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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. MISSING
Regular Panel Decision

Memorial Hermann Health System v. Coastal Drilling Co., LLC Employee Benefit Trust

Plaintiff Memorial Hermann Health System (MHHS) sued Coastal Drilling for breach of contract and recovery of benefits under the Employee Retirement Income Security Act (ERISA). MHHS claimed Coastal Drilling breached a contract to pay for healthcare services at PPOplus Contracted Rates. The Court determined that MHHS's breach of contract claim was not preempted by ERISA but could not be enforced because MHHS was a non-party to the Network Access Agreement and Coastal Drilling, also a non-party, had no direct obligation under it. Regarding the ERISA claim, the Court found that Coastal Drilling, as the plan administrator, had discretionary authority to determine benefits based on the Plan's Applicable Plan Limits (APL). The Court found substantial evidence supporting Coastal Drilling's benefits determination and no evidence of bias affecting the decision, despite a structural conflict of interest. Consequently, the Court granted Coastal Drilling's motion for summary judgment and dismissed MHHS's claims with prejudice.

ERISASummary JudgmentBreach of ContractPlan AdministratorBenefits DenialHealthcare ProviderThird-Party BeneficiaryERISA PreemptionTexas LawFiduciary Duty
References
48
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. 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

Slavik v. Dr. Pepper Bottling Co. of Texas Employee Welfare Benefit Plan

Kurtis Slavik, an eight-year-old, suffered severe injuries, incurring over $150,000 in medical bills, which his father, Robert Slavik, sought coverage for under the Dr. Pepper Employee Medical and Dental Benefits Plan. The Plan administrator, Dr. Pepper Bottling Company of Texas, refused payment until the Slaviks signed a subrogation agreement, aiming to recover the full $100,000 cap from Kurtis's state court tort claim. The federal court determined that Dr. Pepper had abused its discretion, concluding that the Plan did not clearly mandate a subrogation agreement as a precondition for benefits and that Dr. Pepper's interpretation of its subrogation rights was incorrect. Consequently, the Court ordered immediate payment of Kurtis's medical expenses and subordinated the Plan's subrogation rights to the 'make-whole' doctrine, requiring Kurtis to be fully compensated before the Plan could recover. Additionally, the Court awarded attorney fees to the plaintiffs while denying their other claims for monetary damages and the dismissal of the administrator, also ruling that claims for emotional distress and credit reputation were preempted by ERISA.

ERISASummary JudgmentEmployee Benefits PlanSubrogationAbuse of DiscretionMake Whole DoctrinePlan Administrator Fiduciary DutyConflict of InterestMedical Benefits DenialTort Claim Recovery
References
29
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

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

Hamilton v. General Motors Hourly-Rate Employee's Pension Plan

Plaintiff Gary Hamilton, proceeding pro se, initiated this action on June 26, 2014, under the Employee Retirement Income Security Act of 1974 (ERISA), alleging improper denial of pension benefits, breach of fiduciary duty, and equitable estoppel. He sought additional credited service for his tenure at non-foundry plants, contending that a Memorandum of Understanding (MOU) should modify his pension calculation as if his entire service had been at a designated foundry location. The defendants, General Motors Corporation Hourly-Rate Employee’s Pension Plan and General Motors, LLC, argued that the Plan's terms unambiguously require actual employment in designated foundry classifications for enhanced benefits and that the MOU's purpose was solely to facilitate employee transfers, not to alter pension benefits. The Court, applying an arbitrary and capricious standard of review, found the defendants' interpretation of both the Plan and the MOU to be reasonable. Consequently, the Court granted the defendants' motion for summary judgment and denied the plaintiff's claims in their entirety.

ERISAPension BenefitsFiduciary DutyEquitable EstoppelSummary JudgmentPlan AdministratorCredited ServiceFoundry JobsMemorandum of UnderstandingArbitrary and Capricious Standard
References
30
Case No. MISSING
Regular Panel Decision

Independent Ass'n of Publishers' Employees, Inc. v. Dow Jones & Co.

Plaintiffs, the Independent Association of Publishers’ Employees, Inc. (IAPE) and ten Canadian employees, sued defendant Dow Jones & Company, Inc., alleging a breach of fiduciary duty under ERISA. The plaintiffs claimed that Dow Jones violated its fiduciary obligations by changing the Profit-Sharing Retirement Plan's benefit allocation formula, which resulted in reduced benefits for Canadian employees due to currency conversion. Dow Jones argued it was not a fiduciary for this specific act or that the action was not a breach, asserting the right to amend plan contributions. The court, treating the motion as one for summary judgment, found that Dow Jones's fiduciary duties under ERISA did not extend to the method of calculating employer contributions or modifying non-accrued benefits. The court concluded that both the Plan provisions and ERISA allowed prospective changes in contributions by the employer, and therefore, Dow Jones had not breached any fiduciary duty. Defendants' motion for summary judgment was granted.

ERISAFiduciary DutyProfit-Sharing PlanBenefit AllocationSummary JudgmentNon-Accrued BenefitsPlan AmendmentEmployer ContributionsCanadian EmployeesDistrict Court
References
5
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