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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

Yklik Medical Supply, Inc. v. Allstate Insurance

Plaintiff Yklik Medical Supply, Inc., a medical supply provider, sued Allstate Insurance Company to recover $317 in unpaid medical bills for equipment supplied to its assignor, Tammy Agosto. Yklik moved for summary judgment, asserting proper bill submission and Allstate's failure to timely pay or deny the claim. Allstate argued that the charges exceeded the Workers' Compensation fee schedule and that a partial payment had been made. The court found that Yklik established a prima facie case. The central issue was whether Allstate's fee schedule defense was precluded due to its failure to issue a timely denial within 30 days as mandated by Insurance Law § 5106 (a) and 11 NYCRR 65-3.5. The court ruled that since Allstate waited 56 days to send its denial, it was precluded from raising the fee schedule defense, and therefore, summary judgment was granted to the plaintiff.

No-fault insurancesummary judgmenttimely denialfee schedulepreclusion ruleinsurance lawmedical supplybilling practicespersonal injury protectionassignor
References
19
Case No. MISSING
Regular Panel Decision
May 14, 2014

Forest Rehabilitation Medicine PC v. Allstate Insurance

Plaintiff Forest Rehabilitation Medicine PC sued defendant Allstate to recover $3,490 for no-fault medical benefits provided to assignor Tracy Fertitta. The core issue was the medical necessity of "Calmare pain therapy" (scrambler therapy), a novel treatment. The court conducted a bench trial, hearing expert testimony from both sides. Dr. Ayman Hadhoud, for the defense, argued the treatment was not medically necessary, not cost-effective, and essentially a form of physical therapy. Dr. Jack D’Angelo, for the plaintiff, countered that the therapy, though new, had FDA approval, was used by the military, and reduced the assignor's pain levels. Applying the Frye standard, the court found the evidence regarding Calmare scrambler therapy reliable and ruled it was medically necessary for Ms. Fertitta's pain management. Consequently, judgment was awarded to the plaintiff, Forest Rehabilitation Medicine PC, for $3,490 plus attorney's fees and interest.

No-Fault InsuranceMedical NecessityCalmare Pain TherapyScrambler TherapyNovel TreatmentFrye StandardExpert TestimonyPain ManagementFDA ApprovalCervical Radiculopathy
References
14
Case No. 2019 NY Slip Op 03749
Regular Panel Decision
May 15, 2019

Allstate Ins. Co. v. Buffalo Neurosurgery Group

The plaintiff, Allstate Insurance Company, appealed an order from the Supreme Court, Nassau County, which denied its motion for summary judgment on a complaint seeking a de novo determination of no-fault insurance benefits and, upon searching the record, awarded summary judgment to the defendant, Buffalo Neurosurgery Group. The case originated from a motor vehicle accident where Christopher Krull underwent spinal fusion surgery. The defendant, as Krull's assignee, submitted a claim for no-fault benefits, which Allstate denied. The matter proceeded through arbitration, with the master arbitrator affirming an award to the defendant. The Appellate Division modified the Supreme Court's order. It granted Allstate's motion for summary judgment on the grounds that the amount of benefits sought by the defendant was not in accordance with the workers' compensation fee schedule, and it deleted the provision awarding summary judgment to the defendant. The court affirmed the denial of Allstate's motion concerning the medical necessity of the surgery, stating Allstate failed to meet its prima facie burden on that issue. The order was affirmed as modified, with costs payable to the plaintiff.

no-fault insurance benefitsworkers' compensation fee schedulesummary judgmentmedical necessityde novo determinationarbitration awardappellate reviewspinal fusion surgeryinsurance law § 5106assignee claim
References
10
Case No. MISSING
Regular Panel Decision
Mar 18, 2016

Friedman v. Allstate Ins. Co.

This case involves an appeal from a Civil Court judgment that awarded the plaintiff, Paul Friedman, L.Ac., LMT, the principal sum of $2,160 for assigned first-party no-fault benefits for acupuncture services. The defendant, Allstate Insurance Company, denied the claims based on an independent medical examination (IME) by Dr. Chiu, which concluded that the assignor's injuries had resolved. However, the plaintiff's expert, Dr. Friedman, testified that further treatment was necessary. The Civil Court found the services medically necessary, and the appellate court affirmed this judgment, concluding that the plaintiff met its burden of demonstrating medical necessity.

