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

Case No. 03-12-00293-CV
Regular Panel Decision
Jul 12, 2013

Southwest Pharmacy Solutions, Inc. D/B/A American Pharmacies v. Texas Health and Human Services Commission and Thomas Suehs, Solely in His Official Capacity as Executive Commissioner of the Texas Health and Human Services Commission

Southwest Pharmacy Solutions, Inc. d/b/a American Pharmacies appealed a trial court's judgment granting a plea to the jurisdiction filed by the Texas Health and Human Services Commission (HHSC) and its Executive Commissioner. American Pharmacies challenged HHSC's rulemaking obligations and specific rules related to pharmacy benefits under the Texas Medicaid managed care (MMC) program. They argued that HHSC failed to regulate reimbursement rates for pharmacies and did not comply with statutory requirements for analyzing the economic impact on small businesses. The appellate court affirmed the trial court's judgment, concluding that HHSC was not obligated to set reimbursement rates under the MMC model and had substantially complied with the relevant government code regarding small business impact. The court also determined that American Pharmacies lacked a justiciable interest as their economic losses stemmed from legislative changes rather than the challenged rules.

Medicaid Managed CarePharmacy BenefitsReimbursement RatesAdministrative Procedure ActDeclaratory JudgmentPlea to the JurisdictionUltra ViresStatutory ConstructionSmall Business ImpactTexas Court of Appeals
References
37
Case No. MISSING
Regular Panel Decision
Apr 27, 2012

China Auto Care, LLC v. China Auto Care (Caymans)

Plaintiffs China Auto Care, LLC and China Auto Care Holdings, LLC brought an action against China Auto Care (Caymans), Digisec Corporation, and the estate of Chander Oberoi, alleging various causes of action stemming from the 2011 sale of Digisec's assets. Defendants sought to dismiss the complaint and compel arbitration, citing an arbitration clause in the parties' "Business Relationship and Shareholder Agreement." The court analyzed the scope of the arbitration clause under the Federal Arbitration Act. Finding the clause to be broad, the court concluded that the plaintiffs' claims were within its scope, as they "touch matters" governed by the Shareholder Agreement. Consequently, the court granted the defendants' motion, staying the litigation and compelling arbitration.

ArbitrationShareholder AgreementCorporate DisputeMotion to CompelFederal Arbitration ActSecond Circuit PrecedentFraudulent InducementCorporate GovernanceCayman Islands LawStay of Proceedings
References
25
Case No. MISSING
Regular Panel Decision
Mar 03, 2008

Texas Mutual Insurance Co. v. Sara Care Child Care Center, Inc.

Texas Mutual Insurance Company appealed two summary judgment orders and a final judgment in favor of its insured, Sara Care Child Care Center, Inc., and employee Martha Martinez. The core issue was whether Sara Care's workers' compensation policy was extended due to Texas Mutual's alleged failure to comply with statutory cancellation notice requirements, thus covering Ms. Martinez's injury. The Workers' Compensation Commission Appeals Panel and the trial court affirmed coverage. The appellate court affirmed the trial court's judgment regarding judicial review of the Appeals Panel decision, Sara Care's common law claims (breach of contract, promissory estoppel), and the attorney's fee award. However, the court reversed and remanded the trial court's judgment on Sara Care's statutory claims (Texas Insurance Code and Texas Deceptive Trade Practices Act) and the 'knowingly' finding, stating a fact issue remained on whether coverage liability was 'reasonably clear' for these claims.

Workers' Compensation InsurancePolicy NonrenewalStatutory Notice RequirementsSummary Judgment ReviewAppellate Court DecisionBreach of ContractTexas Insurance Code ViolationsDTPA ViolationsAttorney's FeesJudicial Review
References
30
Case No. 08-08-00192-CV
Regular Panel Decision
Sep 15, 2010

Texas Mutual Insurance Company v. Sara Care Child Care Inc. and Martha Martinez

This case involves an appeal by Texas Mutual Insurance Company (TMI) against Sara Care Child Care Center, Inc. and Martha Martinez, challenging summary judgment orders and a final judgment. The core dispute revolves around workers' compensation insurance coverage for an employee's work-related injury, which TMI denied based on policy expiration. The appeals panel and trial court found TMI liable due to its failure to comply with Texas Labor Code Section 406.008 notice requirements for policy cancellation or nonrenewal, extending Sara Care's coverage. The appellate court affirmed the trial court's decision regarding TMI's judicial review petition and its liability for common law claims and attorney's fees. However, the court reversed and remanded the judgment concerning Sara Care's statutory claims under the Texas Insurance Code and the Deceptive Trade Practices Act, as a fact issue remained regarding whether TMI's coverage liability was "reasonably clear," impacting the "knowingly" finding for additional damages.

