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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

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. 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. 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. 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
Oct 24, 2017

Humana, Inc. v. Shrader & Assocs., LLP

Plaintiffs (Humana, Inc., United Healthcare Services, Inc., and Aetna Inc.), acting as insurers and administrators of health benefit plans, sued Defendant Shrader & Associates, LLP, a law firm, seeking reimbursement for medical expenses paid for clients who received asbestos injury recoveries. Plaintiffs asserted claims under ERISA for equitable lien, constructive trust, and equitable restitution, and under the Medicare Secondary Payer (MSP) Act for a private cause of action and declaratory judgment. State-law claims for unjust enrichment and money had and received were also included. Defendant moved to dismiss on several grounds, including lack of subject matter jurisdiction, failure to state a claim, and failure to join indispensable parties, and also sought severance. The court denied the motion to dismiss for lack of subject matter jurisdiction and denied without prejudice the motions concerning indispensable parties and severance. The motion to dismiss for failure to state a claim was granted only with respect to the unjust enrichment and money had and received claims, which were deemed preempted by ERISA or barred by the existence of express contracts. The court also vacated the Amended Docket Control Order and denied the Joint Motion for Continuance as moot.

ERISAMedicare Secondary Payer ActAsbestos LitigationReimbursement ClaimsEquitable LienConstructive TrustEquitable RestitutionMotion to DismissSubject Matter JurisdictionIndispensable Parties
References
66
Case No. MISSING
Regular Panel Decision

Wesby v. Act Pipe & Supply, Inc.

Glenn Wesby was injured while working on Act Pipe & Supply, Inc.'s premises, employed by Labor Express Temporary Services. He sued Act Pipe for negligence. Act Pipe sought summary judgment, arguing that Wesby's claims were barred by Texas Workers’ Compensation statutes under either the Staff Leasing Services Act or the borrowed servant doctrine. The trial court granted summary judgment without specifying the grounds. On appeal, the court affirmed the summary judgment, finding that Wesby was Act Pipe’s borrowed servant and Act Pipe's workers’ compensation insurance applied, thus barring his common law claims, irrespective of whether notice of coverage was provided.

Personal InjurySummary JudgmentBorrowed Servant DoctrineStaff Leasing Services ActWorkers' Comp ExclusivityTemporary EmploymentNegligence ClaimsAppellate AffirmationEmployer Affirmative DefenseTexas Labor Law
References
28
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. MISSING
Regular Panel Decision

Lasater v. Hercules Powder Co.

This action was brought by employees of Volunteer Ordnance Works against their employer, operating under a government contract, seeking unpaid overtime compensation, liquidated damages, and attorney's fees under the Fair Labor Standards Act of 1938. The dispute centered on whether time spent at plant gates and in transit on the employer's premises constituted compensable working time. The court found that while the Fair Labor Standards Act generally applied to government contracts and the plaintiffs were engaged in the production of goods for commerce, the specific time claimed was not part of a statutory workweek, particularly considering the wartime context and the benefit to the national war effort. Furthermore, the court determined that the Portal-to-Portal Act of 1947 barred the plaintiffs' claims and affirmed the constitutionality of its provisions, including Section 9, which provides a defense for employers acting in good faith reliance on administrative interpretations. Consequently, judgment was awarded to the defendant.

Overtime CompensationFair Labor Standards ActPortal-to-Portal ActWartime ProductionGovernment ContractorsEmployee WagesStatutory WorkweekJurisdictionConstitutional LawDe Minimis Rule
References
17
Case No. MISSING
Regular Panel Decision

Rodriguez v. Texas Employers' Insurance Ass'n

This case concerns an appeal from a summary judgment granted in favor of a workers' compensation carrier. The appellant's husband died at work, and the carrier denied death benefits, leading the appellant to sue for benefits under the Workers' Compensation Act and for treble damages under the Texas Deceptive Trade Practices Act (DTPA). While the appellant successfully recovered workers' compensation benefits, the trial court granted summary judgment on the DTPA claim, ruling that the decedent was not a "consumer" as defined by the Act. The appellate court affirmed this decision, concluding that the relationship between the decedent and the compensation carrier was statutory, not contractual, meaning there was no "purchase" of goods or services to establish consumer status under the DTPA. Therefore, the denial of workers' compensation liability alone did not give rise to a cause of action under the Deceptive Trade Practices Act.

Workers' CompensationDeceptive Trade PracticesSummary Judgment AppealConsumer StatusInsurance LiabilityStatutory RelationshipContractual RelationshipDeath Benefits ClaimTreble DamagesAppellate Court Decision
References
2
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