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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

Mid-Century Insurance Co. of Texas v. Kidd

This case addresses whether an insured can recover the same loss under both uninsured/underinsured motorist (UM/UIM) and personal injury protection (PIP) coverages of a standard automobile insurance policy in Texas. The Supreme Court consolidated two cases, Kidd and Gerlich, where lower courts refused to enforce a policy provision barring duplication of UM and PIP benefits. The Court held that a non-duplication-of-PIP-benefits provision is valid and enforceable, reversing the judgments of the courts of appeals. The decision clarifies that this offset provision prevents double recoveries, rather than reducing UM/UIM policy limits or causing insureds to recover less than actual damages, and is consistent with Texas statutes and common law.

Automobile InsuranceUninsured/Underinsured MotoristPersonal Injury ProtectionInsurance Policy InterpretationDouble RecoveryNon-Duplication ClauseCollateral Source RuleStatutory InterpretationInsurance LawPolicy Offsets
References
26
Case No. MISSING
Regular Panel Decision
Jun 16, 2006

Fortis Benefits v. Cantu

Vanessa Cantu suffered severe injuries in a car accident and sued multiple parties. Her medical insurer, Fortis Benefits, intervened, seeking subrogation for medical benefits paid under the policy. After Cantu settled with the defendants, Fortis pursued recovery from Cantu. Cantu argued that the equitable "made whole" doctrine barred Fortis's claim because her total losses exceeded the settlement amount plus the benefits Fortis paid. The trial court and court of appeals sided with Cantu. The Texas Supreme Court reversed, holding that the "made whole" doctrine does not override an insurer's clear contractual subrogation rights. The Court affirmed the dismissal of Fortis's claims against Ford due to a pretrial agreement.

Insurance SubrogationMade Whole DoctrineContractual SubrogationEquitable SubrogationERISATexas LawInsurance Policy InterpretationPersonal InjuryAutomobile AccidentSettlement Proceeds
References
28
Case No. MISSING
Regular Panel Decision
Feb 22, 1984

Barnhardt v. Hudson Valley District Council of Carpenters Benefit Funds

The plaintiff, injured in May 1978 during maintenance work, was denied workers' compensation due to the absence of an employer-employee relationship. Subsequently, he sought reimbursement for medical expenses from the Hudson Valley District Council of Carpenters Benefit Funds (Benefit Funds) through a union insurance policy. Continental Assurance Company (Continental), Benefit Funds' insurer, rejected the claim, citing an employment-related injury exclusion in the policy. The plaintiff then initiated an action against Benefit Funds, which in turn filed a third-party action against Continental seeking indemnification. Continental's motion for summary judgment, asserting the exclusion, was denied by the County Court. The appellate court affirmed this denial, ruling that the exclusionary language was ambiguous and applied only in cases where a clear employer-employee relationship existed, a fact still to be determined.

Insurance Policy InterpretationEmployment StatusWorkers' Compensation ExclusionSummary Judgment MotionContractual AmbiguityGroup Health InsuranceMedical Expense ReimbursementThird-Party ActionAppellate ReviewEmployer-Employee Relationship
References
10
Case No. MISSING
Regular Panel Decision

Cook v. Pension Benefit Guarantee Corp.

The Trustees of the Local 852 General Warehouseman’s Union Pension Fund sued the Pension Benefit Guarantee Corporation (PBGC) seeking reimbursement for pension benefits paid to retirees of two closed warehouses. The Fund argued for recovery based on equitable estoppel, asserting detrimental reliance on an initial PBGC determination that it would guarantee these benefits. The PBGC moved for summary judgment, contending that estoppel against a federal agency requires a showing of affirmative misconduct or manifest injustice. The Court found no evidence of affirmative misconduct by the PBGC and concluded that its change in determination, made to conform with Congressional intent, did not constitute manifest injustice. Consequently, the Court granted the PBGC's motion for summary judgment, ruling that equitable estoppel was inapplicable.

Equitable EstoppelFederal Agency EstoppelSummary JudgmentERISAPension BenefitsMulti-employer PlanPension Benefit Guarantee Corporation (PBGC)Affirmative MisconductManifest InjusticeDetrimental Reliance
References
10
Case No. Civ. A. No. 3:93-CV-0171-G.
Regular Panel Decision
Aug 31, 1993

Mills v. INJURY BENEFITS PLAN OF SCHEPPS-FOREMOST

Walter Mills was injured during his employment and sought benefits under his employer's Injury Benefits Plan. He subsequently filed a civil action alleging wrongful termination in retaliation for filing a workers' compensation claim under Texas law. Defendants removed the case to federal court, asserting ERISA preemption. The court granted the defendants' motion to dismiss Mills' claims against the Injury Benefits Plan, finding them preempted by ERISA. However, the court denied the dismissal of Mills' state law claims against Schepps-Foremost, Inc., d/b/a Oak Farms Dairies. Ultimately, the court remanded the remaining state law claims against Schepps-Foremost, Inc. to the County Court at Law Number 5 of Dallas County, Texas, due to a lack of federal subject matter jurisdiction.

