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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

Pacific Indemnity Insurance Company v. Liberty Mutual Insurance Company and Vidal Lopez

Pacific Indemnity Insurance, a workers' compensation carrier, sued Liberty Mutual Insurance for reimbursement in district court without first exhausting administrative remedies with the Industrial Accident Board (IAB). This lawsuit stemmed from a worker's injury in 1984 and subsequent re-injury in 1988. Pacific Indemnity, the carrier for the initial injury, continued to pay benefits after the re-injury and sought reimbursement from Liberty Mutual, the subsequent carrier, which was denied. The IAB issued orders regarding payments but did not address the reimbursement claim. The district court granted summary judgment for Liberty Mutual, a decision upheld on appeal because Pacific Indemnity failed to obtain an IAB ruling on the reimbursement issue before filing suit, thereby lacking jurisdiction in district court. The failure to exhaust administrative remedies bars the suit as a matter of law.

Administrative RemediesExhaustion DoctrineSummary JudgmentInsurance ReimbursementIndustrial Accident BoardJurisdictionAppellate ReviewCarrier DisputeRepetitious TraumaTexas Workers' Compensation Law
References
3
Case No. 03-08-00766-CV
Regular Panel Decision
Feb 25, 2010

Service Lloyds Insurance Company v. American Alternative Insurance Corporation

This workers' compensation case involves an appeal by Service Lloyds Insurance Company against American Alternative Insurance Corporation (AAIC). The Texas Department of Insurance, Division of Workers' Compensation, ordered Service Lloyds to reimburse AAIC for benefits erroneously paid to an injured employee, Emmit Hines, for whom Service Lloyds was the liable carrier. Service Lloyds argued that a workers' compensation carrier cannot be a 'subclaimant' under Texas Labor Code section 409.009 and that the Division lacked jurisdiction over such a claim. The district court affirmed the Division's decision. The Court of Appeals affirmed the district court's judgment, concluding that a workers' compensation carrier can indeed be a subclaimant and the Division has jurisdiction to resolve such independently-raised subclaims.

Workers' CompensationInsurance LawSubrogationStatutory InterpretationTexas CourtsAppellate ReviewAdministrative LawReimbursementInsurance DisputeJurisdiction
References
20
Case No. 03-15-00314-CV
Regular Panel Decision
Aug 07, 2015

California Insurance Guarantee Association, Oklahoma Property and Casualty Insurance Guaranty Association, and Texas Property and Casualty Insurance Guaranty Association v. Hill Brothers Transportation, Inc.

The appellants, California Insurance Guarantee Association (CIGA), Oklahoma Property and Casualty Insurance Guaranty Association (OPCIGA), and Texas Property and Casualty Insurance Guaranty Association (TPCIGA), collectively "Guaranty Associations," are appealing a summary judgment granted in favor of the appellee, Hill Brothers Transportation, Inc. ("Hill Bros."). The suit was filed on March 31, 2009, alleging Hill Bros. failed to reimburse the Guaranty Associations for payments of workers' compensation benefits and claim handling expenses within the deductible limits of a policy issued by the insolvent Legion Insurance Company ("Legion"). The District Court granted summary judgment to Hill Bros. based on the statute of limitations, ruling that the cause of action accrued on April 1, 2002. The Guaranty Associations argue that the accrual date is incorrect, as their statutory obligations had not been triggered, payments had not been made, and demand for reimbursement had not occurred by that date. They also contend that their compliance with Pennsylvania law (the "Pennsylvania Act") in seeking reimbursement through Legion in Liquidation constitutes a mitigating circumstance for any delay, making reasonableness a fact question. Furthermore, they assert the policy was a continuing contract, and the statute of limitations should not have accrued until full performance on April 28, 2009. Alternatively, they argue that claims for deductible payments made within four years of filing suit (March 31, 2005) are not barred.

