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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

Long Island Neurological Assocs., P.C. v. Highmark Blue Shield & Reed Smith LLP

Plaintiff Long Island Neurological Associates, P.C. sued Highmark Blue Shield and Reed Smith LLP for under-reimbursement of surgical services under ERISA. The case involved a 4-year-old patient who received complex out-of-network surgery from Dr. Schneider due to the unavailability of in-network providers. Highmark significantly under-reimbursed the billed amount and denied multiple appeals, failing to provide requested documentation. The patient's parents assigned their rights to the Plaintiff, leading Defendants to move for dismissal, asserting an anti-assignment provision in their Administrative Service Agreement (ASA). The Court denied the motion, ruling that the ASA is not an ERISA plan document and thus its anti-assignment clause is not binding on plan participants, confirming Plaintiff's standing. The Rule 12(b)(6) motion was also denied as abandoned.

ERISAMotion to DismissAnti-assignment clauseAdministrative Service Agreement (ASA)Plan DocumentSubject Matter JurisdictionStandingUnder-reimbursementOut-of-network providerHealth Insurance
References
27
Case No. MISSING
Regular Panel Decision

Blue Cross & Blue Shield v. State Division of Human Rights

This decision vacates a previous order and remands the matter to the State Division of Human Rights for a hearing. The initial court had dismissed a complaint, finding New York's Human Rights Law pre-empted by ERISA regarding pregnancy disability benefits. The Court of Appeals remitted for reconsideration in light of Shaw v Delta Airlines, which clarified that pre-emption only applies when a state law prohibits practices lawful under federal law. The court noted that the discrimination, alleged in 1977, predated the federal prohibition against pregnancy discrimination (effective April 29, 1979). However, ERISA exempts plans maintained solely for complying with disability insurance laws. The record is unclear if petitioner's plan is a separate plan (where NY Human Rights Law would apply) or part of a larger employee benefit plan (where ERISA would control). Therefore, the case is remanded for a determination on this specific factual issue only.

ERISA Pre-emptionHuman Rights LawPregnancy DiscriminationDisability Benefits LawState Law Pre-emptionFederal Law ConflictRemittiturEmployee Benefit PlansJudicial RemandWorkers' Compensation Law Art 9
References
3
Case No. MISSING
Regular Panel Decision
Oct 15, 1999

Garofalo v. Empire Blue Cross and Blue Shield

Plaintiffs Laurie Garofalo and Hilary Rosser, as class representatives, sued their health insurer, Empire Blue Cross and Blue Shield, under ERISA. They alleged Empire paid less than its required 80% share of certain inpatient hospital expenses due to a bimodal coinsurance calculation method (actual charges for participants, DRG rates for insurer). Plaintiffs argued this method violated New York Public Health Law § 2807-c(12) and was preempted by ERISA. The court granted summary judgment to Empire, ruling that its calculation method complied with the NYPHRM, specifically § 2807-c(11)(n)(i), and that ERISA did not preempt this state law as it regulates insurance. The court found plaintiffs lacked standing for the remaining claims and dismissed all inpatient hospitalization claims with prejudice.

ERISA LitigationHealth Insurance LawCoinsurance CalculationDRG RatesSummary JudgmentClass Action LawsuitPlaintiff StandingStatutory PreemptionNew York Public Health LawEmpire Blue Cross Blue Shield
References
39
Case No. MISSING
Regular Panel Decision

Empire Blue Cross & Blue Shield v. Consolidated Welfare Fund

Empire Blue Cross and Blue Shield (Empire) sued the Consolidated Welfare Fund and other defendants for breach of contract, fraud, and RICO violations. The defendants moved for partial judgment on the pleadings, asserting that the state law claims were preempted by ERISA. The court analyzed whether the Fund qualified as an 'employee welfare benefit plan' (EWBP) under ERISA. Finding that the Fund, with its 'associate members' from diverse backgrounds and commercial solicitation, did not meet the criteria of an EWBP, the court concluded that ERISA preemption did not apply. Therefore, the defendants' motion for partial judgment on the pleadings was denied, allowing Empire's state law claims to proceed.

ERISA PreemptionEmployee Welfare Benefit PlanHealth Insurance FraudLabor Union MembershipAssociate MembersRule 12(c) MotionFederal Civil ProcedureStatutory InterpretationCommercial Insurance SchemesDistrict Court Ruling
References
11
Case No. MISSING
Regular Panel Decision

Star Multi Care Services, Inc. v. Empire Blue Cross Blue Shield

This case involves Star Multi Care Services, Inc. (plaintiff) suing Empire Blue Cross Blue Shield (defendant) and Demetria Sarris and Van Sarris (Sarris defendants) for breach of contract regarding home health care services. Star initially filed the action in New York State Supreme Court, alleging Empire breached a contract to pay for services provided to Ms. Sarris under an ERISA plan. Empire removed the case to federal court, arguing ERISA preemption, and filed a motion to dismiss, while Star moved to remand to state court. The District Court denied Star's motion to remand, finding the claim was preempted by ERISA. The court granted Empire's motion to dismiss, concluding that Empire was not a proper defendant under ERISA and Star failed to exhaust administrative remedies. The remaining state law claims against the Sarris defendants were remanded to the Supreme Court of the State of New York, County of Suffolk, as the federal court declined to exercise supplemental jurisdiction.

