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

Case No. No. CIV.A. G-96-441
Regular Panel Decision
Jan 12, 1998

What Happened in Felix vs. Weber Metals Reconsideration?

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. 15-24-00114-CV
Regular Panel Decision
Oct 04, 2024

How Did the WCAB Rule in Hardgrove vs. Intercon Security?

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
95
Case No. 2018 NY Slip Op 05049 [163 AD3d 577]
Regular Panel Decision
Jul 05, 2018

What Did the WCAB Decide in Cuadra vs. Community Home Care?

This case concerns an appeal by Jeanette Peterson, representing the Historic Southside Neighborhood Association, challenging a lower court's decision that upheld a negative declaration issued by the Planning Board of the City of Poughkeepsie. The negative declaration was related to Thomas LaPerch's application for site plan approval to construct multi-family housing near a historic district. The Association argued that the Planning Board's determination violated the State Environmental Quality Review Act (SEQRA) by failing to adequately assess environmental impacts. The Appellate Division reversed the judgment, finding the Planning Board's issuance of a negative declaration arbitrary and capricious due to its conclusory findings regarding historic impact and its unsubstantiated claims about vegetation removal. The court remitted the matter to the Planning Board, ordering the preparation of an Environmental Impact Statement.

Environmental ReviewSEQRAPlanning BoardNegative DeclarationEnvironmental Impact StatementHistoric PreservationJudicial ReviewArbitrary and CapriciousSite Plan ApprovalDutchess County
References
14
Case No. MISSING
Regular Panel Decision

How Were Death Benefits Handled in Bocanegra vs. Sun-Gro Commodities?

Kenneth Kirschenbaum, the Chapter 7 Trustee for The Robert Plan Corporation and The Robert Plan of New York Corporation, sought court approval for fee awards for himself and his professionals for administering an ERISA plan. The U.S. Department of Labor (DOL) objected, asserting the court lacked jurisdiction to award fees from Plan assets and had specific objections to the reasonableness of the fees. The court affirmed its core jurisdiction over the Trustee's actions as Plan administrator and his professionals' compensation, regardless of whether payments came from Plan or estate assets, citing previous rulings. The court analyzed whether Bankruptcy Code §§ 326 and 330 conflicted with ERISA statutes concerning fiduciary compensation, concluding no substantive conflict existed and the Bankruptcy Code's specific compensation scheme governed. Ultimately, the court largely overruled DOL's objections and granted the fee applications for the Trustee, K & K, Witz, and Whitfield, deeming the requested amounts reasonable and compliant with the Bankruptcy Code. The awards are payable from the Plan's Pguy Account, with any shortfall covered by the Debtors' estate.

Bankruptcy LawERISAChapter 7 TrusteeFee ApplicationPlan AdministrationJurisdictionReasonable CompensationStatutory ConstructionDepartment of LaborFiduciary Duties
References
50
Case No. 07-09-00163-CV
Regular Panel Decision
Mar 12, 2010

Can a WCJ Be Disqualified for Appearance of Bias?

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. 13-15-00312-CV
Regular Panel Decision
May 15, 2015

What Were the Key Rulings in Torrez vs. SuperShuttle?

This case involves an appeal by Brian O’Grady, M.D. and The O’Grady Family Partnership, Ltd. (Appellants) against National Union Fire Insurance Company of Pittsburgh, P.A. (Appellee). The Appellants challenged a trial court’s judgment that confirmed an arbitration award. The arbitration panel had found no insurance coverage under a professional liability policy for a FINRA arbitration award against Woodbury Financial Services, Inc.'s agents, Miller and Schulick. The Appellants argue that the arbitration panel exceeded its powers by making improper factual findings at the summary judgment stage, particularly regarding whether Woodbury approved or distributed certain investment products and whether the agents' actions were "dishonest, malicious, or knowingly wrongful," which would trigger an exclusion. They contend these findings were made without coverage-specific discovery or a full evidentiary hearing, thereby denying them due process. The appeal seeks to vacate or modify the portion of the award denying coverage for the "Asset Protection Plan" and remand for a full evidentiary hearing.

AppealArbitrationInsurance CoverageProfessional LiabilitySummary JudgmentArbitrator PowersTexas LawFINRA AwardInvestment ProductsDue Process
References
29
Case No. MISSING
Regular Panel Decision

Why Was Removal Denied in Rush vs. California Correctional Institution?

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
44
Case No. 03-13-00077-CV
Regular Panel Decision
Feb 25, 2015

What Did the WCAB Clarify in Ontiveros vs. Savers Stores?

The amicus brief, submitted by The Association of Marital and Family Therapy Regulatory Boards (AMFTRB), urges the Third Court of Appeals to grant en banc reconsideration and reverse a panel's decision that found 22 TEX. ADMIN CODE §801.42(13) invalid. The brief argues that Licensed Marriage and Family Therapists (LMFTs) are fully qualified, trained, and tested to perform diagnostic assessments within their therapeutic role. It asserts that diagnosis alone, in the context of marriage and family therapy, does not constitute the practice of medicine under the Texas Medical Practice Act, and preventing LMFTs from performing these assessments would effectively prohibit their professional practice and create a shortage of mental health professionals in Texas. The AMFTRB also highlights that the legislature did not intend for LMFTs to be supervised by physicians and that the structure of the Occupations Code supports marriage and family therapy as a stand-alone profession. Additionally, the brief questions the qualification of the Texas Medical Association's expert witness due to prior ethical lapses.

Marriage and Family TherapyDiagnostic AssessmentMedical Practice ActOccupations CodeRegulatory BoardsLicensureScope of PracticeMental Health ServicesTexasAccreditation
References
9
Case No. MISSING
Regular Panel Decision

Why Was Reconsideration Denied in Gomez vs. Dorothy Stevens?

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
Case No. MISSING
Regular Panel Decision

Why Was Reconsideration Dismissed in Sabino vs. Johnson Pump Company?

Plaintiff Thomas J. Pronti sued CNA Financial Corporation and CNA Retirement Plan (collectively, "Defendants") alleging misrepresentations regarding his pension benefits. Pronti claimed his benefits were wrongfully calculated because his prior service with Continental Insurance Company was not credited under the CNA Plan, despite alleged representations to the contrary. Pronti brought claims for benefits, breach of fiduciary duty, breach of contract, and estoppel. The Court granted Defendants' motion to dismiss the breach of fiduciary duty claim, finding it duplicated the claim for benefits under ERISA, and the breach of contract claim, finding it preempted by ERISA. However, the Court denied Defendants' motion to dismiss the promissory estoppel claim, concluding that Pronti had sufficiently alleged a promise, reliance, injury, injustice, and "extraordinary circumstances" under ERISA's federal common law.

ERISAPension BenefitsFiduciary DutyBreach of ContractPromissory EstoppelMotion to DismissPreemptionEmployee BenefitsRetirement PlanBenefit Accrual
References
29
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