Workers' CompensationInsurance Guaranty AssociationStatute of LimitationsBreach of ContractDeductible ReimbursementInsolvencyInsurance PolicyContinuing ContractPennsylvania ActTravis County
References
21
Case No. 18-0216
Regular Panel Decision
Jun 26, 2020

Texas Mutual Insurance Company, Hartford Underwriters Insurance Company, Tasb Risk Management Fund, Transportation Insurance Company, Truck Insurance Exchange, Twin City Fire Insurance Company, Valley Forge Insurance Company v. Phi Air Medical, LLC

This concurring opinion addresses whether the Texas Workers' Compensation Act is shielded from federal preemption by the McCarran–Ferguson Act. The core issue is whether the Texas Act, which dictates how insurance carriers pay claimants like air-ambulance services, constitutes the 'business of insurance.' Justice Bland argues that the Act was indeed enacted for regulating the business of insurance, particularly given Texas's reliance on private insurers for workers' compensation. Therefore, its provisions should be protected from federal encroachment, leading to the reversal of the court of appeals' judgment.

McCarran-Ferguson ActFederal PreemptionState Insurance RegulationTexas Workers' Compensation ActBusiness of InsuranceAir-ambulance ServicesInsurance CarriersPolicyholder RiskThird-Party BeneficiaryAntitrust Exemption
References
19
Case No. 03-21-00242-CV
Regular Panel Decision
Dec 28, 2022

Vista Medical Center Hospital, Surgery Specialty Hospital of America, Southeast Houston and Vista Hospital of Dallas v. Texas Mutual Insurance Company

This appeal stems from a dispute over workers' compensation medical benefits reimbursement between multiple hospitals (Vista Parties) and numerous insurance carriers (Carriers) in Texas. The core issue revolves around the application of a "stop-loss exception" under Former Rule 134.401, designed for unusually costly or lengthy hospital stays, which the Vista Parties sought for 542 injured workers. After the State Office of Administrative Hearings (SOAH) largely denied additional reimbursement, the district court affirmed SOAH's order. The Court of Appeals, Third District, affirmed the district court's judgment, rejecting the Vista Parties' arguments that the SOAH order was arbitrary and capricious or lacked substantial evidence. The court found that SOAH properly conducted a case-by-case inquiry into whether services were "unusually costly and unusually extensive" and did not err in its application of the rule or in its findings.

Workers' CompensationMedical ReimbursementStop-Loss ExceptionAdministrative LawAppellate CourtTexas Court of AppealsSubstantial Evidence ReviewArbitrary and CapriciousFee GuidelinesHospital Reimbursement
References
51
Case No. 14-04-00651-CV
Regular Panel Decision
Mar 08, 2007

Coastal Refining & Marketing, Inc., Coastal Offshore Insurance Limited, and Lexington Insurance Company v. United States Fidelity and Guaranty Company

This insurance coverage dispute centers on whether United States Fidelity and Guaranty Company (USF&G) had a duty to reimburse its insured, Coastal Refining & Marketing, Inc., and two other carriers, Coastal Offshore Insurance Limited and Lexington Insurance Company, for costs incurred in settling a personal injury lawsuit. USF&G moved for summary judgment, arguing late notice, settlement without consent, and failure to cooperate by its insured. The appellate court reversed the trial court's summary judgment, finding that USF&G failed to produce evidence of actual prejudice resulting from the insured's actions. The court clarified that for bodily injury and property damage claims, actual, not merely speculative, prejudice must be demonstrated to void coverage. The case was remanded for further proceedings consistent with this opinion.

Insurance CoverageSummary JudgmentPrejudice (Insurance Law)Late Notice (Insurance)Voluntary Payment ClauseDuty to Cooperate (Insurance)IndemnificationContract LawAppellate ReviewTexas Law
References
41
Case No. 14-02-00860-CV
Regular Panel Decision
Feb 23, 2006

Lennar Corporation, Lennar Homes of Texas Land and Construction, Limited, and Lennar Homes of Texas Sales and Marketing, Limited, D/B/A Village Builders v. Great American Insurance Company, American Dynasty Surplus Lines Insurance Company, Markel American Insurance Company Gerling America Insurance Company, RLI Insurance Company, Insurance Company of the State of Pennsylvania and Westchester Fire Ins Company

