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

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

Texas Health Care Information Council v. Seton Health Plan, Inc.

Seton Health Plan, Inc., a licensed health maintenance organization (HMO), failed to file its annual Health Plan Employer Data Information Set (HEDIS) reports for 1999 and 2000 with the Texas Health Care Information Council, leading to a dispute over civil penalties. The State, through the Attorney General, initially demanded $153,000, interpreting 'each act of violation' as each day of non-compliance, while Seton contended the maximum penalty was $10,000 per unfiled report. Seton filed a declaratory judgment action to construe the statute, and the district court sided with Seton, assessing a minimum penalty of $1,000 for each report. The State appealed, raising issues of mootness, sovereign immunity, the penalty amount, denial of injunctive relief, and attorney's fees. The appellate court affirmed the district court's interpretation of the penalty, the assessed penalties, and the denial of injunctive relief, but remanded the issue of the State's attorney's fees.

Declaratory JudgmentStatutory ConstructionCivil PenaltiesSovereign ImmunityInjunctive ReliefAttorney's FeesHEDIS ReportHealth Maintenance OrganizationTexas Health and Safety CodeAdministrative Procedure Act
References
43
Case No. 03-02-00114-CV
Regular Panel Decision
Dec 19, 2002

Texas Health Care Information Council and the State of Texas, Office of the Attorney General v. Seton Health Plan, Inc.

This case involves an appeal by the Texas Health Care Information Council and the State of Texas, Office of the Attorney General, against Seton Health Plan, Inc. The core dispute centered on the interpretation of civil penalties for Seton's failure to file annual Health Plan Employer Data Information Set (HEDIS) reports as required by the Texas Health and Safety Code. Seton sought a declaratory judgment asserting that the maximum penalty for such a violation was $10,000 per report, while the State initially pursued a penalty based on each day of violation. The district court sided with Seton on the maximum penalty, assessed minimum penalties of $1,000 for each of the two unfiled reports, denied the State's request for injunctive relief, and ordered the State to pay Seton's attorney's fees. On appeal, the Court of Appeals affirmed the district court's declaratory judgment, the denial of injunctive relief, and the penalty assessment. However, the appellate court reversed and remanded the issue of the State's attorney's fees, ruling that the State was statutorily entitled to reasonable attorney's fees under Government Code section 402.006(c) due to its recovery of a civil penalty.

Texas LawHealth Care RegulationHEDIS Report ViolationCivil PenaltiesDeclaratory Judgment ActionSovereign Immunity WaiverInjunctive Relief DeniedAttorney's Fees AwardStatutory ConstructionAdministrative Law
References
44
Case No. MISSING
Regular Panel Decision

Murphy v. Wal-Mart Associates' Group Health Plan

Hazel and Charlie Murphy sued Wal-Mart Associates’ Group Health Plan and Prudential Health Care Plan after the Plan denied coverage for Mr. Murphy's high-dose chemotherapy and autologous bone marrow transplant for Non-Hodgkin’s Lymphoma. The Murphys alleged the Wal-Mart Plan acted arbitrarily and capriciously in denying benefits and their subsequent appeal, and brought state law claims against Prudential. The court found that Wal-Mart Plan's decision was based on medical expert opinions and was not arbitrary and capricious. Furthermore, it determined that ERISA preempted all state law claims against Prudential. Consequently, the court granted summary judgment for both defendants, dismissing the plaintiffs' claims.

ERISAEmployee BenefitsHealth InsuranceSummary JudgmentArbitrary and Capricious StandardMedical NecessityHigh-Dose ChemotherapyAutologous Bone Marrow TransplantNon-Hodgkin’s LymphomaPlan Administrator Discretion
References
28
Case No. No. 11, No. 12
Regular Panel Decision
Mar 26, 2019

Lilya Andryeyeva v. New York Health Care , Adriana Moreno v. Future Care Health Services

The New York Court of Appeals addressed a common issue in two joint appeals: whether home health care aides on 24-hour shifts must be paid for each hour. The Department of Labor (DOL) interpreted its Wage Order (12 NYCRR part 142) to allow payment for at least 13 hours if the employee receives at least 8 hours for sleep (with 5 uninterrupted) and 3 hours for meals. The Appellate Division rejected this, but the Court of Appeals reversed, deferring to DOL's interpretation as rational and consistent with the Wage Order's plain language. The cases were remitted for lower courts to evaluate class certification issues in accordance with DOL's interpretation.

