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

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. 03-07-00429-CV
Regular Panel Decision
Dec 12, 2008

Texas Health Insurance Risk Pool v. Southwest Service Life Insurance Company and Regal Life of America Insurance Company

Southwest Service Life Insurance Company and Regal Life of America Insurance Company (Appellees) brought a declaratory-judgment action against the Texas Health Insurance Risk Pool (Appellant) to challenge assessments levied against them, arguing their policies qualified as 'other limited benefit coverage' under the Texas Insurance Code. The trial court granted summary judgment in favor of the Appellees and awarded attorney's fees. The Pool appealed, contending the summary judgment was erroneous and the attorney's fee award should be reversed. The appellate court affirmed the trial court's judgment, holding that the policies issued by Southwest and Regal were indeed covered by the 'limited benefit coverage' exception, and thus the summary judgment and attorney's fee award were proper.

Insurance LawHealth InsuranceStatutory ConstructionDeclaratory JudgmentSummary JudgmentAttorney's FeesTexas Insurance CodeLimited Benefit CoverageHIPAAAdministrative Law
References
15
Case No. MISSING
Regular Panel Decision
Dec 11, 2008

Texas Health Insurance Risk Pool v. Southwest Service Life Insurance Co.

Southwest Service Life Insurance Company and Regal Life of America Insurance Company initiated a declaratory-judgment action against the Texas Health Insurance Risk Pool, challenging their liability for certain assessments. The central legal question involved the interpretation of "other limited benefit coverage" under Texas Insurance Code Ann. § 1506.002(b)(7) to determine if the plaintiffs' policies were exempt from these assessments. The trial court granted summary judgment for the insurance companies and awarded attorney's fees. On appeal, the court affirmed, concluding that the policies did fall under the statutory exception, rejecting the Pool's arguments for a narrower interpretation and finding the attorney's fee award appropriate.

Declaratory JudgmentStatutory ConstructionInsurance LawHealth InsuranceRisk PoolLimited Benefit CoverageSummary JudgmentAttorney's FeesAppellate ReviewHIPAA
References
36
Case No. 15-25-00092-CV
Regular Panel Decision
May 06, 2025

Bright Health Management, Inc. v. Texas Department of Insurance and Cantilo & Bennett, L.L.P., Special Deputy Receiver of Bright Healthcare Insurance Company of Texas

This case involves an appeal by Bright Health Management, Inc. (BHM) against Bright Health Insurance Company of Texas (BHICOT), which is currently in receivership. The appeal challenges an order from the 455th Judicial District Court in Travis County, Texas. The Special Deputy Receiver (SDR) for BHICOT moved to compel BHM, a non-party to the liquidation, to produce all BHICOT-related records, specifically electronically stored information (ESI) from BHM's integrated email system. BHM requested the implementation of ESI protocols to protect its privacy, privileged, and confidential information related to its other clients, and sought reimbursement for the costs of production, citing its Management Services Agreement (MSA) with BHICOT and Texas law governing non-party discovery. The District Court, adopting the Special Master's recommendation, denied BHM's request for ESI protocols and ordered BHM to bear all production costs, asserting that BHM created the commingled system for its own economic benefit. BHM argues that this ruling disregards established Texas ESI jurisprudence and its contractual and statutory rights to cost reimbursement, and seeks reversal of the District Court's order.

Insurance ReceivershipElectronic DiscoveryESI ProtocolsNon-Party DiscoveryCost ReimbursementAffiliate TransactionsManagement Services AgreementTexas Insurance LawConfidentialityPrivilege Protection
References
20
Case No. M2007-02787-COA-R3-CV
Regular Panel Decision
Mar 19, 2009

Liberty Mutual Insurance Company v. Friendship Home Health Agency, LLC

This case involves an appeal from the Chancery Court for Davidson County concerning a dispute over workers' compensation insurance premiums. Liberty Mutual Insurance Company sued Friendship Home Health Agency, LLC for unpaid balances after audits revealed underreported payroll. Friendship Home Health Agency, LLC appealed the trial court's judgment, citing the denial of a continuance, the rejection of an accord and satisfaction defense, and a waived statute of frauds argument. The Court of Appeals of Tennessee affirmed the trial court's decision, finding no abuse of discretion in denying the continuance and no evidence to preponderate against the finding of no accord and satisfaction. The court also deemed the statute of frauds defense waived due to improper raising.

Workers' Compensation InsuranceInsurance PremiumsAudit DisputeContinuance MotionAccord and SatisfactionStatute of FraudsAbuse of DiscretionAppellate ReviewContract LawPayroll Underestimation
References
37
Case No. 03-07-00682-CV
Regular Panel Decision
Nov 13, 2008

Texas Mutual Insurance Company, Liberty Mutual Insurance Company, Zenith Insurance Company and Zurich American Insurance Company v. Vista Community Medical Center, LLP, D/B/A Vista Medical Center Hospital Christus Health Gulf Coast And the Texas Department of Insurance, Division of Workers' Compensation

This appeal concerns a challenge to the validity and interpretation of Rule 134.401, promulgated by the Texas Department of Insurance, Division of Workers’ Compensation, which governs hospital fee reimbursement for inpatient services to injured workers. The trial court had ruled that the 'Stop-Loss Exception' applied solely if audited charges exceeded $40,000 and deemed the 2005 Staff Report an invalid rule. The appellate court reversed, holding that eligibility for stop-loss reimbursement requires proof of both audited charges exceeding $40,000 and unusually costly and extensive services. The court also reversed the declaration that the 2005 Staff Report was an invalid rule, affirming the trial court's stance on auditing implantable charges.

