Justia U.S. 5th Circuit Court of Appeals Opinion Summaries

Petitioner, a skilled nursing facility that participated in the federal Medicare and Medicaid programs, petitioned for review of the final decision of the Departmental Appeals Board (DAB) of the U.S. Department of Health and Human Services (HHS) finding that petitioner was in substantial noncompliance with regulations covering skilled nursing facilities, and affirming civil monetary penalties and denial of payment for new admissions. Finding that the DAB's decisions were supported by substantial evidence and were not arbitrary and capricious, an abuse of discretion, or otherwise not in accordance with law, the court dismissed the petition for review.

Appellant appealed the district court's summary judgment on her ERISA, 29 U.S.C. 1132(a)(1)(B), claim to recover denied health care benefits and the magistrate judge's decision to limit discovery. At issue was the scope of admissible evidence and permissible discovery in an ERISA action to recover benefits under section 1132(a)(1)(B). The court held that the district court too narrowly defined the scope of discovery where appellant sought to discover evidence that would indicate whether the administrative record was complete, whether Blue Cross complied with ERISA's procedural requirements, and whether Blue Cross previously afforded coverage claims related to the jaw, teeth, or mouth. The court concluded that appellant's discovery request was at least reasonably calculated to lead to the discovery of some admissible evidence and that the district court's abuse of discretion prejudiced appellant's ability to demonstrate that Blue Cross failed to comply with ERISA's procedural requirements. Accordingly, the court vacated and remanded for further proceedings.

Dr. Tandy McElwee, Ava McElwee, and Wendy Chriss, three former employees of a private medical practice, were convicted for engaging in a conspiracy to fraudulently obtain large amounts of hydrocodone, a controlled substance. All three appellants challenged their sentences. The court affirmed the 60 month sentence with respect to Dr. McElwee and the $550,000 fine imposed by the district court. As to Mrs. McElwee, the court held that the evidence was sufficient to support her conviction, that the district court committed no error affecting her substantial rights in its issuance of instructions to the jury, and that the district court did not abuse its discretion in sentencing her to a 36 month term of imprisonment. Finally, the court affirmed Chriss' 21 month sentence, including the district court's denial of the safety-valve reduction and its refusal to apply a reduction for her role in the offense.

This case involved the construction and application of a combined professional and general liability insurance policy issued by appellant to appellee where appellee requested a defense from appellant under the policy for a civil lawsuit. In that underlying suit, plaintiff alleged that while her mother was terminally ill, she consented to appellee's harvesting of some of her mother's organs and tissues after her mother's death and consented to the harvesting because appellee was a non-profit corporation. Appellee, instead, transferred the tissues to a for-profit company, which sold the tissues to hospitals at a profit. Appellee subsequently sought coverage under its general liability insurance with appellant and appellant denied coverage because the conduct alleged was outside the scope of the insurance policy's coverage. The court certified the following questions to the Supreme Court of Texas: (1) "Does the insurance policy provision for coverage of 'personal injury,' defined therein as 'bodily injury, sickness, or disease including death resulting therefrom sustained by any person,' include coverage for mental anguish, unrelated to physical damage to or disease of the plaintiff's body?" (2) "Does the insurance policy provision for coverage of 'property damage,' defined therein as 'physical injury to or destruction of tangible property, including consequential loss of use thereof, or loss of use of tangible property which has not been physically injured or destroyed,' include coverage for the underlying plaintiff's loss of use of her deceased mother's tissues, organs, bones, and body parts?"

This case involved a coverage dispute between St. Paul Fire & Marine Insurance Company ("St. Paul") and its insured where the insured wrote a recommendation letter for a former employee who later injured a patient. St. Paul appealed the district court's judgment, in which the court concluded that the commercial general liability policy issued by St. Paul covered the insured's claim for the damages he was required to pay in a misrepresentation lawsuit. The court held that there was no coverage under the policy for the amounts at issue and therefore, reversed the district court's judgment and remanded for entry of judgment in favor of St. Paul.