in Re Texas Mutual Insurance Company
09-15-00265-CV
| Tex. App. | Aug 13, 2015Background
- Plaintiff Ellis (employer) sued Texas Mutual seeking an order requiring the insurer to provide workers’ compensation benefits to employee Larry Smith and to reimburse Ellis for medical expenses after Smith’s alleged on-the-job injury on June 23, 2014.
- Texas Mutual denied Smith’s claim, asserting the workers’ compensation policy had expired about three weeks before the injury.
- Texas Mutual moved to dismiss for lack of subject-matter jurisdiction, arguing Ellis had not pursued the Division of Workers’ Compensation’s administrative process.
- Ellis asserted the trial court retained jurisdiction because his claim was premised on equitable estoppel/waiver (relying on Dairyland v. Mason).
- The trial court denied Texas Mutual’s motion to dismiss; Texas Mutual petitioned this Court for mandamus relief.
- The Court of Appeals concluded Ellis’s claim falls within the Division’s exclusive administrative jurisdiction, that Ellis had not exhausted administrative remedies, and thus the trial court abused its discretion by denying dismissal.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the trial court has jurisdiction over Ellis’s claim for benefits/reimbursement | Ellis: claim is based on equitable estoppel/waiver (Mason) so court may decide insurer’s cancellation/waiver | Texas Mutual: claim concerns carrier handling of a workers’ comp claim and falls within the Division’s exclusive administrative jurisdiction; Ellis failed to pursue administrative remedies | Held: Trial court lacked subject-matter jurisdiction; administrative process is exclusive and mandatory |
| Whether Ellis must pursue administrative remedies before seeking judicial relief | Ellis: court can adjudicate equitable estoppel/waiver without administrative exhaustion | Texas Mutual: Act requires exhaustion; Crawford & Co. and Ruttiger confirm exclusive administrative scheme | Held: Ellis must use the Division’s administrative process prior to judicial review; failure to do so requires dismissal |
Key Cases Cited
- Dairyland County Mutual Insurance Company of Texas v. Mason, 460 S.W.2d 481 (Tex. Civ. App.—Beaumont 1970) (discussing insurer waiver/cancellation issues)
- Texas Mutual Insurance Co. v. Ruttiger, 381 S.W.3d 430 (Tex. 2012) (explaining the Workers’ Compensation Act’s comprehensive administrative scheme)
- In re Crawford & Co., 458 S.W.3d 920 (Tex. 2015) (holding Division has exclusive jurisdiction over carrier handling/settlement disputes)