Austin: Denial of ERS benefits reversed

RECENT HEALTH CARE AND INSURANCE LAW DECISIONS FROM
HOUSTON COURTS OF APPEALS
   

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Health Care Liability Claims (Medical Malpractice)

Ambulatory Infusion Therapy Specialists, Inc. v. North American Administrators, Inc. (Tex.App.-
Houston [1st Dist.] Juy 10, 2008)(Keyes) (health care coverage law, provider's state law claims
arising from partial denial of plan members' claim preempted by ERISA, alternatively barred by
statute of limitations)
AFFIRM TC JUDGMENT: Opinion by Justice Keyes  
Before Justices Taft, Keyes and Alcala
01-06-00756-CV        Ambulatory Infusion Therapy Specialists, Inc. v. North American
Administrators, Inc. d/b/a North American Health Plans and Osmose, Inc.
Appeal from 125th District Court of Harris County
Trial Court J
udge:  Hon. John Coselli

Schwartz v. The Insurance Company of the State of Pennsylvania
(Tex.App.- Houston [1st Dist.] June 19, 2008)(Hanks)
(
health insurance coverage, delay in approval)
AFFIRM TC JUDGMENT: Opinion by
Justice George C. Hanks, Jr.
Before Justices Nuchia, Hanks and Higley
01-07-00193-CV Rosa Schwartz v. The Insurance Company of The State of Pennsylvania,
Gallagher Bassett Services, Inc., and Belinda Ybarra
Appeal from 295th District Court of Harris County
Trial Court
Judge: Hon. Tracy Christopher  

Late discovery and policy and belated notice of claims did not relief insurer of obligation
to pay cancer insurance claims - no prejudice shown
National Family Life Ins. Co. (Tex.App.- Houston [1st Dist.] Feb. 7, 2008)(Alcala)
(
insurance law, timeliness of notice, sicko law, health insurance coverage)
AFFIRM TC JUDGMENT: Opinion by Justice Alcala
Before Chief Justice Radack, Justices Alcala and Bland
01-06-00245-CV National Family Care Life Insurance Company v. Lelia E. Vann
Appeal from 239th District Court of Brazoria County (Judge Patrick Edward Sebesta)

Soto v. International Medical Group, Inc. (Tex.App.- Houston [14th Dist.] Apr. 3, 2007)(Anderson)
(medical insurance contract was properly rescinded)
[
insurance law, coverage dispute, rescission, accord and satisfaction]
Iris Reyes Soto purchased medical insurance from International Medical Group ("IMG") while she
worked for the Honduran Consulate in Houston, Texas.  She submitted application materials
indicating that she had no health problems.  Subsequent to her application, Ms. Reyes underwent a
hysterectomy.  IMG rescinded Ms. Reyes's insurance coverage for all of her medical bills due to
what they deemed material misrepresentations on her application for insurance.  Ms. Reyes filed
suit raising numerous grounds for relief.  A bench trial was held, and the trial court entered findings
of fact and conclusions of law after determining that Ms. Reyes had no valid claim.  Ms. Reyes now
appeals some of those findings and conclusions.  We affirm.

Bosch v. Provident American Life and Health Ins. Co. (Tex. App. [14th Dist.] Oct. 25, 2007)(op. on
rehearing by Justice Hedges)(Insurance cancellation, coverage denial, no FoF)
AFFIRMED: Opinion by Chief Justice Hedges
Before Chief Justice Hedges, Justices Hudson and Guzman
14-06-00694-CV Yigal Bosch v. Provident American Life and Health Insurance Company
Appeal from
113th District Court of Harris County (name of judge not shown)

Kim v. Farmers Ins. Exchange (Tex.App.- Houston [1st Dist.] Oct. 25, 2007)(Hanks)(insurance claim,
failure to notify, prejudice, no actual notice)
AFFIRM TC JUDGMENT: Opinion by Justice Hanks
Before Justices Taft, Hanks and Higley
01-05-01112-CV John Kim, as Receiver for Dale McPherson d/b/a Jamac Services, Inc., (Judgment
Debtor to Sharon Berryman) v. Farmers Insurance Exchange
Appeal from 164th District Court of Harris County (
Hon. Martha Hill Jamison)
It is undisputed that McPherson did not comply with the notice provisions of his policy.  We hold that Farmers has
shown that it was prejudiced by McPherson’s failure to notify it.  We further hold that there is no more than a scintilla
of evidence that Farmers had actual notice of Berryman’s claim.  Accordingly, we overrule issue four.
Because the grounds analyzed under this issue were sufficient to sustain the trial court’s rendition of summary
judgment, we need not consider the other bases for reversal asserted in this appeal.  

Harris v. Winston (Tex.App. - Houston [1st Dist.] May 24, 2007)(Alcala)
[life insurance proceeds, interpleader,
motion to recuse filed with wrong clerk]
AFFIRM TC JUDGMENT: Opinion by Justice Alcala
Before Justices Taft, Jennings and Alcala
01-05-00962-CV     William Francis Harris v. Antionette Richardson Winston
Appeal from Probate Court of Galveston County (Judge Hon. Gladys B. Burwell)
Judgment for Medical Insurer in Claim Denial Case Affirmed; Plaintiff did not disclose pre-existing
condition making her uninsurable on insurance application. Policy rescinded
Sicko Law Cases
(Tex.App.- Houston)
Houston Opinions

Texas Supreme Court Cases on the
Subject

Paj, Inc. v. The Hanover Ins. Co.,
No. 05-0849 (Tex. Jan. 11, 2008)
(Opinion by
Justice O'Neill)
(
insurance law, effect of failure to comply with notice
of claim requirements)
PAJ, INC. D/B/A PRIME ART & JEWEL v. THE
HANOVER INSURANCE COMPANY; from Dallas
County; 5th district (05-04-01047-CV, 170 S.W.3d
258, 08/26/05)
The Court reverses the court of appeals' judgment,
renders judgment in part, and remands the case to
the trial court in part.
Justice O'Neill delivered the opinion of the Court, in
which Chief Justice Jefferson, Justice Brister, Justice
Medina, and Justice Green joined.
Justice
Willett delivered a dissenting opinion, in which
Justice Hecht, Justice Wainwright, and Justice
Johnson joined.


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6/28/09