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Case Law Database

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

Case No. MISSING
Regular Panel Decision
Sep 04, 2013

Matter of Madigan v. ARR ELS

In 1994, the claimant sustained a low back injury during employment as a machinist, leading to workers' compensation benefits. Liability for the case was transferred to the Special Fund for Reopened Cases in 2003. Due to poor surgical outcomes, the claimant has been on pain medication, including oxycontin, since at least 2007, with doses escalating. A consultant for the Special Fund questioned the necessity of the increased medication, prompting a hearing. A Workers’ Compensation Law Judge ruled that the pain medications should continue, with the Special Fund covering the costs, until new Board guidelines or physician recommendations advised otherwise. The Workers’ Compensation Board affirmed this decision, citing that their Medical Treatment Guidelines for chronic pain were still in draft form at the time. The appellate court subsequently affirmed the Board's decision, noting that the guidelines were not yet in effect at the time of the Board's ruling and that the Board's interim guidance was rational.

Workers' CompensationPain ManagementOpioid PrescriptionsMedical Treatment GuidelinesSpecial FundReopened CasesLumbar InjuryOxycontinAppellate ReviewAdministrative Law
References
4
Case No. 526425
Regular Panel Decision
Nov 15, 2018

Matter of Gasparro v. Hospice of Dutchess County

Mary Ann Gasparro, a claimant with a permanent partial disability from a 1995 work injury, moved to Nevada. In 2016, her employer's workers' compensation carrier objected to payments for topical pain relief products, LidoPro and Terocin patches, prescribed by a Nevada pain management specialist. The Workers' Compensation Board reversed a Workers' Compensation Law Judge's ruling, deciding that New York's Medical Treatment Guidelines apply to out-of-state treatment for nonresident claimants, a departure from its prior decisions. The Board found the prescribed medications were not in accordance with the guidelines due to concomitant use and duration. The Appellate Division, Third Department, affirmed the Board's decision, deeming its change in course rational and its application of the guidelines to out-of-state treatment reasonable. The court concluded that the Board's finding of medical necessity and non-compliance with guidelines was supported by substantial evidence.

Workers' CompensationMedical Treatment GuidelinesOut-of-State Medical CareNonresident ClaimantsPain ManagementTopical Pain ReliefLidoProTerocin PatchesAppellate DivisionBoard Reversal
References
12
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. SAL SJO 252436 (MF); SJO 246192
Regular
Jul 02, 2007

NIHAL HORDAGODA vs. State Compensation Insurance Fund

This case involves an employer's petition for reconsideration of an order authorizing medical treatment and admitting the Qualified Medical Examiner's (QME) reports. The employer argued the QME reports were inadmissible due to an alleged ex parte communication between the applicant and the QME, and that the awarded treatments were improper. The report recommends denying the petition, finding the communication was permissible under LC § 4062.3(h) and that the QME's opinions and awarded treatments for chronic pain were reasonable and not governed by ACOEM guidelines.

Workers' Compensation Appeals BoardPetition for ReconsiderationQualified Medical EvaluatorLabor Code Section 4062.3Ophthalmological evaluationFunctional capacity evaluationUtilization ReviewACOEM GuidelinesChronic spinal conditionTreating physician
References
0
Case No. 2020 NY Slip Op 03966 [185 AD3d 1263]
Regular Panel Decision
Jul 16, 2020

Matter of McKay v. Southampton Hosp.

The case concerns an appeal by Jacqueline McKay (claimant) from a Workers' Compensation Board decision. The Board had affirmed a Workers' Compensation Law Judge (WCLJ) ruling to consider weaning the claimant from opioid medications based on an independent medical examiner's opinion under the Non-Acute Medical Treatment Guidelines (NAPMTG). The claimant argued that the Board exceeded its authority in promulgating these guidelines. The Appellate Division, Third Department, affirmed the Board's decision, holding that the Board properly exercised its broad regulatory power under the Workers' Compensation Law to issue the NAPMTG. The court found the guidelines rational and not unreasonable, arbitrary, capricious, or contrary to the statute, emphasizing that the NAPMTG furthered the aim of ensuring prompt and appropriate medical care for injured workers by expanding existing treatment guidelines to address comprehensive pain management, including the safe use of narcotics.

