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

Case No. 25 NY3d 907
Regular Panel Decision
2015-XX-XX

Government Employees Insurance v. Avanguard Medical Group, PLLC

This case addresses whether no-fault insurance carriers are obligated to pay facility fees to New York State-accredited office-based surgery (OBS) centers for the use of their premises and support services. The court concluded that neither existing statutes nor regulations mandate such payments. Plaintiffs, a group of GEICO insurers, successfully sought a declaratory judgment that they are not legally required to reimburse Avanguard Medical Group, PLLC, for OBS facility fees, totaling over $1.3 million. The decision affirmed the Appellate Division's ruling, emphasizing that OBS facility fees are not explicitly covered by statute or fee schedules, nor do they fall under reimbursable "professional health services" as per 11 NYCRR 68.5. The court highlighted the distinct regulatory frameworks for OBS centers compared to hospitals and ambulatory surgery centers, declining to mandate policy changes best left to the legislature.

No-Fault InsuranceOffice-Based Surgery (OBS)Facility FeesInsurance LawBasic Economic LossFee SchedulesWorkers' Compensation BoardDepartment of Financial ServicesStatutory InterpretationRegulatory Framework
References
16
Case No. 2014-1081 K C
Regular Panel Decision
Oct 05, 2016

High Quality Med. Supplies, Inc. v. Mercury Ins. Group

This case involves an appeal concerning assigned first-party no-fault benefits sought by High Quality Medical Supplies, Inc., as assignee of Charles Botwee. The defendant, Mercury Ins. Group, appealed an order from the Civil Court that denied its motion for summary judgment to dismiss the complaint. Mercury Ins. Group contended that billing for durable medical equipment not listed in a fee schedule is not compensable. However, the Appellate Term affirmed the lower court's decision, citing 11 NYCRR 68.5, which specifically permits reimbursement for healthcare services not explicitly covered by fee schedules, thereby rejecting the defendant's argument.

No-Fault BenefitsFirst-Party BenefitsDurable Medical EquipmentFee ScheduleSummary JudgmentAppellate TermAssigned BenefitsInsurance LawReimbursementCivil Court
References
3
Case No. MISSING
Regular Panel Decision
Aug 02, 2013

National Integrated Group Pension Plan v. Dunhill Food Equipment Corp.

This case, filed under ERISA, involves the National Integrated Group Pension Plan and its Board of Trustees (Plaintiffs) seeking to collect withdrawal liability from Dunhill Food Equipment, Esquire Mechanical, Geoffrey Thaw, Sanford Associates, and Custom Stainless (Defendants). The core dispute revolved around whether the non-Dunhill defendants were part of a commonly controlled group at the time of Dunhill's withdrawal from the pension plan, and whether Geoffrey Thaw could be held personally liable through veil piercing. The court ruled that Dunhill, Esquire, and Thaw were jointly and severally liable for the withdrawal liability, attorney's fees, costs, interest, and liquidated damages, finding Thaw's complete domination and misuse of corporate funds justified piercing the corporate veil. However, the claims against Sanford and Custom Stainless were dismissed, as they were determined to have effectively dissolved prior to the withdrawal date, thus not being members of the controlled group.

ERISA LitigationMPPAA LiabilityPension WithdrawalCorporate Veil PiercingSummary Judgment MotionControlled Group LiabilityCorporate DissolutionPersonal LiabilityEmployee Benefits LawFiduciary Breach
References
48
Case No. ADJ1857578
Regular
Jun 23, 2009

MIRNA LICEA vs. MINSON CORPORATION, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for PHICO INSURANCE COMPANY in liquidation

This case involves a lien claim by Missirian Orthopedic Medical Group, assigned to KM Financial Services, for medical treatment provided to Mirna Licea. The California Insurance Guarantee Association (CIGA), representing the insolvent insurer Phico Insurance Company, denied the lien based on Insurance Code § 1063.1(c)(9), which excludes claims by assignees. The Workers' Compensation Appeals Board denied reconsideration, affirming that the statute clearly prohibits payment to assignees, including medical providers who have assigned their accounts receivable. The Board relied on *Baxter Healthcare Corp. v. CIGA* for the principle that assigned claims are not "covered claims" under the Guarantee Act.

Workers' Compensation Appeals BoardCalifornia Insurance Guarantee AssociationCIGAPhico Insurance Companyliquidationinsolvent insurerlien claimantassigneecovered claimInsurance Code 1063.1(c)(9)
References
4
Case No. MISSING
Regular Panel Decision
Sep 16, 1992

Pica v. Montefiore Medical Group

The Supreme Court, Bronx County, dismissed a personal injury action brought by an employee of Montefiore Hospital and Medical Center against Montefiore Medical Group. The dismissal was based on the affirmative defense of Workers' Compensation. The plaintiff failed to demonstrate that Montefiore Medical Group was a separate legal entity from Montefiore Hospital and Medical Center, whose employee controlled her work. Consequently, the court found recovery barred under Workers' Compensation Law § 11. The appellate court unanimously affirmed the dismissal.

