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Case Law Database

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

Case No. ADJ6888108
Regular
Aug 15, 2013

WENDY PARUSZKIEWICZ vs. AMERICAN MEDICAL RESPONSE; ACE AMERICAN INSURANCE, Adjusted by SEDGWICK CMS

This case involves an applicant, Wendy Paruszkiewicz, and defendants American Medical Response and ACE American Insurance. The Workers' Compensation Appeals Board dismissed the applicant's petition for reconsideration because it was filed from a non-final, interlocutory order. Such interim procedural rulings, concerning evidence or trial setting, do not determine substantive rights and are therefore not subject to reconsideration. The petition for removal was also denied as no irreparable harm or prejudice was shown, nor was reconsideration deemed an inadequate remedy.

Petition for ReconsiderationPetition for RemovalFinal OrderInterlocutory OrderSubstantive RightLiabilityAdministrative Law JudgeReport and RecommendationSubstantial PrejudiceIrreparable Harm
References
10
Case No. 19 Misc 3d 1104(A), 2008 NY Slip Op 50546(U)
Regular Panel Decision

Westchester Medical Center v. American Transit Insurance

This case involves an appeal in an action to recover no-fault medical payments. The plaintiff, Westchester Medical Center (WMC), as assignee of Daphne McPherson, sought summary judgment against American Transit Insurance Company, arguing that the defendant failed to timely pay or deny benefits. The Supreme Court initially granted WMC summary judgment. However, the appellate court reversed this judgment, finding that the defendant had presented a prima facie case for a timely request for additional verification, which effectively tolled the period for denying the claim. The defendant's denial was based on the premise that McPherson might be entitled to workers' compensation benefits. While reversing the summary judgment for WMC, the appellate court declined the defendant's request for summary judgment or referral to the Workers' Compensation Board due to insufficient evidence from the defendant regarding workers' compensation eligibility.

No-fault medical paymentsInsurance disputeSummary judgment reversalTimely denialAdditional verificationWorkers' compensation eligibilityAppellate DivisionAssignee claimMotor vehicle accidentCivil Practice Law and Rules
References
6
Case No. ADJ10125079
Regular
Feb 22, 2017

BIRGIT GALINDO vs. AMERICAN MEDICAL RESPONSE, ACE AMERICAN INSURANCE COMPANY

This case involves a petition for removal filed by the defendants, American Medical Response and its insurer. The Workers' Compensation Appeals Board (WCAB) denied the petition, citing that removal is an extraordinary remedy only granted in cases of substantial prejudice or irreparable harm. The WCAB found that the defendants failed to demonstrate such harm and that reconsideration would be an adequate remedy if an adverse decision is eventually issued. Therefore, the defendants' contentions can be raised with the trial judge.

Petition for RemovalWorkers' Compensation Appeals BoardSubstantial PrejudiceIrreparable HarmReconsiderationWCJ AnalysisAdministrative Law JudgeExtraordinary RemedyFinal DecisionTrial Judge
References
2
Case No. MISSING
Regular Panel Decision

Curry v. American International Group, Inc. Plan No. 502

Curry, a former Regional Insurance Underwriting Manager for AIG, sued American International Group, Inc. Plan No. 502 and American International Life Assurance Co. of New York ("AI Life") under ERISA § 502(a) after her long-term disability benefits were terminated. Curry suffers from degenerative osteoarthritis and diabetes. AI Life initially approved her benefits but later terminated them, alleging she could perform a sedentary occupation, relying on unverified medical responses. The court found AI Life's decision to be arbitrary and capricious due to its reliance on unreliable medical opinions, failure to clarify the record, and disregard for Curry's doctors' reports. Consequently, the court granted Curry's motion for summary judgment, denying the defendants' motion, and ordered the reinstatement of her benefits with prejudgment interest and attorney's fees.

ERISALong-term disabilityBenefits terminationArbitrary and capricious standardConflict of interestMedical opinionUnreliable evidenceSummary judgmentOrthopaedic conditionsDiabetes
References
10
Case No. ADJ10034122
Regular
Dec 22, 2017

CRYSTAL WYANT vs. AMERICAN MEDICAL RESPONSE, ACE AMERICAN INSURANCE COMPANY

This case concerns an applicant's industrial back injury requiring lumbar spinal fusion. Defendants sought to overturn a prior award granting ongoing medical treatment, arguing a subsequent Utilization Review (UR) certification was invalid. The Appeals Board denied reconsideration, finding the UR process was correctly followed. A second Request for Authorization (RFA) submitted by the applicant's physician included "Change in Material Facts," triggering a new review. This second UR decision, dated September 11, 2017, authorized the surgery as medically necessary, superseding the earlier denial.

Utilization ReviewIndependent Medical ReviewReconsiderationFindings and AwardAdministrative Law JudgeLabor Code Section 4610Request for AuthorizationLumbar Spinal FusionMedical TreatmentChange in Material Facts
References
4
Case No. 2016-1618 K C
Regular Panel Decision
Mar 22, 2019

Active Care Med. Supply Corp. v. American Tr. Ins. Co.

