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

Case No. MISSING
Regular Panel Decision

Franzese v. United Health Care/Oxford

Plaintiffs Robert and Elizabeth Franzese, parents and legal guardians of disabled adult Robert Franzese Jr. ("Bobby"), sued United Health Care/Oxford under ERISA to recover medical benefits. Bobby, suffering from chronic lung disease, requires 24/7 in-home nursing care. Oxford denied preauthorization for private duty nursing, citing it as an exclusion, and denied home health care services. The court granted Oxford's summary judgment motion regarding private duty nursing and Xopenex preauthorization, finding private duty nursing not covered. However, the court denied Oxford's motion regarding home health care services, deeming Oxford's denial arbitrary and capricious due to lack of substantial evidence. The case is remanded to Oxford for reconsideration of home health care benefits.

Employee Retirement Income Security Act (ERISA)Medical BenefitsHealth Insurance DenialSummary JudgmentArbitrary and Capricious StandardHome Health CarePrivate Duty NursingPreauthorizationMedical NecessityChronic Lung Disease
References
37
Case No. No. 11, No. 12
Regular Panel Decision
Mar 26, 2019

Lilya Andryeyeva v. New York Health Care , Adriana Moreno v. Future Care Health Services

The New York Court of Appeals addressed a common issue in two joint appeals: whether home health care aides on 24-hour shifts must be paid for each hour. The Department of Labor (DOL) interpreted its Wage Order (12 NYCRR part 142) to allow payment for at least 13 hours if the employee receives at least 8 hours for sleep (with 5 uninterrupted) and 3 hours for meals. The Appellate Division rejected this, but the Court of Appeals reversed, deferring to DOL's interpretation as rational and consistent with the Wage Order's plain language. The cases were remitted for lower courts to evaluate class certification issues in accordance with DOL's interpretation.

Home Health Care24-Hour ShiftsMinimum Wage ActWage OrderDepartment of Labor InterpretationClass CertificationAppellate ReviewLabor Law ViolationsSleep BreaksMeal Breaks
References
49
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
43
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
44
Case No. MISSING
Regular Panel Decision

Washington Heights-West Harlem-Inwood Mental Health Council, Inc. v. District 1199, National Union of Hospital & Health Care Employees, RWDSU

This case involves a dispute between District 1199, National Union of Hospital and Health Care Employees, and Washington Heights-West Harlem-Inwood Mental Health Council, Inc. The union sought to enforce an arbitration award requiring the Council to rehire and provide back pay to an employee, Edward Lane. The Council cross-moved to vacate the award, arguing that no valid collective bargaining agreement with an arbitration clause existed between the parties. Although the parties had acted under the terms of a proposed agreement for a period, including processing some grievances and wage increases, no formal, signed contract had ever been executed. Citing recent appellate court decisions emphasizing contract formalism over implied intent, the District Court granted the Council's motion to vacate the arbitration award and denied the union's motion to enforce it, concluding that without a signed agreement, there was no contractual duty to arbitrate.

Arbitration AwardSummary JudgmentContract FormationCollective BargainingLabor DisputeContract FormalismVacation of AwardEnforcement of AwardMeeting of the MindsFederal Court
References
23
Case No. 2015-03-0237
Regular Panel Decision
May 24, 2018

Yeaman, Lisa v. Kindred Health Care

Lisa Yeaman, an employee, suffered a work-related injury in 2012 and initially settled her workers' compensation claim with Kindred Health Care, her employer. In 2015, she filed for reconsideration and a new petition, which she subsequently withdrew. After two years of inactivity, Yeaman refiled in 2017, prompting Kindred Health Care to move for dismissal due to failure to prosecute. The trial court denied the motion, finding Yeaman's claim timely filed and that the withdrawal did not constitute a voluntary dismissal. The Workers' Compensation Appeals Board affirmed the trial court's decision, concluding that there was no abuse of discretion, despite acknowledging the two-year delay was

Workers' Compensation Appeals BoardFailure to ProsecuteMotion to DismissAbuse of Discretion StandardTrial Court DenialTimeliness of ClaimVoluntary WithdrawalInterlocutory AppealPublic Policy ArgumentRemand
References
9
Case No. 2020 NY Slip Op 04473 [186 AD3d 594]
Regular Panel Decision
Aug 12, 2020

Moreno v. Future Health Care Servs., Inc.

The Appellate Division, Second Department, affirmed the denial of class certification for a putative class action brought by former home health care aides against Future Health Care Services, Inc. Plaintiffs alleged violations of Labor Law article 19, specifically concerning minimum wage payments for 24-hour shifts. The court, upon remittitur from the Court of Appeals, considered the Department of Labor's interpretation of Minimum Wage Order Number 11, which permits exclusion of up to 11 hours for sleep and meal breaks in 24-hour shifts. Consequently, the plaintiffs failed to demonstrate commonality, as they did not allege a lack of prescribed breaks or provide sufficient evidentiary basis for systemwide wage violations, thus failing to meet the requirements of CPLR article 9. Therefore, the Supreme Court's decision to deny class certification was upheld.

Class ActionLabor LawMinimum Wage24-hour ShiftsHome Health Care AidesClass CertificationWage OrderAppellate ReviewJudicial InterpretationNew York Department of Labor
References
7
Case No. 13-16-00201-CV
Regular Panel Decision
Sep 01, 2016

a New Hope Health Care, Inc. and Esperanza Pena v. Gisel Garcia

Gisel Garcia, a former employee of A New Hope Health Care, Inc. and Esperanza Pena, sued her employers for negligence after sustaining severe back injuries while moving heavy boxes. She alleged the employers were non-subscribers to worker's compensation and failed to provide a safe workplace, violating the Texas Labor Code. New Hope moved to dismiss, contending Garcia's claims constituted a health care liability claim requiring an expert report, which Garcia had not filed. The trial court denied New Hope's motion to dismiss. The appellate court affirmed this denial, finding that New Hope had failed to challenge all independent grounds supporting the trial court's judgment, specifically the argument that New Hope waived its right to seek dismissal.

NegligenceExpert ReportHealth Care Liability ClaimMotion to DismissWaiverWorker's Compensation Non-subscriberBack InjuryTexas Labor CodeAbuse of DiscretionAppellate Procedure
References
11
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
95
Case No. 08-05-00033-CV
Regular Panel Decision
Aug 03, 2006

Martha Gray, Rose Marie Salvato, and Edmund Higginbotham of the Estate of Mary Ann Higginbotham v. Woodville Health Care Center Dba Wodville Convalescent Center Dba Cantex Health Care Centers Dba Denison Healthcare Denter Ltd. Co. & Kerry Evans M.D.

This case concerns an appeal by Martha Gray, Rose Marie Salvato, and Edmund Higginbotham, Executor of the Estate of Mary Ann Higginbotham, from summary judgments granted in favor of Dr. Kerry Evans and Woodville Healthcare Center. Appellants filed a wrongful death suit alleging medical malpractice, gross negligence, and negligence per se following the death of Brayton Gray, who was a patient at Woodville nursing home under Dr. Evans' care. The central issue was whether the Appellants provided sufficient evidence of causation to support their claims. The court found that the expert testimony presented was conclusory or speculative and failed to establish the necessary causal link. Additionally, the court ruled that the Appellants lacked standing for constitutional claims and that no state action was involved for a Fourteenth Amendment violation. Consequently, the appellate court affirmed the trial court's judgment.

Medical malpracticeWrongful deathSummary judgmentCausationExpert testimonyNursing home negligenceParkinson's diseaseConstitutional rightsFourteenth AmendmentState action
References
27
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