Workers' CompensationPersonal InjuryEmployer LiabilityCorporate VeilExclusive RemedyAffirmative DefenseAppellate DecisionMotion to DismissSummary JudgmentBronx County
References
3
Case No. MISSING
Regular Panel Decision
Jun 19, 2001

Carman v. Abter

A nurse employed by a medical center providing dialysis services alleged she contracted HIV after a needle stick injury sustained while drawing blood from a patient. She filed a medical malpractice action against the medical center, a salaried physician (Dr. Ma) employed by a nephrology group associated with the center, and an independent infectious disease consultant (Dr. Abter) used by the group. The Supreme Court initially dismissed the complaint against all defendants, applying the Workers' Compensation Law's "fellow employee rule." On appeal, the judgment was modified. The appellate court affirmed the dismissal for the medical center and Dr. Ma, concluding their services to the plaintiff were employment-related and not available to the general public. However, the complaint against Dr. Abter was reinstated, as the fellow-employee rule was found not to apply to him given his status as an independent consultant.

Medical malpracticeHIV exposureNeedle stick injuryWorkers' CompensationFellow employee ruleIndependent contractorPhysician negligenceEmployer liabilityAppellate reviewNew York law
References
1
Case No. 2022 NY Slip Op 02801 [204 AD3d 1016]
Regular Panel Decision
Apr 27, 2022

Matter of Panos v. Mid Hudson Med. Group, P.C.

Spyros Panos was terminated from Mid-Hudson Medical Group (MHMG) for submitting fraudulent medical bills and subsequently pleaded guilty to healthcare fraud. Panos initiated an action for breach of contract against MHMG, which proceeded to arbitration. The arbitrator applied the faithless servant doctrine and granted MHMG's motion for summary judgment, dismissing Panos's claims. Panos then sought to vacate the arbitration award in the Supreme Court, Dutchess County, but the court denied his petition and dismissed the proceeding. On appeal, the Appellate Division affirmed the lower court's judgment, concluding that Panos failed to demonstrate that the arbitrator manifestly disregarded the law.

Arbitration awardVacaturFaithless servant doctrineBreach of contractSummary judgmentHealth care fraudAppellate reviewJudicial reviewEmployment agreementFiduciary duty
References
18
Case No. ADJ3871980 (SBR 0332495) ADJ1578450 (SBR 0333829) ADJ7125261
Regular
Nov 05, 2010

ANITA BAKER vs. SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP, PSI, Adjusted and Administered By KAISER PERMANENTE MEDICAL GROUP

This case involves Anita Baker's workers' compensation claim against Southern California Permanente Medical Group. The Workers' Compensation Appeals Board denied reconsideration of the judge's decision. The primary dispute centered on the calculation of diminished future earning capacity, with the applicant arguing for a calculation based on actual lost earnings and the defendant relying on statutory guidelines and expert testimony. The Board adopted the judge's report, which found in favor of the applicant regarding the calculation of permanent disability, incorporating aspects of both expert opinions and considering the applicant's specific circumstances.

Workers Compensation Appeals BoardSouthern California Permanente Medical GroupKaiser Permanente Medical GroupPetition for ReconsiderationWorkers' Compensation Administrative Law JudgeOgilvie v. City and County of San Franciscodiminished future earning capacityFindings and Awardcontinuous traumabilateral upper extremities
References
1
Case No. ADJ10477247
Regular
Oct 31, 2017

ESTELA WALLE vs. THE PERMANENTE MEDICAL GROUP

Here's a summary of the two cases for a lawyer, in max four sentences each: **Case 1: Estela Walle vs. The Permanente Medical Group (ADJ10477247)** The Workers' Compensation Appeals Board denied reconsideration, affirming the WCJ's finding that the applicant did not sustain a back injury arising out of and in the course of employment. The Board gave significant weight to the WCJ's credibility determination, finding no substantial evidence to warrant overturning it. Therefore, the applicant was awarded nothing on her claim. **Case 2: Estela Walle vs. The Permanente Medical Group (ADJ8620015, ADJ9183471)** The Appeals Board rescinded the WCJ's award for psychiatric injury and returned the case to the trial level for further proceedings. The Board found the analysis of whether the injury was predominantly caused by employment events, and specifically by lawful, good faith personnel actions, to be inadequate under *Rolda*. Further development of the record is required to clarify the events of May 21, 2012, and to determine the precise causal contribution of employment-related factors versus good faith personnel actions.

Workers' Compensation Appeals BoardReconsiderationFindings and OrderApplicantInjury Arising Out of and In the Course of EmploymentAOE/COEBack InjuryWCJCredibility DeterminationGarza v. Workmen's Comp. Appeals Bd.
References
1
Case No. ADJ6713503
Regular
May 16, 2014

MATTHEW JENSON vs. PEPSI BOTTLING GROUP, SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board denied the Petition for Reconsideration filed by South Lake Medical Center and its associated entities. The Board also dismissed the successive Petition for Reconsideration filed by Accurate Medical Assessment Rating Center (AMARC). AMARC's prior petition was already denied, and successive petitions are not permitted, requiring review by the Court of Appeals instead. The Board adopted the WCJ's Report and Recommendation in support of these decisions.

WCABLien ClaimantPetition for ReconsiderationLabor Code section 5813California Code of Regulations title 8 section 10561WCJSanctionsSuccessive PetitionOrder Denying Petitions for ReconsiderationWrit of Review
References
2
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