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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

Winn v. Hudson Valley Equine Center

A claimant, an equine veterinarian, appealed a Workers’ Compensation Board decision regarding an occupational disease affecting his right shoulder and wrist. The claimant developed these conditions from strenuous work at Hudson Valley Equine Center between 1982 and 1988, leading to surgery and a workers' compensation claim in 1988. The Workers’ Compensation Law Judge (WCLJ) found an occupational disease with a disability date of March 23, 1988, ruling the claim timely and estopping the carrier, Insurance Company of North America/CIGNA, from denying coverage. The Workers’ Compensation Board affirmed the WCLJ's findings. The employer and carrier appealed, contending the finding of an occupational disease lacked support and that the claim was time-barred. The appellate court affirmed the Board's decision, citing substantial medical evidence connecting the conditions to the claimant's occupation and upholding the Board's determination of the date of disablement and the carrier's estoppel.

Occupational DiseaseEquine VeterinarianShoulder InjuryWrist InjuryCarpal Tunnel SyndromeWorkers' Compensation LawDate of DisablementTimeliness of ClaimEstoppelInsurance Coverage
References
9
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. 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. 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. 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. MISSING
Regular Panel Decision

Young v. Central Square Central School District

Plaintiff sued Central Square Central School District under the Americans With Disabilities Act (ADA) and the Rehabilitation Act, alleging discrimination due to her multiple sclerosis diagnosis and the District's failure to provide reasonable accommodations. The District moved for summary judgment, arguing collateral estoppel from a prior administrative hearing that found Plaintiff unfit to teach, and also sought to disqualify Plaintiff's counsel. The Court denied the summary judgment motion, ruling that collateral estoppel did not bar the litigation of reasonable accommodation issues. However, the motion to disqualify Plaintiff's law firm, O'Hara & O'Connell, was granted because an associate had previously worked on the District's defense in related matters, creating an appearance of impropriety. Consequently, Plaintiff must secure new legal representation or proceed pro se within ninety days.

Americans with Disabilities ActRehabilitation ActReasonable AccommodationMultiple SclerosisEmployment DiscriminationCollateral EstoppelAttorney DisqualificationConflict of InterestSummary JudgmentTeacher Disability
References
26
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. 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
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