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

Case No. 07-09-00163-CV
Regular Panel Decision
Mar 12, 2010

Potter County, Texas as Plan Administrator for the Health Benefits Plan for the Employees of Potter County, Texas v. Ronda Tuckness and Michael Tuckness

Potter County, acting as the plan administrator for its employee health benefits plan, appealed an order that denied its plea to the jurisdiction. The underlying lawsuit was filed by Ronda and Michael Tuckness, seeking health care benefits after the County denied Michael Tuckness's claim for back surgery costs due to an occupational injury exclusion. The County contended it was immune from suit. The appellate court found that the County's governmental immunity had not been waived by the requests for declaratory relief, the terms of the health plan contract, or the County's conduct. Consequently, the court reversed the trial court's order and dismissed the Tucknesses' case for lack of subject-matter jurisdiction.

Governmental ImmunityImmunity WaiverDeclaratory JudgmentContract LawHealth BenefitsPlan AdministratorOccupational Sickness/InjuryJurisdictionPlea to JurisdictionInterlocutory Appeal
References
20
Case No. MISSING
Regular Panel Decision

Hand v. Stevens Transport, Inc. Employee Benefit Plan

Jean and Howard Hand appealed the trial court's grant of summary judgment which dismissed their claims for health care benefits against the Stevens Transport, Inc. Employee Benefit Plan as time-barred. The Hands argued that the Plan's failure to comply with ERISA's notification requirements should invalidate or toll the contractual limitations period. The appellate court found that while the Plan's notice was non-compliant, it still provided reasonable notice of partial denial, and the Hands failed to exercise due diligence. The court concluded that the twenty-seven month contractual limitations period was reasonable and was not tolled by the Plan's ERISA non-compliance or the pursuit of administrative remedies. Therefore, the Hands' claims were barred, and the trial court's judgment was affirmed.

ERISAHealth Insurance BenefitsContractual Limitations PeriodStatute of LimitationsSummary JudgmentDenial of BenefitsEquitable TollingAdministrative RemediesNotice RequirementsEmployee Benefit Plan
References
19
Case No. Civ. A. No. 3:93-CV-0171-G.
Regular Panel Decision
Aug 31, 1993

Mills v. INJURY BENEFITS PLAN OF SCHEPPS-FOREMOST

Walter Mills was injured during his employment and sought benefits under his employer's Injury Benefits Plan. He subsequently filed a civil action alleging wrongful termination in retaliation for filing a workers' compensation claim under Texas law. Defendants removed the case to federal court, asserting ERISA preemption. The court granted the defendants' motion to dismiss Mills' claims against the Injury Benefits Plan, finding them preempted by ERISA. However, the court denied the dismissal of Mills' state law claims against Schepps-Foremost, Inc., d/b/a Oak Farms Dairies. Ultimately, the court remanded the remaining state law claims against Schepps-Foremost, Inc. to the County Court at Law Number 5 of Dallas County, Texas, due to a lack of federal subject matter jurisdiction.

ERISA preemptionWorkers' CompensationRetaliatory dischargeTexas lawFederal jurisdictionMotion to dismissRemandEmployee benefitsCivil procedureDallas County
References
18
Case No. MISSING
Regular Panel Decision

Jeffries v. Pension Trust Fund of the Pension, Hospitalization & Benefit Plan of the Electrical Industry

Plaintiff Claude Jeffries, a retired electrician, sued the Pension Trust Fund of the Electrical Industry under ERISA, seeking to include pension credits from 1969-1975 in his current benefits. He alleged the Plan should have declared a partial termination during a 1975-1979 New York recession, which would have vested his benefits. The defendant moved to dismiss the complaint, arguing lack of standing and statute of limitations, while plaintiff moved for class certification for similarly affected members. The court denied the defendant's motion to dismiss the claim for benefits, finding it timely, but granted dismissal for the breach of fiduciary duty claim as time-barred. The plaintiff's motion for class certification was denied due to insufficient evidence for numerosity, with leave to refile after discovery.

ERISAPension BenefitsClass CertificationMotion to DismissStatute of LimitationsFiduciary DutyPartial TerminationBenefit ForfeitureUnemploymentLabor Union
References
15
Case No. No. CIV.A. G-96-441
Regular Panel Decision
Jan 12, 1998

Alcorn v. STERLING CHEM. INC. MED. BENEFITS PLAN

Plaintiffs, including Otis Alcorn (as next friend for Juanita Revels), Meditrust Financial Services, and New Medico Associates, sued Sterling Chemicals Incorporation Medical Benefits Plan for denied medical treatment claims under ERISA. Juanita Revels, after a severe head injury in 1986, received rehabilitation, but the Plan denied coverage for later treatments from 1990, deeming them not "medically necessary." Both parties moved for summary judgment. The court, applying an abuse-of-discretion standard, found that the Plan administrator acted reasonably and did not abuse its discretion in determining that the treatments were not medically necessary. This decision was based on multiple claim reviews and the opinions of several physicians. Consequently, the Court granted the Defendant's motion for summary judgment and dismissed all of the Plaintiffs' claims with prejudice.

