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

Case No. 2019 NY Slip Op 06054
Regular Panel Decision
Aug 06, 2019

Wilder v. Fresenius Med. Care Holdings, Inc.

Plaintiff Nicholas Wilder, suffering from end-stage renal disorder, sued Fresenius Medical Care Holdings, Inc. and its subsidiary, Avantus Renal Therapy New York LLC, after they notified him that his dialysis care would be terminated due to disruptive behavior. Wilder sought an injunction to prevent the termination of his life-sustaining dialysis treatment. The Supreme Court, New York County, denied his request for an injunction and vacated a previously granted temporary restraining order (TRO). The Appellate Division, First Department, modified the lower court's order, reversing the denial of the injunction and vacating of the TRO, reinstating the TRO pending a hearing on Wilder's injunction request. The appellate court found that the motion court abused its discretion by vacating the TRO and not holding a hearing on the preliminary injunction, given the substantial factual disputes regarding Wilder's behavior and the defendants' compliance with federal regulations for patient discharge. However, the Appellate Division affirmed the denial of Wilder's request to proceed anonymously and seal records.

Dialysis TreatmentPatient DischargeTemporary Restraining OrderPreliminary InjunctionIrreparable HarmDisruptive Patient BehaviorFederal RegulationsRight to CareAppellate ReviewSealing Records
References
6
Case No. MISSING
Regular Panel Decision
Apr 27, 2012

China Auto Care, LLC v. China Auto Care (Caymans)

Plaintiffs China Auto Care, LLC and China Auto Care Holdings, LLC brought an action against China Auto Care (Caymans), Digisec Corporation, and the estate of Chander Oberoi, alleging various causes of action stemming from the 2011 sale of Digisec's assets. Defendants sought to dismiss the complaint and compel arbitration, citing an arbitration clause in the parties' "Business Relationship and Shareholder Agreement." The court analyzed the scope of the arbitration clause under the Federal Arbitration Act. Finding the clause to be broad, the court concluded that the plaintiffs' claims were within its scope, as they "touch matters" governed by the Shareholder Agreement. Consequently, the court granted the defendants' motion, staying the litigation and compelling arbitration.

ArbitrationShareholder AgreementCorporate DisputeMotion to CompelFederal Arbitration ActSecond Circuit PrecedentFraudulent InducementCorporate GovernanceCayman Islands LawStay of Proceedings
References
25
Case No. MISSING
Regular Panel Decision

Franzese v. United Health Care/Oxford

Plaintiffs Robert and Elizabeth Franzese, parents and legal guardians of disabled adult Robert Franzese Jr. ("Bobby"), sued United Health Care/Oxford under ERISA to recover medical benefits. Bobby, suffering from chronic lung disease, requires 24/7 in-home nursing care. Oxford denied preauthorization for private duty nursing, citing it as an exclusion, and denied home health care services. The court granted Oxford's summary judgment motion regarding private duty nursing and Xopenex preauthorization, finding private duty nursing not covered. However, the court denied Oxford's motion regarding home health care services, deeming Oxford's denial arbitrary and capricious due to lack of substantial evidence. The case is remanded to Oxford for reconsideration of home health care benefits.

Employee Retirement Income Security Act (ERISA)Medical BenefitsHealth Insurance DenialSummary JudgmentArbitrary and Capricious StandardHome Health CarePrivate Duty NursingPreauthorizationMedical NecessityChronic Lung Disease
References
37
Case No. MISSING
Regular Panel Decision

NYAHSA Servs., Inc., Self-Insurance Trust v. People Care Inc.

This case involves an appeal from an order of the Supreme Court, which granted the plaintiff's motions for leave to amend complaints. The plaintiff, a group self-insured trust, initiated collection actions against former member employers, People Care Incorporated and Recco Home Care Services, Inc., for unpaid workers' compensation adjustment bills. The plaintiff sought to add its trustees as party plaintiffs and to update allegations to include subsequently accrued unpaid bills. The appellate court affirmed the Supreme Court's decision, clarifying that an evidentiary showing of merit is not required for leave to amend pleadings under CPLR 3025 (b) unless there is prejudice, surprise, palpable insufficiency, or patent lack of merit. The court found no such grounds for denial and also rejected the defendants' statute of limitations arguments, affirming that for contracts requiring continuing performance, each breach can restart the limitations period.

