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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
Oct 29, 2009

Larry Dean Speegle v. Harris Methodist Health System and Harris Methodist Fort Worth

Appellant Larry Dean Speegle appealed a trial court's summary judgment affirming the validity and amount of a hospital lien filed by appellees Harris Methodist Health System and Harris Methodist Fort Worth, and granting appellees recovery of the lien amount plus attorney's fees. Speegle argued the lien was invalid because the hospital, despite his Medicare eligibility, failed to bill Medicare, contravening state law. The court held that federal Medicare Secondary Payer provisions, allowing hospitals to either bill Medicare or maintain a lien against liability insurance, preempted the Texas state law requiring timely billing of third-party payers like Medicare. Consequently, the appellate court affirmed the trial court's judgment, finding the hospital lien valid and upholding the award of attorney's fees. Speegle's motion for rehearing was denied.

Hospital lienMedicare Secondary PayerFederal PreemptionTexas Property CodeTexas Civil Practice and Remedies CodeAttorney's feesSummary judgmentAutomobile accidentLiability insuranceHealth care provider
References
29
Case No. MISSING
Regular Panel Decision

Humana Insurance v. Farmers Texas County Mutual Insurance

This case concerns Humana Insurance Company's attempt to recover medical expenses from Farmers Texas County Mutual Insurance Company and Mid-Century Insurance Company of Texas, which Humana alleges are primary payers under the Medicare Secondary Payer (MSP) Act. Humana, a Medicare Advantage Organization (MAO), sought reimbursement after paying enrollees' medical costs, but the defendants refused. The United States Magistrate Judge recommended dismissing Humana's federal claims, arguing that MAOs lack a private cause of action under the MSP Act. However, the District Judge rejected this recommendation, concluding that the MSP Act unambiguously provides MAOs with a private right of action for double damages. Consequently, the District Court sustained Humana's objections and denied the defendants' motion to dismiss, allowing Humana's claims to proceed.

Medicare Secondary Payer ActMedicare Advantage OrganizationsPrivate Cause of ActionMotion to DismissFederal ClaimsState Law ClaimsReimbursementAutomobile InsurancePrimary PayerSecondary Payer
References
45
Case No. MISSING
Regular Panel Decision

Ferlazzo v. 18th Avenue Hardware, Inc.

Plaintiff Marie Ferlazzo moved to extinguish liens and subrogation rights asserted by Oxford Health Plan and The Rawlings Company, LLC against her personal injury settlement proceeds. Oxford, administering a Medicare Advantage plan, sought reimbursement for medical expenses. Ferlazzo contended that General Obligations Law § 5-335 (a) barred such claims as Oxford lacked a statutory right of reimbursement. The court examined the Medicare Secondary Payer Act and the Medicare Advantage Program, concluding that unlike Medicare, private Medicare Advantage insurers only have contractual, not statutory, rights to reimbursement. Citing federal precedents, the court ruled that Oxford's claim was subject to state law and not entitled to recovery from the settlement. Consequently, the court granted Ferlazzo's motion to extinguish the liens and subrogation rights.

Personal InjurySubrogationMedicare AdvantageHealth Insurance LienSettlement ProceedsGeneral Obligations LawStatutory InterpretationContractual RightsFederal PreemptionPrivate Insurer
References
4
Case No. 2-08-228-CV
Regular Panel Decision
Dec 17, 2009

Larry Dean Speegle v. Harris Methodist Health System and Harris Methodist Fort Worth

Larry Dean Speegle appealed a trial court's summary judgment, which validated a hospital lien by Harris Methodist Health System and Harris Methodist Fort Worth for services following an automobile accident. Speegle argued the lien was invalid, citing the hospital's failure to bill Medicare as required by Texas state law, despite a settlement agreement that included funds for the lien. The appellate court affirmed, holding that federal Medicare law, which designates Medicare as a secondary payer in such scenarios, preempts conflicting state provisions and allows hospitals to maintain their liens. Furthermore, the court upheld the award of attorney's fees to the appellees, concluding that the claims for declaratory judgment and lien recovery were sufficiently intertwined to negate the need for fee segregation.

Hospital LienMedicare Secondary PayerFederal PreemptionSummary JudgmentAttorney's FeesSegregation of FeesTexas Property CodeTexas Civil Practice and Remedies CodeAutomobile AccidentLiability Insurance
References
29
Case No. ADJ7900836
Regular
Jul 24, 2012

JUAN MONROY CURIEL vs. NEENAH ENTERPRISES, WAUSAU INSURANCE COMPANY

The defendant sought reconsideration of an order denying their petition to set aside a Compromise and Release agreement. The defendant argued the agreement contained a clerical error by not allocating funds for future medical care, thus violating Medicare Secondary Payer laws. The Board denied reconsideration, finding the defendant failed to demonstrate sufficient cause to set aside the agreement. The Board noted parties may file an addendum to allocate settlement proceeds for future Medicare-covered expenses due to bona fide disputes.

Workers' Compensation Appeals BoardReconsiderationCompromise and ReleaseOrder Approving Compromise and ReleaseSet Aside OrderClerical ErrorMedicare Secondary PayerFuture Medical CareAllocation of SettlementBona Fide Dispute
References
3
Case No. MISSING
Regular Panel Decision
Jul 02, 2002

Mason v. American Tobacco Co.

