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

Case No. 07-09-00163-CV
Regular Panel Decision
Mar 12, 2010

Potter County, Texas as Plan Administrator for the Health Benefits Plan for the Employees of Potter County, Texas v. Ronda Tuckness and Michael Tuckness

Potter County, acting as the plan administrator for its employee health benefits plan, appealed an order that denied its plea to the jurisdiction. The underlying lawsuit was filed by Ronda and Michael Tuckness, seeking health care benefits after the County denied Michael Tuckness's claim for back surgery costs due to an occupational injury exclusion. The County contended it was immune from suit. The appellate court found that the County's governmental immunity had not been waived by the requests for declaratory relief, the terms of the health plan contract, or the County's conduct. Consequently, the court reversed the trial court's order and dismissed the Tucknesses' case for lack of subject-matter jurisdiction.

Governmental ImmunityImmunity WaiverDeclaratory JudgmentContract LawHealth BenefitsPlan AdministratorOccupational Sickness/InjuryJurisdictionPlea to JurisdictionInterlocutory Appeal
References
20
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. MISSING
Regular Panel Decision

Kosakow v. New Rochelle Radiology Associates, P.C.

Nancy Kosakow sued her former employer, New Rochelle Radiology Associates, alleging FMLA violations and wrongful denial of severance pay under ERISA. The court previously found FMLA claims collaterally estopped but remanded the ERISA claim to the Plan Administrator for a determination on severance eligibility. The Administrator denied severance, finding Kosakow not "terminated" and, even if so, not entitled to severance. This court reversed the "not terminated" finding, stating Kosakow was terminated due to a reduction in force. However, the court affirmed the Administrator's denial of severance, concluding that the "where applicable" clause in the Plan gave the Administrator broad discretion and that Kosakow's circumstances did not warrant severance. The court found that the denial was not unreasonable, even when considering a severance payment made to another full-time employee under different circumstances.

ERISASeverance PayFMLATerminationSummary JudgmentDe Novo ReviewPlan Administrator DiscretionEmployee BenefitsReduction in ForcePolicy Manual
References
8
Case No. MISSING
Regular Panel Decision

In re Robert Plan Corp.

Kenneth Kirschenbaum, the Chapter 7 Trustee for The Robert Plan Corporation and The Robert Plan of New York Corporation, sought court approval for fee awards for himself and his professionals for administering an ERISA plan. The U.S. Department of Labor (DOL) objected, asserting the court lacked jurisdiction to award fees from Plan assets and had specific objections to the reasonableness of the fees. The court affirmed its core jurisdiction over the Trustee's actions as Plan administrator and his professionals' compensation, regardless of whether payments came from Plan or estate assets, citing previous rulings. The court analyzed whether Bankruptcy Code §§ 326 and 330 conflicted with ERISA statutes concerning fiduciary compensation, concluding no substantive conflict existed and the Bankruptcy Code's specific compensation scheme governed. Ultimately, the court largely overruled DOL's objections and granted the fee applications for the Trustee, K & K, Witz, and Whitfield, deeming the requested amounts reasonable and compliant with the Bankruptcy Code. The awards are payable from the Plan's Pguy Account, with any shortfall covered by the Debtors' estate.

Bankruptcy LawERISAChapter 7 TrusteeFee ApplicationPlan AdministrationJurisdictionReasonable CompensationStatutory ConstructionDepartment of LaborFiduciary Duties
References
50
Case No. MISSING
Regular Panel Decision

American Prescription Plan, Inc. v. American Postal Workers Union AFL-CIO Health Plan

This case involves appeals and a cross-appeal from an order of the Supreme Court, Nassau County. Defendant American Postal Workers Union, AFL-CIO Health Plan (APWU-HP) appealed the denial of its motion for summary judgment concerning the fourth, fifth, and fourteenth causes of action. Defendant Administrative Consultants, Inc. (ACI) appealed the denial of its motion for summary judgment regarding the tenth and eleventh causes of action. The plaintiff cross-appealed the partial dismissal of the first, third, and sixth causes of action. The appellate court reversed the order for the defendants, granting their motions for summary judgment and dismissing all causes of action asserted against them. The order was affirmed insofar as cross-appealed by the plaintiff, upholding the partial dismissals against the plaintiff.

Summary JudgmentContract DisputeOral RepresentationsStatute of FraudsEquitable EstoppelAppellate ProcedureDismissal of ClaimsBreach of ContractMootness DoctrineAuthority to Contract
References
7
Case No. NO. 07-09-00163-CV
Regular Panel Decision
Mar 12, 2010

Damon Cox v. Angie Simmons

Potter County, as administrator of its employee health benefits plan, appealed an order denying its plea to the jurisdiction in a lawsuit filed by Ronda and Michael Tuckness. The Tucknesses sought reimbursement for Michael's back surgery, which the County denied based on a plan exclusion for occupational injuries. The trial court sided with the Tucknesses, but the Court of Appeals reversed. The appellate court held that the County's governmental immunity from suit had not been waived by the Uniform Declaratory Judgment Act, the plan's contract language, the County's conduct in accepting premiums, or by Local Government Code section 271.152, which specifically excludes counties. Consequently, the appellate court dismissed the Tucknesses' case for want of jurisdiction.

