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

Case No. MISSING
Regular Panel Decision

Claim of Cummins v. North Medical Family Physicians

A claimant sustained a work-related back injury and sought continued medical treatment, which was initially authorized. Disputes over authorization led the claimant to retain an attorney. A Workers’ Compensation Law Judge authorized continued medical treatment but denied counsel fees, stating no "money passing" occurred. The Workers' Compensation Board upheld this decision. The claimant appealed, arguing the Board unconstitutionally applied Workers’ Compensation Law § 24, misinterpreted the statute regarding fee payment from medical benefits, and abused its discretion. The appellate court affirmed the Board's decision, ruling that counsel fees must be paid from "compensation," defined as a money allowance, and medical benefits are not considered "compensation" for this purpose, thus finding no abuse of discretion.

Workers' CompensationCounsel FeesAttorney FeesMedical TreatmentStatutory InterpretationConstitutional LawLienCompensation DefinitionAppellate ReviewBoard Decision
References
3
Case No. MISSING
Regular Panel Decision
Oct 14, 2008

Westchester Medical Center v. Lincoln General Insurance

The plaintiff appealed an order from the Supreme Court, Nassau County, which denied its motion for summary judgment to recover no-fault medical benefits. The appellate court reversed the order, granting the plaintiff's motion. The plaintiff successfully demonstrated a prima facie case by showing that statutory billing forms were mailed and received, and the defendant failed to either pay or deny the claim within the 30-day period. The court rejected the defendant's arguments that letters advising of an investigation tolled the statutory period and that the period was tolled pending a no-fault application. Additionally, defenses related to Workers' Compensation benefits or the assignor's failure to appear at an examination under oath were found insufficient to defeat the medical provider's right to benefits.

no-fault insurancemedical benefitssummary judgmentinsurance contractstatutory periodtimely denialworkers' compensationpolicy conditionpreclusion remedyappellate review
References
19
Case No. MISSING
Regular Panel Decision

Lutheran Medical Center v. Hereford Insurance

Maher Kiswani, a livery car driver, was injured in an automobile accident and received medical treatment from Lutheran Medical Center. Lutheran, as Kiswani's assignee, sought payment from Hereford Insurance Company, the no-fault carrier, which refused to pay. After an initial arbitration where the Workers' Compensation Board determined Kiswani was not injured in the course of employment (without Hereford's notice), a second arbitration awarded Lutheran no-fault benefits. The Supreme Court, Kings County, vacated this arbitration award, ruling that Hereford should have been notified of the Workers' Compensation Board hearing. The appellate court affirmed the Supreme Court's decision, holding that a party not afforded an opportunity to participate in a Board hearing is not bound by its determination.

Arbitration AwardNo-Fault InsuranceWorkers' Compensation BoardDue ProcessNotice RequirementsVacated Arbitration AwardAppellate ReviewLivery Car DriverAutomobile AccidentMedical Benefits
References
3
Case No. MISSING
Regular Panel Decision

Dingee v. DiNapoli

The petitioner sought disability retirement benefits after sustaining a back injury at work. The Retirement System denied the application, a decision upheld by the Hearing Officer and subsequently by the respondent, citing the petitioner's failure to prove permanent incapacitation. In reviewing this determination, the court considered conflicting medical opinions from a chiropractor and an orthopedic surgeon, both suggesting that further medical treatment, including weight loss and physical therapy, could potentially alleviate the petitioner's condition. The court found substantial evidence to support the respondent's decision that the petitioner was not permanently disabled due to the availability of further medical treatment. Consequently, the court confirmed the respondent's determination and dismissed the petition.

Disability Retirement BenefitsPermanent IncapacitationCorrection Officer DutiesBack InjuryHerniated DiscConflicting Medical EvidenceOrthopedic Surgeon OpinionChiropractor OpinionWeight Loss RecommendationPhysical Therapy Recommendation
References
7
Case No. ADJ2270634 (VNO 0521616)
Regular
Aug 03, 2018

SHEVON THOMAS vs. POMONA VALLEY HOSPITAL MEDICAL CENTER, Administered by ADMINSURE, INC., SUBSEQUENT INJURIES BENEFITS TRUST FUND

This case concerns an applicant seeking benefits from the Subsequent Injuries Benefits Trust Fund (SIBTF) following a 2005 industrial injury that resulted in a 69% permanent disability and a substantial settlement. The applicant's claim for SIBTF benefits was denied because she failed to establish a prior "labor disabling" permanent disability that existed before the 2005 injury. The Appeals Board upheld the denial, finding that the applicant's evidence of prior symptoms, including a doctor's speculative impairment ratings, lacked substantial medical evidence and did not meet the strict requirements for establishing a pre-existing, labor-disabling condition. The Board emphasized that post-injury medical opinions, especially those based on hypotheticals and inadequate history, cannot retroactively establish a prior disability for SIBTF eligibility.