ERISAEmployee BenefitsMedical NecessitySummary JudgmentAbuse of DiscretionPlan AdministratorFifth CircuitFactual DeterminationHealth InsuranceBenefit Denial
References
28
Case No. MISSING
Regular Panel Decision

Laflamme v. Carpenters Local 370 Pension Plan

Plaintiff Michael LaFlamme initiated a class action against the Carpenters Local #370 Pension Plan and its Board of Trustees, alleging violations of the Employee Retirement Income Security Act (ERISA) concerning the plan's 'freezing rule' for benefit accrual after a 'break in service.' LaFlamme sought a judicial declaration that this rule contravenes ERISA's minimum accrual standards, along with a reformation of the pension plan and recalculation of benefits for all affected class members. The court, presided over by District Judge Hurd, evaluated the motion for class certification under Federal Rule of Civil Procedure 23(a) and (b), finding that the requirements of numerosity, commonality, typicality, and adequacy of representation were met. Consequently, the motion for class certification was granted, establishing a class comprised of all plan participants, active or retired, who experienced a service break resulting in frozen benefit accrual rates. The decision also outlined procedures for providing notice to the newly certified class members, while deferring detailed adjudication of defenses like statute of limitations and exhaustion of remedies to later dispositive motions.

ERISAPension BenefitsClass ActionBenefit AccrualFreezing RuleBreaks in ServiceClass CertificationRule 23(a)Rule 23(b)Federal Civil Procedure
References
49
Case No. 81 Civ. 3958 (KTD)
Regular Panel Decision
Sep 16, 1982

In Re Pension Plan for Emp. of Broadway Maint.

This case involves a dispute between the Pension Benefit Guaranty Corporation (PBGC) and the bankrupt Broadway Maintenance Corporation over the termination date of Broadway's employee pension plan. The PBGC initiated the lawsuit to be appointed statutory trustee, declare the plan terminated, and sought a termination date of March 26, 1981, while Broadway argued for a retroactive date prior to December 31, 1979. Judge Kevin Thomas Duffy acknowledged the appointment of the PBGC as trustee and the plan's termination, with the sole issue being the precise termination date. After considering the interests of the participants, the PBGC, and Broadway, and applying legal precedent, the court ultimately set December 5, 1980, as the earliest valid termination date. This date was chosen because it marked when the PBGC filed its original Proofs of Claim, signaling its clear intent to terminate the plan.

ERISAPension Plan TerminationEmployee BenefitsBankruptcyPBGCStatutory TrusteeRetroactive Termination DateJudicial TerminationParticipant InterestsFinancial Distress
References
3
Case No. MISSING
Regular Panel Decision

B & S Welding LLC Work Related Injury Plan v. Juan Pedro Oliva-Barron and Avelina Oliva

The B & S Welding LLC Work Related Injury Plan appealed a trial court's judgment in favor of Juan Pedro Oliva-Barron, who was denied benefits after a work injury. The Plan had accused Oliva of fraud, while Oliva counterclaimed for ERISA benefits. The appellate court affirmed the trial court's finding that Oliva was excused from exhausting administrative remedies due to the Plan's conduct, and that the Plan's termination of benefits was arbitrary and lacked substantial evidence. However, the court reversed the award of medical expenses due to insufficient evidence but upheld the award of indemnity benefits and attorney's fees.

ERISAEmployee BenefitsPlan AdministrationAbuse of DiscretionSubstantial EvidenceFutility DoctrineAdministrative ExhaustionFraud ClaimsSurveillance EvidenceMedical Denials
References
26
Case No. MISSING
Regular Panel Decision

Schaffer v. Benefit Plan of Exxon Corp.

Plaintiffs Phillip W. Schaffer and David W. Stiefel, former employees of Exxon, filed a lawsuit under the Employee Retirement Income Security Act of 1974 (ERISA) after being denied disability benefits by the Benefit Plan of Exxon Corporation. Both plaintiffs sustained on-the-job elbow injuries. Defendant Exxon moved for summary judgment, asserting that the Plan Administrator's denial of benefits was justified by substantial evidence, indicating that the plaintiffs were either not incapacitated or did not adhere to prescribed treatment plans. The Court applied an abuse of discretion standard of review and determined that the Plan Administrator's decisions were indeed supported by adequate evidence. Therefore, the Court granted the Defendant's motion for summary judgment, denied the Plaintiffs' motions for summary judgment, and dismissed their claims with prejudice.

ERISADisability BenefitsSummary JudgmentAbuse of Discretion StandardEmployee Benefit PlanPlan AdministratorMedical EvaluationWork-Hardening ProgramDenial of BenefitsJudicial Review
References
23
Case No. MISSING
Regular Panel Decision

Murphy v. Wal-Mart Associates' Group Health Plan

Hazel and Charlie Murphy sued Wal-Mart Associates’ Group Health Plan and Prudential Health Care Plan after the Plan denied coverage for Mr. Murphy's high-dose chemotherapy and autologous bone marrow transplant for Non-Hodgkin’s Lymphoma. The Murphys alleged the Wal-Mart Plan acted arbitrarily and capriciously in denying benefits and their subsequent appeal, and brought state law claims against Prudential. The court found that Wal-Mart Plan's decision was based on medical expert opinions and was not arbitrary and capricious. Furthermore, it determined that ERISA preempted all state law claims against Prudential. Consequently, the court granted summary judgment for both defendants, dismissing the plaintiffs' claims.

ERISAEmployee BenefitsHealth InsuranceSummary JudgmentArbitrary and Capricious StandardMedical NecessityHigh-Dose ChemotherapyAutologous Bone Marrow TransplantNon-Hodgkin’s LymphomaPlan Administrator Discretion
References
28
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