This case concerns an appeal by Active Care Medical Supply Corp. against American Transit Ins. Co. regarding first-party no-fault benefits. The plaintiff, an assignee of Luciano Ernesto, sought summary judgment, while the defendant cross-moved to either dismiss the complaint or hold the action in abeyance. The defendant argued that Luciano Ernesto might be eligible for workers' compensation benefits, thus requiring a determination from the Workers' Compensation Board. The Civil Court granted the defendant's cross-motion to hold the action in abeyance. The Appellate Term affirmed this decision, reiterating that the Workers' Compensation Board has primary jurisdiction over the applicability of the Workers' Compensation Law and that courts should defer to the Board's determination.

No-Fault BenefitsWorkers' Compensation LawPrimary JurisdictionAbeyanceAppellate TermSummary JudgmentEligibility DisputeFirst-Party BenefitsInsurance CoverageAssignor-Assignee
References
9
Case No. ADJ9198656; ADJ9192994
Regular
Jul 07, 2025

JEANETTE LIRA vs. COTTAGE HEALTH SYSTEM, PSI, SANSUM SANTA BARBARA MEDICAL, ZURICH AMERICAN INSURANCE COMPANY

Defendants Cottage Health System and Zurich American Insurance Company sought reconsideration of a Joint Findings and Award. Cottage Health contended it was incorrectly identified as the liable employer instead of Sansum Santa Barbara Medical, insured by Zurich. Zurich argued there were multiple injuries or that compensation was barred by the statute of limitations. The Appeals Board denied Zurich's petition, granted Cottage Health's petition, and amended the award to reflect Sansum Santa Barbara Medical, insured by Zurich American Insurance Company, as the liable party.

Workers' Compensation Appeals BoardJeanette LiraCottage Health SystemGallagher BassettZurich American Insurance CompanySansum Santa Barbara MedicalAdjudication NumbersJoint Findings and AwardPetition for ReconsiderationComplex Regional Pain Syndrome
References
6
Case No. ADJ3501807 (SRO 0141934)
Regular
Sep 08, 2011

JESSICA REYNOLDS vs. AMERICAN MEDICAL RESPONSE, ACE AMERICAN INSURANCE

The Appeals Board denied the defendant's Petition for Removal seeking to replace a Qualified Medical Evaluator (QME). The defendant argued the QME violated Administrative Director Rule 34(b) by scheduling an exam at an unlisted address. However, the Board found the defendant failed to demonstrate substantial prejudice or irreparable harm necessary for removal. The Board agreed with the WCJ's finding that the objection appeared to be an attempt at "doctor shopping" and gamesmanship, contrary to the policy of substantial justice.

Petition for RemovalQualified Medical EvaluatorReplacement Panel QMELabor Code section 4062.2Administrative Director Rule 34(b)substantial prejudiceirreparable harmdoctor shoppinggamesmanshipsocial public policy
References
2
Case No. ADJ6552734
Regular
Apr 02, 2015

Diane Garibay-Jimenez vs. Santa Barbara Medical Foundation Clinic, Zurich American Insurance

This case concerns a denied request for left ulnar nerve decompression surgery. The Administrative Law Judge (WCJ) upheld the denial, finding the applicant failed to provide necessary Agreed Medical Examiner (AME) reports to the Independent Medical Review (IMR), making a further review unreasonable. However, the Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinding the WCJ's order. The WCAB found the defendant failed to comply with Labor Code section 4610.5(l) by not providing all relevant medical records to IMR, thus invalidating the prior IMR determination. The matter was returned for a new IMR application, holding the defendant responsible for submitting complete records.

Workers' Compensation Appeals BoardDiane Garibay-JimenezSanta Barbara Medical Foundation ClinicZurich American InsuranceADJ6552734Opinion and Order Granting Petition for ReconsiderationExpedited Findings of Fact and OrderAdministrative Law JudgeIndependent Medical ReviewUtilization Review
References
0
Case No. MISSING
Regular Panel Decision

Veryzer v. American International Life Assurance Co.

Robert Veryzer, Ph.D. ("Plaintiff") sued American International Life Assurance Company of New York ("AI Life") under ERISA, challenging the insurer's denial of his long-term disability benefits. AI Life had limited benefits to 24 months, classifying Veryzer's disability as "Mental Illness" despite extensive medical evidence from his treating physicians and neuropsychologists attributing it to mercury poisoning from Hepatitis A and B vaccinations. The court found AI Life's decision arbitrary and capricious, unsupported by substantial evidence, citing the insurer's reliance on non-examining experts who ignored medical literature and procedural irregularities in the claims process. Highlighting AI Life's conflict of interest as both administrator and payor, the court denied AI Life's motion for summary judgment, granted Veryzer's cross-motion, reversed the denial of benefits, and ordered AI Life to provide the requested coverage.

ERISA claimsLong-term disabilitySummary judgment motionsArbitrary and capricious reviewMercury toxicityVaccination injuryCognitive impairment benefitsMedical expert testimonyInsurance bad faithClaims processing irregularities
References
26
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