Medical Treatment GuidelinesOpioid WeaningRegulatory AuthorityAdministrative LawAppellate ReviewPain ManagementOccupational DiseasePermanent Partial DisabilityWorkers' Compensation BoardIndependent Medical Examination
References
5
Case No. ADJ2068970 (STK 0167616)
Regular
Jul 21, 2016

Norman McAtee vs. Briggs & Pearson Construction, State Compensation Insurance Fund

The applicant seeks reconsideration of a WCJ's decision that dismissed his appeal of an Independent Medical Review (IMR) determination regarding pain medication. The IMR found the medication medically unnecessary, but the applicant argues this was based on a plainly erroneous finding of fact regarding the applicable treatment guidelines. The Appeals Board granted reconsideration, finding the IMR determination was indeed based on a plainly erroneous interpretation of the medical treatment guidelines. Consequently, the Board rescinded the WCJ's decision and remanded the case for a new IMR by a different reviewer.

Workers' Compensation Appeals BoardIndependent Medical ReviewPlainly Erroneous Finding of FactLabor Code Section 4610.6Medical Treatment GuidelineOpioid TherapyPermanent DisabilityVocational RehabilitationAdministrative Law JudgeReconsideration
References
1
Case No. 534239
Regular Panel Decision
Sep 29, 2022

In the Matter of the Claim of Lorna Lyman

Lorna Lyman, a motorized snow operator, sustained lower back and right foot injuries in January 2018. Her workers' compensation claim was accepted and established for a work-related right foot injury, leading to surgery. Medical evaluations by treating podiatrist Carrie O'Neil and orthopedic surgeon Robert Karpman initially assessed schedule loss of use. However, the Workers' Compensation Board affirmed a Workers' Compensation Law Judge's finding that her injury was amenable to a nonschedule classification. This decision was based on findings of a chronic painful condition and marked permanent partial medical impairment, supported by substantial medical evidence of chronic pain and severe swelling despite exhausted treatment options. The Appellate Division affirmed the Board's decision.

Nonschedule classificationPermanent partial disabilityChronic painFoot injurySchedule loss of useMedical impairmentIndependent medical examinationTreating physicianAppellate reviewSubstantial evidence
References
6
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. ADJ2839869 (EUR 0036695)
Regular
Mar 03, 2009

Darlene Counts vs. Sam Kennedy, D.D.S., Zenith Insurance Company

The Workers' Compensation Appeals Board denied Zenith Insurance Company's petition for reconsideration. Zenith argued the WCJ exceeded jurisdiction by awarding benefits beyond the five-year limit without a petition to reopen and challenged medical treatment awards. The Board affirmed the WCJ's decision, finding the original stipulations focused only on medical treatment and did not preclude later determinations on other issues within the statutory timeframe. The WCJ correctly found applicant sustained an industrial injury and ordered appropriate medical treatment, including chronic pain specialist care.

WCABDarlene CountsSam Kennedy DDSZenith Insurance CompanyADJ2839869Supplemental Findings and Awardindustrial injuryright shoulderpsycheleft shoulder
References
0
Case No. MISSING
Regular Panel Decision

Claim of Kigin v. State of New York Workers' Compensation Board

In 1996, claimant sustained work-related injuries, leading to workers' compensation benefits and a classification of permanent partial disability in 2006. Her treating physician, Andrea Coladner, requested a variance for additional acupuncture treatments beyond the scope of the Workers' Compensation Board's Medical Treatment Guidelines, which went into effect in 2010. The Special Fund for Reopened Cases denied the variance based on an independent medical examination by Peter Chiu, citing a lack of objective findings. A Workers' Compensation Law Judge and the Board affirmed this denial, prompting the claimant's appeal. The court affirmed the Board's decision, holding that the Board lawfully promulgated the Guidelines to predetermine medical necessity and that the variance procedure, which shifts the burden of proof to claimants for treatments outside the Guidelines, is permissible and consistent with due process.

Workers' CompensationMedical Treatment GuidelinesAcupunctureVariance RequestPermanent Partial DisabilityMedical NecessityBurden of ProofDue ProcessStatutory InterpretationAdministrative Law
References
19
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