This case concerns an insurance coverage dispute between homebuilder Lennar Corporation and its CGL insurance carriers over damages caused by defective stucco (EIFS) applied to homes. The court analyzed whether negligently defective construction constitutes an "occurrence" and distinguished between covered costs (repairing actual water damage) and non-covered costs (preventative EIFS replacement, overhead). While affirming summary judgment for several insurers due to unmet self-insured retentions based on individual homes as separate occurrences, the court reversed for American Dynasty and Markel, citing unresolved factual issues regarding "known loss" and policy conditions. Lennar's extra-contractual claims against American Dynasty were ultimately denied for lack of proven damages or statutory violations.

Insurance Policy InterpretationConstruction DefectsCommercial Liability InsuranceProperty Damage ClaimsStucco DefectsDuty to IndemnifySelf-Insured RetentionsKnown Loss PrincipleSubcontractor LiabilityTexas Law
References
96
Case No. MISSING
Regular Panel Decision

Argonaut Insurance Co. v. Baker

The case addresses whether a workers’ compensation carrier can seek full reimbursement from a third-party settlement, including amounts paid from an employer’s deductible. The Texas Legislature mandated that carriers offer deductible plans, with carriers making all benefit payments and employers reimbursing the deductible periodically. When an employee is injured by a third-party tortfeasor, the carrier is subrogated to the employee’s rights. The core dispute is if reimbursing the carrier for the deductible amount violates the Insurance Code’s prohibition against requiring an employee to pay any part of the deductible. The Texas Supreme Court concluded that such reimbursement from a third-party recovery is permissible, as the funds originate from the responsible third party, not the employee, and is consistent with established subrogation laws.

Insurance DeductibleSubrogation RightsThird-Party RecoveryStatutory InterpretationEmployer ReimbursementEmployee RightsAppellate ReviewSummary JudgmentInsurance CarrierLabor Code
References
7
Case No. AHM 90917 AHM 90918
Regular
Jul 11, 2007

ANGEL SOSA vs. D.W. FOODS, EVEREST NATIONAL INSURANCE COMPANY, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION, VILLANOVA INSURANCE

This case concerns a dispute over reimbursement between an insurer, Everest, and the California Insurance Guarantee Association (CIGA), which is handling claims for a liquidated insurer, Villanova. The Board denied Everest's petition, upholding a prior award for reimbursement from Everest to CIGA. However, the Board granted CIGA's petition to amend the award to include Villanova Insurance as a party defendant.

CIGAEverest National Insurance CompanyVillanova Insuranceliquidationreconsiderationreimbursementbill review chargesjoint and several liabilitycumulative traumadenied due process
References
0
Case No. 03-18-00663-CV
Regular Panel Decision
Dec 05, 2019

Facility Insurance Company v. Vista Hospital of Dallas, Vista Medical Center Hospital and Surgery Specialty Hospitals of America

This case involves an appeal from a suit for judicial review of an administrative decision concerning workers’ compensation medical benefits. Multiple insurance carriers (Appellants) disputed the reimbursement amounts sought by Vista Hospital entities (Appellees) for outpatient medical services provided between 2002 and 2008. Vista initially claimed 70%-100% of billed charges but later revised its calculations to 200% of the Medicare allowable reimbursement, following a 2008 regulatory change and a clarifying court opinion. The State Office of Administrative Hearings (SOAH) and the trial court affirmed Vista's revised calculations as 'fair and reasonable.' The Court of Appeals affirmed the trial court's judgment, finding substantial evidence to support SOAH's decision regarding the reimbursement methodology and the accrual of interest.

Medical Reimbursement DisputesAdministrative Agency ReviewAppellate Court DecisionTexas Labor CodeFee Guideline InterpretationHospital Billing PracticesWorkers' Compensation InsuranceState Office of Administrative Hearings (SOAH)Due Process RightsStatutory Interpretation
References
18
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