Workers' Compensation InsurancePolicy NonrenewalSummary Judgment AppealTexas Labor CodeTexas Insurance CodeDeceptive Trade Practices Act (DTPA)Breach of ContractPromissory EstoppelAttorney's FeesJudicial Review
References
30
Case No. 04-06-00417-CV
Regular Panel Decision
Jun 25, 2008

Sylvia Casas, Ind. Substantively Consolidated Bankruptcy Estates of Fountain View, Inc. as Successor to Summit Care Corporation, Summit Care Texas, L.P. D/B/A Comanche Trail Nursing Center and Summit Care Management Texas and Robert Gundling, Ind. v. Rosamarie Paradez, as the Administrator and Heir at Law of the Estate of Tranquilino Mendoza

This case involves a medical malpractice survival action initiated by Rosamarie Paradez, daughter of the deceased Tranquilino Mendoza, against Sylvia Casas, Robert Gundling, and the consolidated bankruptcy estates of Fountain View, Inc. (successor to Summit Care Corp. and Summit Care Texas, L.P., operators of Comanche Trail Nursing Center). Mendoza, an 81-year-old nursing home resident, suffered severe injuries after being beaten by a violent roommate, allegedly due to the appellants' negligence. The appellants challenged various aspects of the trial court's judgment, including the denial of new trial motions, sufficiency of damages, excessive awards, and the application of damages caps. The appellate court affirmed the trial court's judgment, upholding the damages awarded for pain, mental anguish, and physical impairment, and finding no error in the application of the damages cap or the finding of negligence against Gundling.

Medical MalpracticeNursing Home NegligencePersonal InjurySurvival ActionAppellate ReviewJury ArgumentDamages CapFactual SufficiencyMental AnguishPhysical Impairment
References
35
Case No. 03-15-00219-CV
Regular Panel Decision

Hallmark Specialty Underwriters, Inc. and Hallmark Specialty Insurance Company v. Texas Mutual Insurance Company

This case arises from a declaratory judgment action filed by Appellee Texas Mutual Insurance Company, seeking a determination regarding its duty to defend Absolute Oil Field Services, LLC. The trial court granted summary judgment in favor of Texas Mutual and denied Appellants Hallmark Specialty Underwriters, Inc. and Hallmark Specialty Insurance Company's cross-motion for summary judgment. Appellants contend that the trial court erred in its decision, arguing that the underlying petition contained sufficient factual allegations to trigger Appellee's duty of defense under the 'eight corners' rule, as the injured party, Jose Guzman, was an employee of Absolute and was potentially injured in the course of his employment. They argue that Texas law requires liberal interpretation of pleadings, resolving doubts in favor of coverage, and that Appellee's arguments misinterpret established legal principles regarding the duty to defend.

Insurance CoverageDuty to DefendWorkers' CompensationEight Corners RuleSummary JudgmentAppellate ReviewTexas LawEmployee InjuryCourse and Scope of EmploymentDeclaratory Judgment Action
References
38
Case No. MISSING
Regular Panel Decision

Moeckel v. Caremark RX Inc.

Plaintiff Robert E. Moeckel, a participant in the John Morrell Employee Benefits Plan, filed a putative class action against Caremark Rx Inc. and Caremark Inc., alleging breaches of fiduciary duty under ERISA. Moeckel claimed that Caremark, as the plan's pharmacy benefits manager, engaged in secret self-dealing by creating hidden pricing spreads, manipulating drug formularies, and retaining undisclosed compensation, leading to increased costs for participants. Defendants moved to dismiss or transfer the complaint. The court granted dismissal of Caremark Rx Inc. due to its lack of a direct contractual relationship with the plan but denied the motion to dismiss Caremark Inc. on grounds of standing, statutory authority, and failure to exhaust administrative remedies. The court also denied the motion to transfer venue to Alabama.

