Updated Daily

Case Law Database

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

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

Case No. 15-24-00114-CV

Regular Panel Decision

Oct 04, 2024

Cecile Erwin Young, in Her Official Capacity as the Executive Commissioner of the Texas Health and Human Services Commission; Molina Healthcare of Texas, Inc.; And Aetna Better Health of Texas, Inc. v. Cook Children's Health Plan, Texas Children's Health Plan, Superior Health Plan, Inc., and Wellpoint Insurance Company

This case involves an appeal concerning a temporary injunction and the denial of a plea to the jurisdiction issued by the 353rd Judicial District of Travis County. The appellants, including Cecile Erwin Young (Executive Commissioner of HHSC), Molina Healthcare of Texas, Inc., and Aetna Better Health of Texas, Inc., are challenging the lower court's decision. The appellees (Cook Children's Health Plan, Texas Children's Health Plan, Superior Health Plan, Inc., and Wellpoint Insurance Company) had sought to enjoin the Texas Health and Human Services Commission (HHSC) from proceeding with STAR & CHIP and STAR Kids managed care procurements. The core legal arguments revolve around whether HHSC's procurement processes violated Texas law, thereby rendering the intended contract awards unlawful ultra vires acts, and whether the appellees' claims are barred by sovereign immunity or failure to exhaust administrative remedies. The appellants contend that the district court abused its discretion by granting the injunction and denying the plea.

Appellate CourtTemporary InjunctionPlea to the JurisdictionSovereign ImmunityUltra Vires ClaimsProcurement DisputeManaged Care ContractsMedicaidCHIPTexas Health and Human Services Commission

References

Case No. MISSING

Regular Panel Decision

Texas Health Care Information Council v. Seton Health Plan, Inc.

Seton Health Plan, Inc., a licensed health maintenance organization (HMO), failed to file its annual Health Plan Employer Data Information Set (HEDIS) reports for 1999 and 2000 with the Texas Health Care Information Council, leading to a dispute over civil penalties. The State, through the Attorney General, initially demanded $153,000, interpreting 'each act of violation' as each day of non-compliance, while Seton contended the maximum penalty was $10,000 per unfiled report. Seton filed a declaratory judgment action to construe the statute, and the district court sided with Seton, assessing a minimum penalty of $1,000 for each report. The State appealed, raising issues of mootness, sovereign immunity, the penalty amount, denial of injunctive relief, and attorney's fees. The appellate court affirmed the district court's interpretation of the penalty, the assessed penalties, and the denial of injunctive relief, but remanded the issue of the State's attorney's fees.

Declaratory JudgmentStatutory ConstructionCivil PenaltiesSovereign ImmunityInjunctive ReliefAttorney's FeesHEDIS ReportHealth Maintenance OrganizationTexas Health and Safety CodeAdministrative Procedure Act

References

Case No. 03-02-00114-CV

Regular Panel Decision

Dec 19, 2002

Texas Health Care Information Council and the State of Texas, Office of the Attorney General v. Seton Health Plan, Inc.

This case involves an appeal by the Texas Health Care Information Council and the State of Texas, Office of the Attorney General, against Seton Health Plan, Inc. The core dispute centered on the interpretation of civil penalties for Seton's failure to file annual Health Plan Employer Data Information Set (HEDIS) reports as required by the Texas Health and Safety Code. Seton sought a declaratory judgment asserting that the maximum penalty for such a violation was $10,000 per report, while the State initially pursued a penalty based on each day of violation. The district court sided with Seton on the maximum penalty, assessed minimum penalties of $1,000 for each of the two unfiled reports, denied the State's request for injunctive relief, and ordered the State to pay Seton's attorney's fees. On appeal, the Court of Appeals affirmed the district court's declaratory judgment, the denial of injunctive relief, and the penalty assessment. However, the appellate court reversed and remanded the issue of the State's attorney's fees, ruling that the State was statutorily entitled to reasonable attorney's fees under Government Code section 402.006(c) due to its recovery of a civil penalty.

Texas LawHealth Care RegulationHEDIS Report ViolationCivil PenaltiesDeclaratory Judgment ActionSovereign Immunity WaiverInjunctive Relief DeniedAttorney's Fees AwardStatutory ConstructionAdministrative Law

References

Case No. MISSING

Regular Panel Decision

Ames v. Group Health Inc.