Subsequent Injuries Benefits Trust FundSIBTFlabor disablingpermanent partial disabilityLabor Code section 4751SB 899apportionmentpreexisting disabilityAMA Guides impairment ratingsretrospective prophylactic work restrictions
References
8
Case No. MISSING
Regular Panel Decision

Claim of Jacob v. New York City Transit Authority

Claimant sustained work-related injuries in January 2000 and later sought workers’ compensation benefits alleging recurrence. An issue arose regarding the veracity of the medical history provided to the employer’s independent medical examiners, specifically concerning undisclosed prior similar injuries. A workers’ compensation law judge and subsequently the Workers’ Compensation Board found that the claimant violated Workers’ Compensation Law § 114-a, leading to disqualification from wage replacement benefits. However, the Board authorized medical treatment for the January 2000 injuries. On cross appeals, the Board’s determination was affirmed, finding substantial evidence supported the violation and the appropriateness of the penalties imposed.

Workers' Compensation Law Section 114-aMedical MisrepresentationWage Replacement Benefits DisqualificationMedical Treatment AuthorizationPrior Injuries DisclosureSubstantial Evidence ReviewIndependent Medical ExaminationWorkers' Compensation Board DecisionAppellate ReviewAffirmed Decision
References
4
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. MISSING
Regular Panel Decision

Queens Blvd. Medical, P.C. v. Travelers Indemnity Co.

The plaintiff, Queens Blvd. Medical, P.C., sought $950 in first-party no-fault benefits for biofeedback medical services provided to its assignor for lower back and chronic pain syndrome. The central issue at trial was the medical necessity of these services under Insurance Law § 5102 (a) (1). The plaintiff established a prima facie case with expert testimony from a board-certified neurologist affirming the medical appropriateness of biofeedback. The defendant insurance company failed to present admissible evidence to disprove medical necessity, as its expert was deemed incompetent to testify on biofeedback for back pain. Consequently, the court granted the plaintiff's motion for a directed verdict, awarding judgment for $950 along with statutory costs, interest, and attorney's fees.

No-fault benefitsMedical necessityBiofeedback treatmentExpert testimonyDirected verdictInsurance lawChronic pain syndromeBack injuryCPT codesBurden of proof
References
9
Case No. ADJ9445538
Regular
Oct 05, 2017

WENDY LEUNG vs. HUNTINGTON MEDICAL FOUNDATION, SUBSEQUENT INJURIES BENEFIT TRUST FUND

The Workers' Compensation Appeals Board denied Wendy Leung's petition for reconsideration of the administrative law judge's decision. The judge found no substantial medical evidence to support a subsequent compensable industrial permanent disability claim sufficient for benefits from the Subsequent Injuries Benefit Trust Fund (SIBTF). Leung contended she met SIBTF eligibility by claiming a prior $43\%$ permanent disability, a subsequent injury, and a resulting combined disability exceeding $70\%$. However, the Board agreed that Leung failed to prove industrial causation for her subsequent injury with reasonable medical probability.

Subsequent Injuries Benefit Trust FundLabor Code Section 4751cumulative injurypermanent disabilityreasonable medical probabilityindustrial causationapportionmentQualified Medical Evaluator (QME)Agreed Medical Evaluator (AME)Workers' Compensation Appeals Board (WCAB)
References
2
Case No. MISSING
Regular Panel Decision

Schonholz v. Long Island Jewish Medical Center

Plaintiff Gleniss Schonholz sued her former employer, Long Island Jewish Medical Center (LIJ), and several individual defendants under ERISA, seeking severance benefits. Schonholz alleged that LIJ wrongfully denied her severance benefits after requesting her resignation and promising benefits under a May 1991 plan, which she claims was revoked after her employment termination or not in writing. She also brought a promissory estoppel claim and claims against individual defendants for breach of fiduciary duty, seeking punitive damages. The court denied defendants' motion to dismiss the ERISA claim, finding plaintiff adequately alleged non-payment of benefits under a plan in effect at her termination or an invalid unwritten revocation. However, the court granted the motion to dismiss the promissory estoppel claim with leave to amend, as plaintiff failed to allege actual reliance. Claims against individual defendants for breach of fiduciary duty and for punitive damages were dismissed with prejudice, as fiduciary duties run to the plan, not individuals, and punitive damages are generally unavailable under ERISA. Cross-motions for Rule 11 sanctions were also denied.

ERISAEmployee BenefitsSeverance PayMotion to DismissPromissory EstoppelFiduciary DutyPunitive DamagesRule 11 SanctionsEmployment LawWelfare Plan
References
39
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