ERISA Fiduciary DutyPharmacy Benefits Manager (PBM)Self-Dealing AllegationsMotion to Dismiss Granted in PartStanding in ERISA ActionsExhaustion of Administrative RemediesEmployee Benefit Plan LitigationClass Action SuitCorporate Subsidiary LiabilityDrug Formulary Manipulation
References
54
Case No. 14-07-00925-CV
Regular Panel Decision
Feb 24, 2009

Latoya Basey v. Davita Inc., D/B/A Total Renal Care, Nelda Boatwright and Fresenius Medical Care Holding Inc., D/B/A Fresenius Medical Care North America D/B/A Northwest Houston Dialysis, and Biomedical Applications of Texas, Inc.

Latoya Basey appealed a take-nothing summary judgment in a disability discrimination and tort case against her former employer, DaVita, Inc., and potential employer, Fresenius Medical Care Holding, Inc. Basey claimed DaVita fired her after a work-related back injury and that Fresenius refused to hire her due to her injury and prior discrimination charge. The trial court granted summary judgment without specifying grounds. The appellate court affirmed, finding Basey failed to provide evidence of disability for her discrimination and failure-to-accommodate claims, and lacked evidence of causation for her retaliation claims.

Disability DiscriminationRetaliationSummary JudgmentWorkers' CompensationEmployment LawCausal LinkTexas Court of AppealsADAFailure to AccommodateEmployment Termination
References
11
Case No. 2019 NY Slip Op 05756 [175 AD3d 134]
Regular Panel Decision
Jul 23, 2019

Matter of People Care Inc. v. City of New York Human Resources Admin.

The New York Appellate Division, First Department, affirmed the Supreme Court's decision, which annulled the Human Resources Administration's (HRA) demand to recoup approximately $7 million in Health Care Reform Act (HCRA) funds from People Care Incorporated. The core issue was whether HRA possessed the authority to audit and recover these HCRA funds, established as a distinct Medicaid reimbursement program for worker recruitment and retention, from personal care service providers. The Court found that neither Public Health Law § 2807-v (1) (bb) nor the Memorandum of Understanding between the Department of Health (DOH) and HRA delegated such auditing and recoupment powers to HRA. It rejected HRA's arguments that HCRA funds were merely a subset of general Medicaid funds subject to its existing contractual audit authority, or that DOH's actions constituted ratification of HRA's authority. Consequently, the Court upheld the injunction preventing HRA from recouping the disputed HCRA funds from People Care.

Administrative LawMedicaid ReimbursementAuditing AuthorityStatutory ConstructionInter-agency AgreementsHealthcare Reform ActPersonal Care ServicesGovernment ContractsCPLR Article 78Delegation of Power
References
8
Case No. 2024 NY Slip Op 03519
Regular Panel Decision
Jun 27, 2024

Matter of Reyes Bonilla v. XL Specialty Ins.

Claimants Jose Reyes Bonilla and Marvin Reyes Bonilla, carpenters, were involved in a motor vehicle accident while commuting to a job site in Greenpoint, Brooklyn, in an employer-provided van. They filed workers' compensation claims, which were established against XL Specialty Insurance by a Workers' Compensation Law Judge (WCLJ). XL Specialty appealed, arguing its policy did not cover commuting injuries and that it was not the proper carrier. The Workers' Compensation Board affirmed the WCLJ's decisions, finding XL Specialty failed to preserve its challenge to being the carrier and that the employer's responsibility for transportation made the injuries compensable. The Appellate Division, Third Department, affirmed, agreeing that the issue was unpreserved and that the injuries arose out of and in the course of employment due to the employer's control over the conveyance.

Workers' CompensationMotor Vehicle AccidentEmployment InjuriesCommuting AccidentEmployer Provided TransportationWrap-up PolicyInsurance Coverage DisputeCarrier LiabilityIssue PreservationAppellate Review
References
16
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