Plaintiffs, including trustees John Ames and Michael Pantony of the United Welfare Fund-Welfare Division (UWF) and participant Fred Tremarcke, sued Group Health Incorporated (GHI) under ERISA and HIPAA. They alleged GHI illegally discriminated against Tremarcke by denying his health coverage after he went on disability leave, arguing it violated HIPAA's anti-discrimination provisions and breached the insurance policy. Tremarcke's employer, Classic Chevrolet, continued making health contributions on his behalf, and a 'Side Letter of Understanding' with his union attempted to maintain his 'active employee' status. The court ultimately ruled in favor of GHI, finding that Tremarcke did not meet the eligibility requirements of the UWF-GHI plan, which required working over 20 hours per week, and that the 'Side Letter' could not unilaterally alter GHI's contractual obligations. Consequently, the plaintiffs' motion for partial summary judgment was denied, and the defendant's motion for partial summary judgment was granted, dismissing the second and third causes of action.

ERISAHIPAACOBRAHealth InsuranceDisability BenefitsSummary JudgmentFiduciary DutyBreach of ContractMulti-employer FundCollective Bargaining Agreement

References

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

Case No. 2017-08-0078

Regular Panel Decision

Feb 07, 2018

Powell-Kamisso, Karen v. Health Services Management Group

Ms. Kamisso, a certified nursing assistant, sustained a compensable injury while working for Health Services Management Group (HSMG). HSMG accommodated her physical restrictions but reduced her work hours during two periods, leading to a loss of $5,040.77 in wages. Ms. Kamisso requested $3,360.51 in temporary partial disability (TPD) benefits under Tennessee Code Annotated section 50-6-207(2), arguing she earned less than her average weekly wage due to her partially disabled condition. HSMG denied TPD, claiming it provided the guaranteed two days of restricted duty work per pay period. The Court found Ms. Kamisso presented sufficient evidence, ruling that the statute only requires establishing a loss of average weekly wage while working in a light-duty capacity, regardless of employment contract terms, and thus granted her request for TPD benefits.

expedited hearingtemporary partial disabilityTPD benefitswage lossworkers' compensationlight dutyphysical restrictionsemployment contractstatutory interpretationTennessee law

References

Case No. MISSING

Regular Panel Decision

Aug 02, 2013

National Integrated Group Pension Plan v. Dunhill Food Equipment Corp.

This case, filed under ERISA, involves the National Integrated Group Pension Plan and its Board of Trustees (Plaintiffs) seeking to collect withdrawal liability from Dunhill Food Equipment, Esquire Mechanical, Geoffrey Thaw, Sanford Associates, and Custom Stainless (Defendants). The core dispute revolved around whether the non-Dunhill defendants were part of a commonly controlled group at the time of Dunhill's withdrawal from the pension plan, and whether Geoffrey Thaw could be held personally liable through veil piercing. The court ruled that Dunhill, Esquire, and Thaw were jointly and severally liable for the withdrawal liability, attorney's fees, costs, interest, and liquidated damages, finding Thaw's complete domination and misuse of corporate funds justified piercing the corporate veil. However, the claims against Sanford and Custom Stainless were dismissed, as they were determined to have effectively dissolved prior to the withdrawal date, thus not being members of the controlled group.

ERISA LitigationMPPAA LiabilityPension WithdrawalCorporate Veil PiercingSummary Judgment MotionControlled Group LiabilityCorporate DissolutionPersonal LiabilityEmployee Benefits LawFiduciary Breach

References

Case No. MISSING

Regular Panel Decision

Pig Newton, Inc. v. Boards of Directors of the Motion Picture Industry Pension Plan

Plaintiff Pig Newton, Inc. commenced an action against the Boards of Directors of the Motion Picture Industry Pension Plan, Health Plan, and Individual Account Plan, seeking a declaration that certain provisions of the Plans’ Trust Agreements were invalid and unenforceable. The Defendants counterclaimed for delinquent contributions under ERISA. The core dispute revolved around "Controlling Employee Provisions" in the Trust Agreements, which obligated employers to contribute for Controlling Employees for a specified number of hours and weeks regardless of actual hours worked. Pig Newton argued these provisions were invalid, not properly incorporated, or conflicted with collective bargaining agreements (CBAs). The Court, applying federal common law and an arbitrary and capricious standard of review for the Directors' interpretation, found the provisions valid, properly incorporated, and not in conflict with the CBAs, concluding that Szekely (Pig Newton's sole owner) qualified as a Controlling Employee. Consequently, the Court denied Plaintiff's motion for summary judgment and granted Defendants' cross-motion for summary judgment, dismissing Plaintiff's complaint and awarding Defendants the sought-after contributions, interest, auditors’ fees, and liquidated damages.