Governmental ImmunityImmunity from SuitContract DisputeDeclaratory Judgment ActHealth Benefits PlanPotter CountyTexas LawAppellate ReviewJurisdictionPlea to Jurisdiction
References
26
Case No. 2017 NY Slip Op 04184 [150 AD3d 1589]
Regular Panel Decision
May 25, 2017

New York State Workers' Compensation Board v. Program Risk Management, Inc.

The New York State Workers' Compensation Board, acting as administrator and successor to the Community Residence Insurance Savings Plan, initiated legal action against various entities and individuals after the trust became severely underfunded. Defendants include Program Risk Management, Inc. (administrator), PRM Claims Services, Inc. (claims administrator), individual officers of PRM, the Board of Trustees, and Thomas Gosdeck (trust counsel). The plaintiff sought damages for claims such as breach of contract, breach of fiduciary duty, and legal malpractice. The Supreme Court's order partially dismissed some claims and denied others. On cross-appeal, the Appellate Division, Third Department, modified the Supreme Court's order, notably reversing the dismissal of several breach of fiduciary duty claims and common-law indemnification against PRMCS, while affirming denials of motions to dismiss breach of contract, legal malpractice, and unjust enrichment claims. The court's decision was influenced by recent rulings in State of N.Y. Workers' Compensation Bd. v Wang.

Workers' Compensation LawGroup Self-Insured TrustBreach of ContractBreach of Fiduciary DutyLegal MalpracticeUnjust EnrichmentStatute of LimitationsEquitable EstoppelAlter Ego LiabilityCommon-Law Indemnification
References
20
Case No. 5615/89; 2643/91
Regular Panel Decision

In re the Director of the Assigned Counsel Plan

The court denies the Director of the Assigned Counsel Plan of the City of New York's request for further reconsideration of 'reasonable compensation' awarded to expert witness Hillel Bodek in People v Toe and People v Hoe. Judge Goodman reaffirmed the original compensation, emphasizing that judicial determinations of expert fees under County Law § 722-c are not subject to administrative review by the Director. The court rejected arguments regarding excessive compensation, lack of specificity in orders, and the expert's qualifications, highlighting the confidentiality of reports and the judge's sole authority in such matters. The opinion clarified the roles of judges and administrators in the assigned counsel plan. The Director was ordered, under penalty of contempt, to process the payment of $5,200 and $200 for Bodek's services.

Expert Witness CompensationCounty Law § 722-cJudicial DiscretionAdministrative ReviewForensic Social WorkMental Health EvaluationConfidentiality of ReportsProfessional QualificationsExtraordinary CircumstancesContempt Order
References
11
Case No. MISSING
Regular Panel Decision

Veera v. Ambac Plan Administrative Order Committee

This class action was initiated by a former employee of Ambac Financial Group, Inc. against the company's Plan Investment Committee, Plan Administrative Committee, Compensation Committee, and individual defendant Leonard. The plaintiff alleged that the defendants breached their fiduciary duties under ERISA by continuing to offer Ambac stock as an investment option in the employer-sponsored Savings Incentive Plan. This was deemed imprudent given their alleged knowledge of Ambac's significant financial decline during the Class Period of October 2006 to July 2008. The defendants moved to dismiss, arguing they had no fiduciary obligation to remove or diversify the stock and were protected by a presumption of prudence for employer stock investments. The court denied the motion, concluding that ERISA's fiduciary duties override contradictory plan documents. It also found that the plaintiff's detailed factual allegations were sufficient to potentially overcome the presumption of prudence, allowing the case to proceed. The ruling affirmed that fiduciaries cannot blindly adhere to plan terms if those terms are inconsistent with ERISA's prudence mandates.

ERISAFiduciary DutyClass ActionMotion to DismissEmployer StockSavings Incentive PlanPrudence StandardDiversification ExemptionMoench PresumptionFinancial Decline
References
19
Case No. 03-04-00050-CV
Regular Panel Decision
Jul 29, 2004

Al Boenker Insurance Agency, Inc. v. the Texas FAIR Plan Association The Texas Department of Insurance And Jose Montemayor, Commissioner of Insurance

Appellant Al Boenker Insurance Agency, Inc. appealed a summary judgment ruling in favor of the Texas FAIR Plan Association (FAIR Plan). Al Boenker had challenged a bulletin issued by FAIR Plan, which restricted fees insurance agencies could charge for homeowners insurance applications and allowed for termination of agencies violating the contract. Al Boenker argued that FAIR Plan violated the separation-of-powers doctrine and exceeded its statutory authority. The Court of Appeals affirmed the district court's judgment, concluding that FAIR Plan is not a state agency subject to the Texas Administrative Procedure Act's rulemaking provisions and acted within its authority derived from the FAIR Plan Act and its Plan of Operation by contractually limiting agent compensation and establishing conditions for agent termination.

Administrative LawInsurance LawContract LawSummary JudgmentDeclaratory JudgmentInjunctionAgency AuthoritySeparation of PowersStatutory ConstructionTexas Court of Appeals
References
16
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