Workers' Compensation LawAdministrative Rule ChallengeHospital Fee ReimbursementStop-Loss ExceptionRule InterpretationMedical Cost ControlDeclaratory Judgment ActionAppellate ReviewTexas Labor CodeTexas Government Code
References
39
Case No. 03-19-00185-CV
Regular Panel Decision
Mar 05, 2020

Texas Department of Insurance v. Texas Association of Health Plans

The Texas Department of Insurance appealed the denial of its plea to the jurisdiction against the Texas Association of Health Plans. The Association filed claims challenging Department rules under the Administrative Procedure Act (APA) and the constitutionality of Texas Insurance Code provisions under the Uniform Declaratory Judgments Act (UDJA). The Department argued sovereign immunity barred both claims. The appellate court affirmed the trial court's decision, ruling that the APA's waiver of immunity extends to associational plaintiffs and that the UDJA claim constituted a viable constitutional challenge not precluded by the redundant remedies doctrine.

Sovereign immunityAdministrative Procedure ActDeclaratory Judgments ActAssociational standingConstitutional challengePlea to the jurisdictionTexas Insurance CodeHealth plans regulationAppellate reviewStatutory interpretation
References
39
Case No. W2008-01771-COA-R3-CV
Regular Panel Decision
Jan 26, 2011

Shelby County Health Care Corporation, d/b/a Regional Medical Center v. John Baumgartner, Elizabeth Baumgartner, a/k/a Daray Baumgartner, Nationwide Mutual Insurance Company, and Hartford Accident and Indemnity

This appeal concerns the impairment of a hospital lien by Shelby County Health Care Corporation (The MED) against John Baumgartner and his insurance providers, Nationwide Mutual Insurance Company and Hartford Accident and Indemnity. Mr. Baumgartner received extensive medical treatment at The MED following an automobile accident, incurring over $500,000 in expenses, for which The MED filed a hospital lien. Subsequently, Nationwide and Hartford settled with the Baumgartners, paying out policy limits of $25,000 and $100,000 respectively, without remitting any funds to The MED. The trial court initially granted partial summary judgment, finding impairment of the lien and awarding damages. On appeal, the Court of Appeals affirmed the finding of lien impairment but reversed the damage awards, concluding that The MED's recovery is limited to one-third of the amounts the insurers paid to the Baumgartners, and remanded the case for further proceedings consistent with this interpretation.

Hospital Lien ActInsurance LawAutomobile AccidentSubrogationMade-Whole DoctrineStatutory InterpretationDamages for ImpairmentConstructive NoticeMedical ExpensesSettlement Agreements
References
33
Case No. MISSING
Regular Panel Decision

Government Employees Insurance v. Uptown Health Care Management, Inc.

Plaintiffs GEICO allege a scheme where defendants, including Uptown Health Care Management d/b/a East Tremont, Hisham Elzanaty, Alan Goldenberg, Dr. Hisham Ahmed, and Dr. Jadwiga Pawlowski, fraudulently billed GEICO for millions in services. GEICO contends East Tremont was ineligible for reimbursement under New York's no-fault insurance laws, operating without a legitimate medical director, violating its operating certificate, and paying kickbacks for referrals. The complaint raises six causes of action, including declaratory judgment, RICO violations (18 U.S.C. §§ 1962(c), 1962(d)), common law fraud, aiding and abetting fraud, and unjust enrichment. Defendants moved to dismiss under Rule 12(b)(1) for Burford abstention and Rule 12(b)(6) for failure to state a claim, arguing GEICO's claims would invalidate a DOH license and interfere with state oversight. Citing the similar Allstate Ins. v. Elzanaty action, the court denied defendants' motions, affirming that insurers can challenge fraudulent licensing and conduct under RICO and fraud claims, even if state authorities have approved the facility. The court concluded that such claims do not disrupt New York's regulatory scheme and need not be raised exclusively with the DOH or through an Article 78 proceeding.

Insurance FraudNo-Fault InsuranceRICO ActMedical LicensingHealthcare FraudAbstention DoctrineRule 12(b)(1) MotionRule 12(b)(6) MotionArticle 28 FacilitiesKickbacks
References
21
Case No. 03-05-00837-CV
Regular Panel Decision
Dec 23, 2008

Diana Foster v. Texas Retirement System, Trustee for Texas Public Retired School Employees Group Insurance Program Aetna Life Insurance Company And Aetna Health Management, LLC

Diana Foster, a retired teacher, sued the Teacher Retirement System of Texas (TRS) and its insurance administrators, Aetna, after her claim for intravenous immune globulin infusion therapy (IVIG) was denied. She asserted claims for breach of contract, breach of the duty of good faith and fair dealing, violations of the insurance code, and deceptive trade practices, along with a request for declaratory judgment. The trial court granted appellees' pleas to the jurisdiction, dismissing the lawsuit without prejudice, citing sovereign immunity. Foster appealed, arguing her declaratory judgment claim was not barred, legislative immunity was waived, the administrative procedures act provided for judicial review, and Aetna was not protected by sovereign immunity. The appellate court affirmed the trial court's dismissal, finding that sovereign immunity applied to TRS and, by extension, to Aetna as its agent, and that Foster's claims did not fall under any exceptions for judicial review or waiver of immunity.

Sovereign ImmunityGovernment AgencyInsurance DisputeDeclaratory JudgmentAdministrative Procedures ActAgency AdjudicationJudicial ReviewBreach of ContractDuty of Good Faith and Fair DealingDeceptive Trade Practices Act
References
26
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