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Case Law Database

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

Case No. M2011-02746-COA-R3-CV / 1018991
Regular Panel Decision
Nov 26, 2012

Advantage Personnel Consultants, Inc. v. Tennessee Department of Commerce

This case involves a dispute between Advantage Personnel Consultants, Inc. (insured) and Liberty Mutual Insurance Company (insurer) regarding the proper classification of employees for workers' compensation insurance premiums. Advantage disputed Liberty's reclassification of its employees from 'manufacture of small tools' (3113) to 'machine shop' (3632), and later to 'construction or agricultural machinery mfg.' (3507) for employees working at TAG Manufacturing Company. Advantage contended the correct classification was 'boilermaking' (3620). The Department of Commerce and Insurance ruled in favor of the insurer (Liberty), classifying the work as 3507, which was affirmed by the Chancery Court for Davidson County and subsequently by the Court of Appeals, finding substantial and material evidence to support the Commissioner's decision.

Workers' CompensationInsurance ClassificationEmployee ClassificationPremium AuditAdministrative LawAppellate ReviewSubstantial EvidenceMaterial EvidenceStatutory InterpretationCode Classification
References
7
Case No. 03-96-00336-CV
Regular Panel Decision
Apr 17, 1997

Southwest-Tex Leasing Company, Inc. D/B/A Advantage Rent-A-Car and D/B/A Premier Parking And Walker Resources, Inc. v. Elton Bomer, Commissioner of Insurance And Texas Workers' Compensation Insurance Facility

This case involves an appeal by Southwest-Tex Leasing Company, Inc. and Walker Resources (collectively 'Advantage') against the Commissioner of Insurance and the Texas Workers' Compensation Insurance Facility. The dispute arose when Advantage's workers' compensation insurance premiums increased due to the retroactive application of an experience modifier and surcharge by Liberty Mutual, a servicing company for the Facility, after Advantage initially received a policy based on an Assigned Risk Rating Program (ARRP) factor. Advantage challenged the Facility's and Commissioner's decisions upholding Liberty Mutual's actions. The appellate court affirmed the district court's judgment, finding that the Commissioner's decision was supported by substantial evidence and was not an error of law, as the TDI rules allowing retroactive application of the experience modifier were incorporated into the policy and consistent with its terms.

Workers' CompensationInsurance PolicyPremium AdjustmentExperience ModifierAssigned Risk Rating ProgramRegulatory InterpretationAdministrative LawAppellate ReviewTexas Insurance CodeContract Ambiguity
References
15
Case No. 2016-334 S C
Regular Panel Decision
Apr 27, 2017

2 & 9 Acupuncture, P.C. v. 21st Century Advantage Ins. Co.

This case concerns an appeal by 2 & 9 Acupuncture, P.C. from an amended order that granted summary judgment to 21st Century Advantage Insurance Company, dismissing a complaint to recover assigned first-party no-fault benefits. The defendant argued it had paid the plaintiff in accordance with the workers' compensation fee schedule. The Appellate Term, Second Department, reversed the lower court's decision, finding that the defendant failed to prima facie demonstrate proper denial of payment for services billed under CPT codes 97026 and 97016. Consequently, the defendant's motion for summary judgment regarding these specific CPT codes was denied.

No-Fault BenefitsSummary JudgmentCPT CodesWorkers' CompensationAppellate ReviewInsurance LawMedical BillingAcupunctureSuffolk CountyPayment Dispute
References
3
Case No. 2015-232 K C
Regular Panel Decision
Dec 19, 2017

Easy Care Acupuncture, P.C. v. 21 Century Advantage Ins. Co.

In this action, Easy Care Acupuncture, P.C., acting as an assignee, sought to recover first-party no-fault benefits from 21 Century Advantage Ins. Co. The plaintiff appealed an order from the Civil Court of the City of New York, Kings County, which granted the defendant's motion for summary judgment, dismissing the complaint. The defendant successfully argued that it had fully paid the plaintiff for the services according to the workers' compensation fee schedule. The Appellate Term affirmed the order, finding that the defendant's proof was sufficient to establish proper mailing of the denial of claim form and the correct application of the workers' compensation fee schedule.

No-Fault BenefitsSummary JudgmentWorkers' Compensation Fee ScheduleAppellate TermFirst-Party BenefitsDenial of Claim FormInsurance DisputeAssigned BenefitsCivil CourtAcupuncture Services
References
1
Case No. 01-15-01006-CV
Regular Panel Decision
Dec 11, 2015

Professional Advantage Software Solutions, Inc. v. West Gulf Maritime Asociation Inc.

West Gulf Maritime Association (appellee) filed a response opposing Professional Advantage Software Solutions, Inc.'s (appellant) Emergency Motion for Temporary Relief. The appellant sought to halt an upcoming trial to appeal the denial of its motion to compel arbitration. The appellee contends that the appellant waived its right to arbitrate through extensive participation in the litigation process over three years, including numerous motions, discovery, and mediation. The appellee claims significant prejudice due to the appellant's delay and alleged manipulation of arbitral rights. Therefore, West Gulf Maritime Association requests the court to deny the appellant's motion for temporary relief and allow the case to proceed to trial.