AcupunctureMedical NecessityNo-Fault BenefitsIMEAssignorProvider ActionCivil Court AppealExpert TestimonyInsurance Denial
References
2
Case No. 2016-198 Q C
Regular Panel Decision
Jun 01, 2018

Comprehensive Care Physical Therapy, P.C. v. Allstate Ins. Co.

This case concerns a provider, Comprehensive Care Physical Therapy, P.C., seeking no-fault benefits from Allstate Insurance Company. The Civil Court initially denied the plaintiff's summary judgment motion and granted the defendant's cross-motion, dismissing the complaint based on the assignor's failure to appear for independent medical examinations (IMEs) and claims exceeding the fee schedule. On appeal, the Appellate Term modified this order, finding that Allstate failed to provide sufficient proof of timely denial form mailing, thereby precluding its defenses regarding IMEs and the fee schedule. Consequently, Allstate's cross-motion for summary judgment was denied, reversing that part of the lower court's decision. However, the Appellate Term affirmed the denial of the plaintiff's summary judgment motion, as the plaintiff also failed to establish their claims.

no-fault insurancesummary judgmentindependent medical examinationstimely denialinsurance defenseappellate reviewmedical billingassignee rightsprocedural requirementsfee schedule
References
5
Case No. 2016-1458 K C
Regular Panel Decision
Nov 09, 2018

Pavlova v. Allstate Ins. Co.

This case concerns an appeal regarding first-party no-fault benefits sought by Ksenia Pavlova, D.O., as assignee of Cosby Reavis, against Allstate Insurance Company. The Civil Court had denied the plaintiff's motion for summary judgment and partially granted the defendant's cross-motion, dismissing claims for services billed under CPT code 20999, arguing plaintiff was not entitled to payment under the workers' compensation fee schedule. The Appellate Term modified the Civil Court's order, finding that Allstate's denial of claims for CPT code 20999 was without merit because the insurer failed to request additional documentation as required by 11 NYCRR 65-3.5(b) for "By Report" codes. However, the Appellate Term affirmed the denial of the plaintiff's summary judgment motion, noting the plaintiff failed to demonstrate that claims were not timely denied or that denials were conclusory. The matter was remitted to the Civil Court for a determination on the medical necessity of the CPT code 20999 services, a ground not previously addressed.

No-Fault BenefitsSummary JudgmentAppellate TermCPT Code 20999Workers' Compensation Fee ScheduleMedical NecessityClaim DenialVerification Request11 NYCRR 65-3.5(b)Insurance Law
References
0
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. 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. 2013-1456 K C
Regular Panel Decision
Mar 11, 2016

EMC Health Prods., Inc. v. Allstate Ins. Co.

This case involves an appeal from an order of the Civil Court of the City of New York, Kings County, which had granted the plaintiff's motion for summary judgment. The plaintiff, EMC Health Products, Inc., as an assignee, sought to recover assigned first-party no-fault benefits from Allstate Insurance Company. The Appellate Term affirmed the Civil Court's decision concerning the first and second causes of action, determining that the defendant failed to establish timely mailing of denial of claim forms. However, the court modified the original order by denying summary judgment for the third and fourth causes of action. This modification was based on the defendant successfully raising triable issues of fact regarding timely denial due to lack of medical necessity and claims exceeding the workers' compensation fee schedule.

Summary JudgmentNo-Fault BenefitsFirst-Party BenefitsMedical NecessityWorkers' Compensation Fee ScheduleTimely DenialAppellate ReviewCivil Court OrderAssignee ClaimsInsurance Law
References
3
Case No. 2014-505 Q C
Regular Panel Decision
Sep 27, 2016

GBI Acupuncture, P.C. v. Allstate Ins. Co.

This case involves an appeal by GBI Acupuncture, P.C. from an order of the Civil Court which granted Allstate Insurance Company's motion for summary judgment, dismissing several causes of action for assigned first-party no-fault benefits. Allstate's defense was based on the premise that it had fully paid the plaintiff according to the workers' compensation fee schedule. However, the appellate court found that Allstate failed to provide sufficient evidence, specifically affidavits, to demonstrate a standard office practice or procedure ensuring the timely mailing of denial of claim forms. Consequently, the appellate order reversed the lower court's decision, denying Allstate's motion for summary judgment on the contested causes of action.

No-Fault BenefitsSummary JudgmentDenial of ClaimTimely MailingAffidavitsStandard Office PracticeWorkers' Compensation Fee ScheduleAppellate ReviewCivil CourtInsurance Dispute
References
1
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