against over $3 million in unreimbursed claims it paid as a participant in a national syndication arrangement for LTV/Republic. The Bankruptcy Court found no mutuality between BCWP and LTV Steel to permit the set-off under 11 U.S.C. § 553(a). BCWP argued for third-party beneficiary status and equitable principles. The District Court affirmed the denial, ruling that BCWP was not a third-party beneficiary and that allowing the set-off would create an inequitable preference for BCWP over other creditors.

BankruptcyAutomatic StaySet-offMutualityThird-Party BeneficiaryInsurance ContractsHealth Care BenefitsSyndication ArrangementEmployer-Employee BenefitsDebtor in Possession
References
5
Case No. 01-15-00152-CV
Regular Panel Decision
Feb 10, 2015

Donald B. Mullins and Blue Sky Right of Way, L.L.C. v. Martinez R.O.W., LLC F/K/A Martinez Investments

Donald B. Mullins and Blue Sky Right of Way, L.L.C. (Appellants) contracted with Southern Brush S.W., Inc., and then subcontracted part of the work to Martinez R.O.W., L.L.C. (Appellee). An employee of Martinez, Bonifacio Gomez, was injured on the job and sued Mullins. Mullins filed a cross-claim against Martinez for indemnity and contribution, arguing Martinez agreed to indemnify Blue Sky and Mullins. Martinez, a workers' compensation subscriber, moved for summary judgment under Tex. Labor Code § 417.004, asserting no written agreement for liability assumption existed. The trial court granted Martinez's summary judgment and denied Mullins' subsequent motions to vacate and amend. This appeal concerns whether the district court properly granted summary judgment, given the absence of a pre-accident written agreement where Martinez assumed Mullins' liability.

Workers' CompensationIndemnityContributionSummary JudgmentTexas Labor CodeExpress Negligence RuleThird-Party LiabilityInsurance CertificateGross NegligenceEmployer Protection
References
32
Case No. MISSING
Regular Panel Decision

Blue Cross & Blue Shield v. State Division of Human Rights

This decision vacates a previous order and remands the matter to the State Division of Human Rights for a hearing. The initial court had dismissed a complaint, finding New York's Human Rights Law pre-empted by ERISA regarding pregnancy disability benefits. The Court of Appeals remitted for reconsideration in light of Shaw v Delta Airlines, which clarified that pre-emption only applies when a state law prohibits practices lawful under federal law. The court noted that the discrimination, alleged in 1977, predated the federal prohibition against pregnancy discrimination (effective April 29, 1979). However, ERISA exempts plans maintained solely for complying with disability insurance laws. The record is unclear if petitioner's plan is a separate plan (where NY Human Rights Law would apply) or part of a larger employee benefit plan (where ERISA would control). Therefore, the case is remanded for a determination on this specific factual issue only.

ERISA Pre-emptionHuman Rights LawPregnancy DiscriminationDisability Benefits LawState Law Pre-emptionFederal Law ConflictRemittiturEmployee Benefit PlansJudicial RemandWorkers' Compensation Law Art 9
References
3
Case No. MISSING
Regular Panel Decision
Oct 15, 1999

Garofalo v. Empire Blue Cross and Blue Shield

Plaintiffs Laurie Garofalo and Hilary Rosser, as class representatives, sued their health insurer, Empire Blue Cross and Blue Shield, under ERISA. They alleged Empire paid less than its required 80% share of certain inpatient hospital expenses due to a bimodal coinsurance calculation method (actual charges for participants, DRG rates for insurer). Plaintiffs argued this method violated New York Public Health Law § 2807-c(12) and was preempted by ERISA. The court granted summary judgment to Empire, ruling that its calculation method complied with the NYPHRM, specifically § 2807-c(11)(n)(i), and that ERISA did not preempt this state law as it regulates insurance. The court found plaintiffs lacked standing for the remaining claims and dismissed all inpatient hospitalization claims with prejudice.

ERISA LitigationHealth Insurance LawCoinsurance CalculationDRG RatesSummary JudgmentClass Action LawsuitPlaintiff StandingStatutory PreemptionNew York Public Health LawEmpire Blue Cross Blue Shield
References
39
Case No. MISSING
Regular Panel Decision

Empire Blue Cross & Blue Shield v. Consolidated Welfare Fund

Empire Blue Cross and Blue Shield (Empire) sued the Consolidated Welfare Fund and other defendants for breach of contract, fraud, and RICO violations. The defendants moved for partial judgment on the pleadings, asserting that the state law claims were preempted by ERISA. The court analyzed whether the Fund qualified as an 'employee welfare benefit plan' (EWBP) under ERISA. Finding that the Fund, with its 'associate members' from diverse backgrounds and commercial solicitation, did not meet the criteria of an EWBP, the court concluded that ERISA preemption did not apply. Therefore, the defendants' motion for partial judgment on the pleadings was denied, allowing Empire's state law claims to proceed.

ERISA PreemptionEmployee Welfare Benefit PlanHealth Insurance FraudLabor Union MembershipAssociate MembersRule 12(c) MotionFederal Civil ProcedureStatutory InterpretationCommercial Insurance SchemesDistrict Court Ruling
References
11
Case No. MISSING
Regular Panel Decision

Star Multi Care Services, Inc. v. Empire Blue Cross Blue Shield

This case involves Star Multi Care Services, Inc. (plaintiff) suing Empire Blue Cross Blue Shield (defendant) and Demetria Sarris and Van Sarris (Sarris defendants) for breach of contract regarding home health care services. Star initially filed the action in New York State Supreme Court, alleging Empire breached a contract to pay for services provided to Ms. Sarris under an ERISA plan. Empire removed the case to federal court, arguing ERISA preemption, and filed a motion to dismiss, while Star moved to remand to state court. The District Court denied Star's motion to remand, finding the claim was preempted by ERISA. The court granted Empire's motion to dismiss, concluding that Empire was not a proper defendant under ERISA and Star failed to exhaust administrative remedies. The remaining state law claims against the Sarris defendants were remanded to the Supreme Court of the State of New York, County of Suffolk, as the federal court declined to exercise supplemental jurisdiction.

ERISA preemptionRemoval jurisdictionMotion to remandMotion to dismissRule of unanimitySubject matter jurisdictionBreach of contractHealth care benefitsEmployee welfare benefit planAdministrative remedies exhaustion
References
73
Case No. MISSING
Regular Panel Decision

Westchester Radiological Associates, P.C. v. Empire Blue Cross & Blue Shield, Inc.

Plaintiffs, a group of hospital-based radiologists, sued Empire Blue Cross and Blue Shield, Inc., alleging violations of Sections 1 and 2 of the Sherman Act and the New York Donnelly Act. The radiologists claimed unlawful restraint of trade, monopolization, and price fixing due to Empire's policy preventing direct billing for professional radiological services. Empire moved to dismiss the complaint, arguing failure to state a claim under Section 1, lack of standing for Section 2 claims, and consequently, dismissal of the pendent state law claim. The court denied Empire's motion in its entirety, determining that Empire acted as an intervening "third force" in a non-exempt relationship and that the radiologists had direct standing due to the precisely intended nature of their alleged injuries.

Antitrust LawSherman ActDonnelly ActMonopolyPrice FixingHealth InsuranceRadiologyBlue Cross Blue ShieldLegal StandingMotion to Dismiss
References
27
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