Arbitration WaiverEmergency MotionTemporary ReliefSoftware DisputeMaritime IndustryContract LawSummary Judgment MotionEconomic Loss RuleDTPA ExemptionBreach of Warranty
References
62
Case No. 2016-329 S C
Regular Panel Decision
Apr 27, 2017

Spineisland for Chiropractic, P.C. v. 21st Century Advantage Ins. Co.

This case involves an appeal by Spineisland For Chiropractic, P.C., acting as an assignee, against 21st Century Advantage Insurance Company concerning first-party no-fault benefits. The plaintiff sought to recover for services billed under CPT code 95831. The District Court of Suffolk County had previously granted the defendant's motion for summary judgment, asserting that the defendant had appropriately paid the plaintiff based on the workers' compensation fee schedule. On appeal, the Appellate Term affirmed the lower court's decision. The Appellate Term found that the defendant had adequately demonstrated the proper application of CPT code 95833 for the services billed under CPT code 95831, and the plaintiff failed to present a triable issue of fact.

No-fault benefitsSummary judgmentCPT codeWorkers' compensation fee scheduleAppellate TermSuffolk CountyAssigneeInsurance disputeChiropractic servicesMedical billing
References
1
Case No. 2016-318 S C
Regular Panel Decision
Apr 27, 2017

Dynasty Med. Care, P.C. v. 21st Century Advantage Ins. Co.

This case involves an appeal by Dynasty Medical Care, P.C., as an assignee, seeking first-party no-fault benefits from 21st Century Advantage Insurance Company. The District Court of Suffolk County initially granted the defendant's motion for summary judgment, agreeing that payments were made in accordance with the workers' compensation fee schedule. The Appellate Term, Second Department, reviewed and subsequently affirmed this amended order. The court determined that the defendant had sufficiently demonstrated the proper application of the fee schedule, and the plaintiff failed to present a triable issue of fact to dispute this claim.

No-fault benefitsSummary judgmentWorkers' compensation fee scheduleAppellate reviewInsurance disputeMedical providerAssigneeProcedural lawFactual disputeDistrict Court
References
2
Case No. 2014-06-0063
Regular Panel Decision
Feb 27, 2015

McCord, Patricia v. Advantage Human Resourcing

Patricia McCord, an employee of Advantage Human Resourcing, sought an expedited hearing for medical benefits after sustaining a back and shoulder injury on October 3, 2014, while lifting boxes at work. She contended the injury was work-related and that she timely reported it. Advantage Human Resourcing argued the injury was not work-related and that McCord failed to provide timely notice, citing initial medical records that did not list the injury as work-related. The Workers' Compensation Judge, Joshua Davis Baker, found Ms. McCord's testimony credible, determining she suffered a compensable work-related injury and reported it within the statutory 30-day timeframe. Consequently, the Court ordered Advantage Human Resourcing to provide Ms. McCord with medical treatment, including a panel of three physicians, in accordance with Tennessee workers' compensation law.

Workers' CompensationBack InjuryShoulder InjuryExpedited HearingMedical BenefitsEmployment InjuryAccident ReportTimely NoticeCausationHerniated Disc
References
1
Case No. MISSING
Regular Panel Decision

Normile v. Allstate Insurance

Chief Judge Cooke's dissenting opinion critiques the majority's interpretation of Insurance Law section 671 (subd 2, par [b]) regarding how collateral source payments affect an insurer's aggregate $50,000 liability for basic economic loss. The dissent argues that the majority's method, which allows insurers to reduce their total liability by these payments, leads to an incomplete recovery for injured parties, particularly when total losses exceed $50,000. Cooke proposes an alternative allocation where collateral source payments are first applied to cover losses beyond the $50,000 basic economic loss threshold. This approach, he contends, ensures that insurers pay the full $50,000 in first-party benefits and only take credit for collateral sources that would otherwise result in a double recovery within the basic economic loss limit, or for amounts exceeding the $50,000 threshold. The dissenting judge asserts that the Legislature did not intend to create such an inequity, where injured individuals are left with less than full compensation while insurers avoid their primary obligation.

Insurance Law InterpretationBasic Economic LossCollateral Source PaymentsNo-Fault InsuranceWorkers' Compensation BenefitsSocial Security Disability BenefitsDissenting OpinionAggregate LiabilityFirst-Party BenefitsDouble Recovery
References
2
Case No. 2014-07-0018
Regular Panel Decision
Feb 09, 2015

Chambers, Dustin v. Advantage Resourcing

Dustin Chambers filed for an expedited hearing to determine entitlement to medical and temporary disability benefits after sustaining a back injury at Advantage Human Resources. The Court found that Mr. Chambers properly reported his injury and is entitled to a panel of neurosurgeons for evaluation, overturning Advantage's denial based on an internal determination. However, the claim for temporary disability benefits was denied at this interlocutory stage due to a lack of medical proof establishing a causal connection between the injury and disability, pending a causation opinion from the selected panel physician.

Workers' CompensationBack InjuryExpedited HearingMedical BenefitsTemporary DisabilityCausationPre-existing ConditionEmployee CredibilityEmployer LiabilityPanel of Physicians
References
5
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