ERISA preemptionWorkers' CompensationRetaliatory dischargeTexas lawFederal jurisdictionMotion to dismissRemandEmployee benefitsCivil procedureDallas County
References
18
Case No. MISSING
Regular Panel Decision

Jeffries v. Pension Trust Fund of the Pension, Hospitalization & Benefit Plan of the Electrical Industry

Plaintiff Claude Jeffries, a retired electrician, sued the Pension Trust Fund of the Electrical Industry under ERISA, seeking to include pension credits from 1969-1975 in his current benefits. He alleged the Plan should have declared a partial termination during a 1975-1979 New York recession, which would have vested his benefits. The defendant moved to dismiss the complaint, arguing lack of standing and statute of limitations, while plaintiff moved for class certification for similarly affected members. The court denied the defendant's motion to dismiss the claim for benefits, finding it timely, but granted dismissal for the breach of fiduciary duty claim as time-barred. The plaintiff's motion for class certification was denied due to insufficient evidence for numerosity, with leave to refile after discovery.

ERISAPension BenefitsClass CertificationMotion to DismissStatute of LimitationsFiduciary DutyPartial TerminationBenefit ForfeitureUnemploymentLabor Union
References
15
Case No. MISSING
Regular Panel Decision

Memorial Hermann Health System v. Coastal Drilling Co., LLC Employee Benefit Trust

Plaintiff Memorial Hermann Health System (MHHS) sued Coastal Drilling for breach of contract and recovery of benefits under the Employee Retirement Income Security Act (ERISA). MHHS claimed Coastal Drilling breached a contract to pay for healthcare services at PPOplus Contracted Rates. The Court determined that MHHS's breach of contract claim was not preempted by ERISA but could not be enforced because MHHS was a non-party to the Network Access Agreement and Coastal Drilling, also a non-party, had no direct obligation under it. Regarding the ERISA claim, the Court found that Coastal Drilling, as the plan administrator, had discretionary authority to determine benefits based on the Plan's Applicable Plan Limits (APL). The Court found substantial evidence supporting Coastal Drilling's benefits determination and no evidence of bias affecting the decision, despite a structural conflict of interest. Consequently, the Court granted Coastal Drilling's motion for summary judgment and dismissed MHHS's claims with prejudice.

ERISASummary JudgmentBreach of ContractPlan AdministratorBenefits DenialHealthcare ProviderThird-Party BeneficiaryERISA PreemptionTexas LawFiduciary Duty
References
48
Case No. ADJ7699696
Regular
Apr 06, 2020

George Ramirez, Jr vs. Preston Pipelines, Subsequent Injuries Benefits Trust Fund

This case concerns the applicant's claim for Subsequent Injuries Benefits Trust Fund (SIBTF) benefits, which was initially denied by the WCJ who excluded Dr. Chen's medical reports as inadmissible "doctor shopping." The applicant appealed, arguing Dr. Chen's reports were admissible and not duplicative of Dr. Lockwood's initial, incomplete report. The Appeals Board rescinded the prior order, finding the applicant should not be denied benefits solely due to the exclusion of Dr. Chen's reports, and returned the matter to the trial level to allow the applicant to obtain supplemental reporting from Dr. Lockwood to address his SIBTF eligibility.

Subsequent Injuries Benefits Trust FundSIBTFLabor Code section 4751inadmissible evidencedoctor shoppingQME evaluationsLabor Code section 5703examining physiciancumulative traumaCompromise and Release
References
1
Case No. 2014-01-0002
Regular Panel Decision
Oct 16, 2015

Howard, Denita v. US Xpress Enterprises

Denita Howard, a trainee truck driver for USXpress Enterprises, Inc., filed for an expedited hearing seeking medical benefits for emergency treatment after a work injury and temporary partial disability benefits. The alleged injury occurred when her tractor-trailer overturned near Acadia, Louisiana. The Court found Ms. Howard entitled to the requested medical benefits for charges from Jefferson Davis Emergency Group, LLC, as the employer's carrier, Liberty Mutual, had already paid the bill. However, her claim for temporary partial disability benefits from January 7, 2015, to February 18, 2015, was denied, as she was deemed to have reached maximum medical improvement as of December 18, 2014, by Dr. Venugopal Gadipudi. The employer's request for reimbursement of temporary partial disability benefits paid after the MMI date was deferred.

Workers' CompensationExpedited HearingMedical BenefitsTemporary Partial DisabilityMaximum Medical Improvement (MMI)Emergency TreatmentTruck Driver InjuryMotor Vehicle AccidentNeurological CareInsurance Carrier Liability
References
4
Case No. 2017-06-1778
Regular Panel Decision
Apr 11, 2018

Demotte, Julie v. UPS

Julie Demotte sustained a workplace injury involving a broken hip and leg in November 2016 while working for UPS. UPS initially accepted the claim and provided temporary disability benefits. Dr. Jason Evans, the authorized treating physician, placed Ms. Demotte at maximum medical improvement and assigned a three-percent whole-person impairment rating. A compensation hearing was held to determine Ms. Demotte's entitlement to permanent disability, temporary disability, and future medical benefits. The Court ordered UPS to provide lifetime medical benefits for Ms. Demotte's workplace injury, but denied her claims for both temporary and permanent disability benefits. The denial of permanent disability was based on the inadmissibility of Form C-30A as proof of impairment, as Ms. Demotte failed to present admissible evidence. Additionally, the claim for further temporary disability benefits was denied due to an earlier overpayment by UPS that exceeded any subsequent amounts due.

Workplace InjuryFuture Medical BenefitsTemporary Disability BenefitsPermanent Disability BenefitsAdmissibility of Medical ReportsForm C-30AForm C-32Impairment RatingHearsayMaximum Medical Improvement
References
2
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