ERISAMultiemployer PlanPension PlanHealth PlanDeclaratory JudgmentSummary JudgmentTrust AgreementsCollective Bargaining AgreementsControlling Employee ProvisionsDelinquent Contributions

References

Case No. MISSING

Regular Panel Decision

Dec 27, 2001

MacRo v. Independent Health Ass'n, Inc.

Plaintiffs Cheryl Macro and Kim Zastrow, insured under a group health contract with Independent Health through the Tonawanda City School District, initiated a class action in state court to challenge Independent Health's modification of infertility treatment coverage. Defendant Independent Health removed the case to federal court, asserting ERISA preemption. Plaintiffs moved to remand, arguing that their claims fell under New York Insurance Law, which is exempt from ERISA preemption by the saving clause, and that their health plan qualified as a 'governmental plan' also exempt from ERISA. The District Court granted the plaintiffs' motion, concluding that the claims were indeed saved from ERISA preemption and that the plan was exempt, thus rendering federal subject matter jurisdiction absent. The court accordingly remanded the case back to New York State Supreme Court.

Infertility CoverageHealth Insurance DisputesERISA PreemptionSaving ClauseGovernmental PlansRemoval to Federal CourtSubject Matter JurisdictionNew York Insurance LawClass Action LitigationEmployee Benefits Plan

References

Showing 1-10 of 18,845 results

Ready to streamline your practice?

Apply these legal strategies instantly. CompFox helps you find decisions, analyze reports, and draft pleadings in minutes.

Updated Daily

Case Law Database

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

Case No. MISSING

Regular Panel Decision

Murphy v. Wal-Mart Associates' Group Health Plan

References

Case No. 15-24-00114-CV

Regular Panel Decision

Oct 04, 2024

Cecile Erwin Young, in Her Official Capacity as the Executive Commissioner of the Texas Health and Human Services Commission; Molina Healthcare of Texas, Inc.; And Aetna Better Health of Texas, Inc. v. Cook Children's Health Plan, Texas Children's Health Plan, Superior Health Plan, Inc., and Wellpoint Insurance Company

Appellate CourtTemporary InjunctionPlea to the JurisdictionSovereign ImmunityUltra Vires ClaimsProcurement DisputeManaged Care ContractsMedicaidCHIPTexas Health and Human Services Commission

References

Case No. MISSING

Regular Panel Decision

Texas Health Care Information Council v. Seton Health Plan, Inc.

References

Case No. 03-02-00114-CV

Regular Panel Decision

Dec 19, 2002

Texas Health Care Information Council and the State of Texas, Office of the Attorney General v. Seton Health Plan, Inc.

References

Case No. MISSING

Regular Panel Decision

Ames v. Group Health Inc.

ERISAHIPAACOBRAHealth InsuranceDisability BenefitsSummary JudgmentFiduciary DutyBreach of ContractMulti-employer FundCollective Bargaining Agreement

References

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

Governmental ImmunityImmunity WaiverDeclaratory JudgmentContract LawHealth BenefitsPlan AdministratorOccupational Sickness/InjuryJurisdictionPlea to JurisdictionInterlocutory Appeal

References

Case No. 2017-08-0078

Regular Panel Decision

Feb 07, 2018

Powell-Kamisso, Karen v. Health Services Management Group

expedited hearingtemporary partial disabilityTPD benefitswage lossworkers' compensationlight dutyphysical restrictionsemployment contractstatutory interpretationTennessee law

References

Case No. MISSING

Regular Panel Decision

Aug 02, 2013

National Integrated Group Pension Plan v. Dunhill Food Equipment Corp.

ERISA LitigationMPPAA LiabilityPension WithdrawalCorporate Veil PiercingSummary Judgment MotionControlled Group LiabilityCorporate DissolutionPersonal LiabilityEmployee Benefits LawFiduciary Breach

References

Case No. MISSING

Regular Panel Decision

Pig Newton, Inc. v. Boards of Directors of the Motion Picture Industry Pension Plan

ERISAMultiemployer PlanPension PlanHealth PlanDeclaratory JudgmentSummary JudgmentTrust AgreementsCollective Bargaining AgreementsControlling Employee ProvisionsDelinquent Contributions

References

Case No. MISSING

Regular Panel Decision

Dec 27, 2001

MacRo v. Independent Health Ass'n, Inc.

References

Showing 1-10 of 18,845 results

Ready to streamline your practice?

Apply these legal strategies instantly. CompFox helps you find decisions, analyze reports, and draft pleadings in minutes.