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

Case No. 2015-2609 Q C
Regular Panel Decision
Jun 01, 2018

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

This case involves an appeal by GL Acupuncture, P.C., as assignee of Dwayne O. Ferguson, against Allstate Insurance Company regarding first-party no-fault benefits. The Civil Court of the City of New York, Queens County, had initially denied plaintiff's motion for summary judgment and granted defendant's cross-motion, dismissing the complaint due to alleged excessive charges. On appeal, the Appellate Term, Second Department, found that Allstate Insurance Company failed to demonstrate timely mailing of denial of claim forms, thus precluding their defense. However, GL Acupuncture, P.C. also failed to establish its entitlement to summary judgment. Therefore, the Appellate Term modified the order by denying the defendant's cross-motion for summary judgment, while affirming the denial of the plaintiff's motion for summary judgment.

No-fault benefitsSummary judgmentDenial of claimTimely mailingStandard office practiceInsurance defenseAppellate reviewPrima facie caseExcess workers' compensation fee scheduleAssignee claims
References
4
Case No. MISSING
Regular Panel Decision
Jul 10, 2013

Christopher C. v. Bonnie C.

This divorce action between Christopher C. and Bonnie C. addresses equitable distribution, spousal maintenance, and counsel fees. The defendant, Bonnie C., who has a court-appointed guardian due to mental and emotional difficulties, had separated from the plaintiff in 2003 and informally divided marital assets. The court ratified this prior asset division, noting the defendant had dissipated her share. Finding the defendant unable to work and self-support, and the plaintiff capable of employment despite his claims of disability, the court awarded the defendant non-durational permanent maintenance of $2,500 per month and substantial attorney's fees. The plaintiff's motion to suspend or refund temporary maintenance was denied.

DivorceSpousal MaintenanceEquitable DistributionGuardianshipMental Health IssuesAsset DissipationAttorney's FeesFinancial CapacityPermanent MaintenanceMarital Property
References
12
Case No. 2015-2389 S C
Regular Panel Decision
Apr 13, 2017

Thomas Dow, D.C., P.C. v. New York Cent. Mut. Fire Ins. Co.

This case involves an appeal from an order of the District Court of Suffolk County concerning a provider's action to recover assigned first-party no-fault benefits. The defendant, New York Central Mutual Fire Ins. Co., moved for summary judgment, asserting that the amount sought by the plaintiff exceeded the workers' compensation fee schedule. The District Court initially denied this motion, citing the defendant's failure to establish timely denial of claims. However, the Appellate Term reversed this decision, finding that the defendant had indeed timely mailed its denial forms and made a prima facie showing that the charges were in excess of the permitted fee schedule. The plaintiff failed to provide admissible evidence to counter the defendant's fee schedule defense. Consequently, the Appellate Term granted the defendant's motion for summary judgment.

No-Fault BenefitsSummary JudgmentWorkers' Compensation Fee ScheduleTimely DenialAppellate TermSuffolk CountyInsurance LawAssigned BenefitsMedical ProviderPrima Facie Showing
References
2
Case No. 2015-1073 K C
Regular Panel Decision
Jan 20, 2017

Acuhealth Acupuncture, P.C. v. Ameriprise Ins. Co.

This case concerns an appeal by Acuhealth Acupuncture, P.C., as assignee of Tykeisha Davis, against Ameriprise Ins. Co. The appeal challenges a Civil Court order that granted summary judgment to the defendant. The defendant successfully argued that it had properly reimbursed the plaintiff for acupuncture services rendered through September 23, 2010, based on workers' compensation fee schedules. For services provided from September 30, 2010, to October 8, 2010, the defendant timely denied reimbursement citing a lack of medical necessity, supported by an independent medical examination. The Appellate Term affirmed the lower court's decision, finding that the plaintiff failed to raise a triable issue of fact against the defendant's defenses.

Acupuncture servicesNo-fault benefitsWorkers' compensation fee schedulesMedical necessitySummary judgmentAppellate TermCivil CourtIndependent medical examinationReimbursementAssignee
References
1
Case No. 2014-1527 Q C
Regular Panel Decision
Dec 08, 2017

AVM Chiropractic, P.C. v. American Tr. Ins. Co.