Home Health Care24-Hour ShiftsMinimum Wage ActWage OrderDepartment of Labor InterpretationClass CertificationAppellate ReviewLabor Law ViolationsSleep BreaksMeal Breaks
References
49
Case No. MISSING
Regular Panel Decision

Franzese v. United Health Care/Oxford

Plaintiffs Robert and Elizabeth Franzese, parents and legal guardians of disabled adult Robert Franzese Jr. ("Bobby"), sued United Health Care/Oxford under ERISA to recover medical benefits. Bobby, suffering from chronic lung disease, requires 24/7 in-home nursing care. Oxford denied preauthorization for private duty nursing, citing it as an exclusion, and denied home health care services. The court granted Oxford's summary judgment motion regarding private duty nursing and Xopenex preauthorization, finding private duty nursing not covered. However, the court denied Oxford's motion regarding home health care services, deeming Oxford's denial arbitrary and capricious due to lack of substantial evidence. The case is remanded to Oxford for reconsideration of home health care benefits.

Employee Retirement Income Security Act (ERISA)Medical BenefitsHealth Insurance DenialSummary JudgmentArbitrary and Capricious StandardHome Health CarePrivate Duty NursingPreauthorizationMedical NecessityChronic Lung Disease
References
37
Case No. 03-13-00063-CV
Regular Panel Decision
Apr 09, 2014

Texas Department of State Health Services And Kyle Janek, in His Official Capacity as Executive Commissioner of the Texas Health and Human Services Commission v. Marcela Balquinta Planned Parenthood of Greater Texas Family Planning and Preventative Health Services, Inc. Planned Parenthood Association of Hidalgo County Texas, Inc. Planned Parenthood Association of Lubbock, Inc.

This case involves an appeal concerning judicial jurisdiction and procedure regarding the exclusion of Planned Parenthood entities from the Texas Women’s Health Program (TWHP), a state-funded health benefits program. The Planned Parenthood entities, along with an enrollee, challenged new administrative rules implemented by the Texas Department of State Health Services (DSHS) and its Executive Commissioner, Kyle Janek, which barred providers affiliated with organizations that perform or promote elective abortions. The appellate court analyzed whether the plaintiffs had constitutional standing and if the district court had subject-matter jurisdiction over their claims, including those filed under the Administrative Procedure Act (APA) and the Uniform Declaratory Judgments Act (UDJA). The court affirmed the district court's jurisdiction over the APA claims and requests for injunctive relief, finding a waiver of sovereign immunity under APA section 2001.038. However, it reversed and rendered judgment dismissing the UDJA claims, deeming them either redundant of the APA claims or not yet ripe for resolution.

Abortion PolicyWomen's Health ProgramMedicaidPlanned ParenthoodTexas Health PolicyStatutory InterpretationAdministrative Procedure ActDeclaratory JudgmentSovereign ImmunityConstitutional Standing
References
68
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. 13-15-00024-CV
Regular Panel Decision
Jul 06, 2015

Maria Zamarripa, as Temporary Guardian of the Estates of R. F. R. and R. J. R., Minors, and Olga Flores, as Temporary Administrator of the Estate of Yolanda Iris Flores v. Bay Area Health Care Group, Ltd. D/B/A Corpus Christi Medical Center, Hidalgo County EMS, and Hidalgo County Emergency Medical Service Foundation

This case involves an appeal by Maria Zamarripa and Olga Flores (Appellants) against Bay Area Health Care Group, Hidalgo County EMS, and Hidalgo County Emergency Medical Service Foundation (Appellees). The Appellants are challenging the trial court's orders that granted the Appellees' motions to dismiss. The core of the appeal centers on the qualifications of Nurse Spears as an expert witness and the sufficiency of expert reports regarding the standard of care, its breach, and causation in a medical malpractice claim involving Yolanda Iris Flores's injuries and death from placenta accreta and pre-term labor. Appellants argue that Nurse Spears is qualified, the expert reports adequately connect CCMC's alleged breach of care to the injuries, and alternatively, they are entitled to amend the reports. They pray for the reversal of the trial court's dismissal orders and a remand for further proceedings.

Medical MalpracticePlacenta AccretaPre-term LaborMedical NegligenceStandard of CareCausationExpert Witness QualificationsHospital LiabilityEmergency Medical Services (EMS)Wrongful Death
References
16
Case No. MISSING
Regular Panel Decision

Cecilia M. Simmons v. Outreach Health Community Care Services, LP. D/B/A Outreach Health Services

Cecilia Simmons, a certified nursing assistant, sued her employer, Outreach Health Community Care Services, for injuries sustained while moving a quadriplegic patient. Simmons alleged a breach of duty to provide a safe work environment. The trial court dismissed her claim with prejudice, deeming it a health care liability claim (HCLC) under the Texas Medical Liability Act (TMLA) that required an expert report, which Simmons failed to provide. On appeal, the court affirmed the dismissal, finding Simmons's claim constituted a breach of safety standards HCLC because her injury occurred while rendering health care services to a patient, and her constitutional challenges to the TMLA's expert report requirement were without merit.

Health Care Liability ClaimTexas Medical Liability ActWorkplace SafetyExpert Report RequirementOpen Courts ProvisionDue ProcessCertified Nursing AssistantEmployer LiabilityPatient Transfer InjuryDismissal with Prejudice
References
25
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