ERISA preemptionRemoval jurisdictionMotion to remandMotion to dismissRule of unanimitySubject matter jurisdictionBreach of contractHealth care benefitsEmployee welfare benefit planAdministrative remedies exhaustion
References
73
Case No. MISSING
Regular Panel Decision

Westchester Radiological Associates, P.C. v. Empire Blue Cross & Blue Shield, Inc.

Plaintiffs, a group of hospital-based radiologists, sued Empire Blue Cross and Blue Shield, Inc., alleging violations of Sections 1 and 2 of the Sherman Act and the New York Donnelly Act. The radiologists claimed unlawful restraint of trade, monopolization, and price fixing due to Empire's policy preventing direct billing for professional radiological services. Empire moved to dismiss the complaint, arguing failure to state a claim under Section 1, lack of standing for Section 2 claims, and consequently, dismissal of the pendent state law claim. The court denied Empire's motion in its entirety, determining that Empire acted as an intervening "third force" in a non-exempt relationship and that the radiologists had direct standing due to the precisely intended nature of their alleged injuries.

Antitrust LawSherman ActDonnelly ActMonopolyPrice FixingHealth InsuranceRadiologyBlue Cross Blue ShieldLegal StandingMotion to Dismiss
References
27
Case No. 2021 NY Slip Op 02784 [194 AD3d 691]
Regular Panel Decision
May 05, 2021

David v. David

The infant plaintiff was injured in an automobile accident. The plaintiffs sought approval for a settlement, but Horizon Blue Cross Blue Shield of New Jersey, the administrator of the infant plaintiff's mother's self-funded employee benefit plan, asserted a subrogation lien for medical expenses. The Supreme Court denied the lien, citing New York's anti-subrogation statute, General Obligations Law § 5-335. On appeal, the Appellate Division reversed, holding that the self-funded plan was governed by ERISA, which preempts the state anti-subrogation statute. Consequently, the subrogation lien was deemed enforceable against the settlement proceeds.

ERISA PreemptionSubrogation LienSelf-Funded Employee BenefitsPersonal Injury SettlementAnti-Subrogation StatuteAppellate DivisionInfant CompromiseAutomobile AccidentReimbursement ClaimsNew York Law
References
5
Case No. MISSING
Regular Panel Decision

Dorato v. Blue Cross of Western New York, Inc.

George Dorato (plaintiff) sued Blue Cross of Western New York (defendant), also known as HealthNow, Inc., doing business as Blue Cross & Blue Shield of Western New York, after his health insurance benefits for a herniated disk were denied. Dorato's workers' compensation claim, which alleged a work-related injury, resulted in a $80,000 Section 32 settlement agreement, although his claim was officially 'disallowed' by the Workers' Compensation Board. HealthNow denied benefits citing a contract exclusion for injuries where payment is available under Workers' Compensation Law, arguing the settlement constituted such payment. Dorato moved for summary judgment, seeking a de novo review and asserting collateral estoppel, and also moved to amend his complaint to recharacterize his claims under ERISA. The court applied an 'arbitrary and capricious' standard of review to HealthNow's decision, noting the contract's discretionary authority. The court found that collateral estoppel did not apply due to lack of identical issues and HealthNow's inability to participate in the WCB proceedings. Ultimately, the court granted HealthNow's motion for summary judgment, ruling that their interpretation of the contract's exclusion was rational and not arbitrary or capricious. Dorato's motions were consequently denied as futile.

ERISAWorkers' CompensationHealth InsuranceSummary JudgmentCollateral EstoppelArbitrary and Capricious StandardDe Novo ReviewBenefit DenialContract ExclusionEmployee Welfare Benefit Plan
References
29
Case No. MISSING
Regular Panel Decision

Dewan v. Blue Man Group Limited Partnership

Plaintiff Brian Dewan, a musician, sued the Blue Man Group entities and individuals, seeking a declaration of co-authorship for musical compositions used in their "Blue Man Group: Tubes" performance and damages for state law claims. Dewan claimed he collaborated with the defendants in composing music for the show and was repeatedly assured of his co-authorship rights and that an agreement would be formalized, but it never materialized. Defendants moved to dismiss, arguing the co-authorship claim under the Copyright Act was time-barred. The court found that Dewan's equitable estoppel argument was unreasonable after late 1993 or 1994, as he had sufficient notice that a lawsuit was necessary. Consequently, the court dismissed the federal co-authorship claim due to the expiration of the statute of limitations and declined to exercise supplemental jurisdiction over the remaining state law claims.

Copyright ActCo-authorshipStatute of LimitationsEquitable EstoppelMotion to DismissFederal JurisdictionState Law ClaimsMusical CompositionsCollaborationDeclaratory Judgment
References
11
Case No. ADJ7722691
Regular
Apr 21, 2014

Tania Bello vs. Barrett Business Services, Inc.

This case involves Blue Shield of California's petition for reconsideration of a WCJ's order dismissing its lien. The lien was dismissed because Blue Shield failed to appear at a Lien Conference, and the WCJ found proper service of the notice. Blue Shield claimed non-receipt of the hearing notice but the WCAB dismissed their petition as untimely. The petition was filed 27 days after the order, exceeding the 25-day jurisdictional limit for filing a petition for reconsideration.

Workers' Compensation Appeals BoardLien claimantPetition for ReconsiderationDismissalLien ConferenceNotice of HearingServiceEAMSUntimely PetitionLabor Code § 5900(a)
References
2
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