This case concerns an appeal from an order of the Civil Court of the City of New York regarding assigned first-party no-fault benefits. Plaintiff, AVM Chiropractic, P.C., sought to recover benefits from American Transit Ins. Co. The Civil Court initially granted some branches of the defendant's motion for summary judgment and reduced claims based on a fee schedule defense. The Appellate Term modified the order, denying summary judgment for the defendant on specific causes of action (second, third, and sixth through eighth) and vacating findings on others (ninth and tenth). The court found that the defendant did not adequately demonstrate appropriate reductions in accordance with workers' compensation Ground Rules for several claims.

No-Fault BenefitsSummary JudgmentWorkers' Compensation Fee ScheduleAppellate ReviewInsurance ClaimsAssigneeFirst-Party BenefitsCivil ProcedureGround RulesNew York Law
References
1
Case No. 2016-910 K C
Regular Panel Decision
Jan 12, 2018

Precious Acupuncture Care, P.C. v. Hereford Ins. Co.

This case concerns an action by Precious Acupuncture Care, P.C., as assignee of James Hough, against Hereford Insurance Company to recover assigned first-party no-fault benefits. Plaintiff sought the unpaid balance of five claims for services rendered between December 2013 and April 2014. Defendant cross-moved for summary judgment, asserting that the amounts claimed exceeded the workers' compensation fee schedule. The Civil Court initially granted plaintiff's motion, ruling that defendant was precluded from the defense due to untimely denial. However, the Appellate Term reversed this decision, clarifying that under 11 NYCRR 65-3.8 (g) (1) (ii); (2), for services rendered after April 1, 2013, payment is not due for fees exceeding permissible charges, irrespective of timely denial. Consequently, the Appellate Term vacated the prior order, denied plaintiff's motion, and granted defendant's cross-motion for summary judgment dismissing the complaint.

No-Fault BenefitsSummary JudgmentFee Schedule DefenseAppellate ReviewTimely DenialWorkers' Compensation Fee ScheduleMedical BillingInsurance LawCivil CourtAppellate Term
References
5
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
Case No. 2015-608 Q C
Regular Panel Decision
Dec 19, 2017

Adelaida Physical Therapy, P.C. v. 21st Century Ins. Co.

In this case, Adelaida Physical Therapy, P.C., acting as an assignee, appealed an order from the Civil Court of the City of New York, Queens County. The original order had granted 21st Century Insurance Company's motion for summary judgment, dismissing parts of a complaint seeking first-party no-fault benefits for services billed under specific CPT codes (97010, 97110, and 97124). The Appellate Term, Second Department, reversed the lower court's decision. The appellate court found that 21st Century Insurance Company failed to demonstrate that it had used the correct conversion factor to calculate the reimbursement rate, thus not establishing its defense that the charged fees exceeded the workers' compensation fee schedule. As a result, the branches of the defendant's motion for summary judgment related to those CPT codes were denied.

No-Fault BenefitsCPT CodesSummary JudgmentWorkers' Compensation Fee ScheduleReimbursement RateAppellate ReviewInsurance DisputeCivil ProcedureConversion FactorMedical Billing
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. 2016-119 K C
Regular Panel Decision
Jul 06, 2018

Jing Luo Acupuncture, P.C. v. NY City Tr. Auth.

This case involves an appeal from an order and judgment concerning a claim for first-party no-fault benefits for acupuncture services. The plaintiff, Jing Luo Acupuncture, P.C., as assignee of Sarah Adams, sought to recover unpaid balances from the NY City Transit Authority. The Civil Court initially granted the plaintiff's motion for summary judgment and denied the defendant's cross-motion. On appeal, the Appellate Term reversed the judgment, finding that the plaintiff failed to establish prima facie entitlement to summary judgment. The court also held that the defendant was not precluded from interposing its fee schedule defense, as it had fully paid for services billed under CPT codes 97811, 97813, and 97814 according to the workers' compensation fee schedule. Consequently, the plaintiff's motion for summary judgment was denied, and the defendant's cross-motion was granted in part for those specific CPT codes, while denied for CPT code 99262 and the seventh cause of action.

Acupuncture ServicesNo-Fault BenefitsSummary JudgmentFee Schedule DefenseWorkers' Compensation Fee ScheduleCPT CodesAppellate ReviewInsurance LawTimely DenialFirst-Party Benefits
References
14
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