Plaintiffs brought a class action under the Medicare as Secondary Payer (MSP) statute, seeking certification for a class of individuals who received or are receiving health care services for tobacco-related illnesses, paid for by Medicare. Defendants opposed certification and moved to dismiss. The court denied class certification and dismissed the case, finding that the plaintiffs' interpretation of the ambiguous MSP statute was inappropriate. The court ruled that the statute does not support a qui tam-type individual action masquerading as a class action, and defendants, as tortfeasors, do not qualify as "self-insured plans" under the statute without specific agreements or funds. The decision emphasized that the legislative history does not indicate a Congressional design to apply the MSP statute broadly to general tortfeasors.

Medicare Secondary Payer ActClass ActionStatutory InterpretationQui Tam ActionSelf-Insured PlanTobacco LitigationHealthcare LawFederal Rules of Civil Procedure Rule 23Motion to DismissClass Certification Denial
References
21
Case No. MISSING
Regular Panel Decision

United States ex rel. Takemoto v. Hartford Financial Services Group, Inc.

Relator Dr. Kent Takemoto initiated a qui tam action under the False Claims Act, alleging that various insurance and holding companies violated the Medicare Secondary Payer Act by knowingly avoiding their obligation to reimburse the government for Medicare payments to beneficiaries. Magistrate Judge Jeremiah J. McCarthy recommended dismissing Takemoto's amended complaint with prejudice, finding a failure to state plausible claims under Federal Rule of Civil Procedure 8(a), specifically due to group pleading and speculative allegations regarding defendants' payment obligations. Both Takemoto and the defendants filed objections to this recommendation. Presiding District Judge William M. Skretny reviewed the objections de novo, ultimately accepting the Magistrate Judge's recommendations. Consequently, Takemoto's objections were denied, the motion to dismiss was granted, and his amended complaint was dismissed with prejudice, without prejudice to the United States.

False Claims ActMedicare Secondary Payer ActQui TamPleading StandardsRule 8Rule 9(b)Motion to DismissDismissal with PrejudiceKnowing AvoidanceRelator
References
38
Case No. CIV-1-89-190
Regular Panel Decision
Jun 14, 1990

Provident Life & Accident Insurance v. United States

This consolidated action involves Provident Life and Accident Insurance Company and the United States Government regarding the Medicare Secondary Payer (MSP) provisions. Provident sought a declaratory judgment disputing its obligations to reimburse Medicare overpayments for "working aged" beneficiaries, while the Government sought reimbursement and identification of beneficiaries. The Court denied both parties' motions to dismiss. On summary judgment, the Court ruled that the Government has an independent statutory right of action against Provident when it acts as an insurer, effective January 1, 1983. However, this right does not apply if Provident served solely as an administrator or if it had already made a primary payment prior to November 13, 1989. The Court also ordered Provident to produce logs and lists of employer group health plans (EGHPs) and beneficiaries subject to MSP provisions. Additionally, the ruling clarified that the Government's right of action extends to "active disabled" and End Stage Renal Disease (ESRD) beneficiaries, specifically against "large group health plans" for the "active disabled," and that "insurer" encompasses various forms of insurance provided by Provident, excluding only solely administrative services.

Medicare Secondary PayerMSP ProvisionsEmployer Group Health PlansERISAMcCarran-Ferguson ActDeclaratory JudgmentSummary JudgmentConditional PaymentsReimbursementStatutory Interpretation
References
35
Case No. MISSING
Regular Panel Decision

Brentwood Academy v. Tennessee Secondary School Athletic Ass'n

Brentwood Academy sued the Tennessee Secondary School Athletic Association (TSSAA) and its Executive Director, Ronnie Carter, alleging violations of the First and Fourteenth Amendments due to TSSAA's Recruiting Rule. The court found the rule unconstitutional as applied to Brentwood Academy for its 'Spring Practice Letter' and complimentary tickets, ruling it was not narrowly tailored, violated substantive due process due to vagueness and lack of notice, and procedural due process because of the consideration of ex parte evidence during deliberations. Consequently, the court declared the August 23, 1997 penalties imposed by the TSSAA against Brentwood Academy void and enjoined them.

Education LawSports LawFirst AmendmentFourteenth AmendmentDue ProcessFreedom of SpeechRecruiting RuleState ActorUnconstitutional As AppliedInjunctive Relief
References
35
Case No. ADJ1581465; (LAO 0850949) ADJ1167896; (LAO 0860970)
Regular
Sep 26, 2008

DANIEL CHAVEZ vs. LEHIGH CONSUMER PRODUCTS, SENTRY CLAIMS SERVICE

Reconsideration granted, rescinding the July 7, 2008 Order Approving Compromise and Release due to potential Medicare Secondary Payer issues. Case returned for further proceedings.

Compromise and ReleaseMedicare Secondary PayerOrder Approving Compromise and ReleasePetition for ReconsiderationWorkers' Compensation Appeals BoardWCJSet Aside OAC&RMedicare Set-Aside ArrangementRescindedTrial Level
References
10
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