Workers' Compensation CoverageSelf-Insured TrustBreach of ContractUnjust EnrichmentPleading AmendmentCPLR 3025 (b)Statute of LimitationsPrejudiceAppellate ReviewSupreme Court Order
References
18
Case No. 2015-2418 K C
Regular Panel Decision
May 25, 2018

Remedial Med. Care, P.C. v. Park Ins. Co.

This case involves an appeal from an order of the Civil Court concerning first-party no-fault benefits. The defendant, Park Insurance Co., sought summary judgment to dismiss the complaint filed by Remedial Medical Care, P.C., as assignee of Thomas Brown. The Civil Court initially denied the motion but found that the defendant had established timely mailing of denials. The Appellate Term modified the order, granting summary judgment to the defendant for a bill of services rendered on August 23, 2012, as it was paid according to the workers' compensation fee schedule. However, for the remaining bills, the defendant failed to prove timely mailing of IME scheduling letters, thus failing to demonstrate that the IMEs were properly scheduled or that the assignor failed to appear. Therefore, the denial of summary judgment for the remaining claims was affirmed.

Summary JudgmentNo-Fault BenefitsIndependent Medical Examination (IME)Timely MailingWorkers' Compensation Fee ScheduleAppellate TermCivil CourtDenial of ClaimFirst-Party BenefitsInsurance Law
References
3
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. 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. 2020 NY Slip Op 04473 [186 AD3d 594]
Regular Panel Decision
Aug 12, 2020

Moreno v. Future Health Care Servs., Inc.

The Appellate Division, Second Department, affirmed the denial of class certification for a putative class action brought by former home health care aides against Future Health Care Services, Inc. Plaintiffs alleged violations of Labor Law article 19, specifically concerning minimum wage payments for 24-hour shifts. The court, upon remittitur from the Court of Appeals, considered the Department of Labor's interpretation of Minimum Wage Order Number 11, which permits exclusion of up to 11 hours for sleep and meal breaks in 24-hour shifts. Consequently, the plaintiffs failed to demonstrate commonality, as they did not allege a lack of prescribed breaks or provide sufficient evidentiary basis for systemwide wage violations, thus failing to meet the requirements of CPLR article 9. Therefore, the Supreme Court's decision to deny class certification was upheld.

Class ActionLabor LawMinimum Wage24-hour ShiftsHome Health Care AidesClass CertificationWage OrderAppellate ReviewJudicial InterpretationNew York Department of Labor
References
7
Case No. 2015-516 Q C
Regular Panel Decision
Dec 19, 2017

Healthway Med. Care, P.C. v. Global Liberty Ins.

The case "Healthway Med. Care, P.C. v Global Liberty Ins." involved an appeal by Healthway Medical Care, P.C. against Global Liberty Insurance concerning assigned first-party no-fault benefits. The plaintiff appealed an order from the Civil Court, Queens County, which denied the plaintiff's motion for summary judgment on certain causes of action (third through tenth) and granted the defendant's cross-motion to dismiss those same causes of action. The Appellate Term, Second Department, modified the Civil Court's order by denying the branches of the defendant's cross-motion seeking summary judgment to dismiss the third through tenth causes of action. The court found the defendant failed to establish that fees exceeded workers' compensation schedules or that independent medical examinations (IMEs) were properly scheduled. However, the plaintiff was not granted summary judgment either, as they failed to demonstrate that the claims were not timely denied or that the denials were without merit. The order was affirmed as modified.

No-fault benefitssummary judgmentindependent medical examinationIME schedulingfee scheduleworkers' compensationappellate reviewcivil proceduremedical billingassigned claims
References
6
Case No. 2019 NY Slip Op 05756 [175 AD3d 134]
Regular Panel Decision
Jul 23, 2019

Matter of People Care Inc. v. City of New York Human Resources Admin.

The New York Appellate Division, First Department, affirmed the Supreme Court's decision, which annulled the Human Resources Administration's (HRA) demand to recoup approximately $7 million in Health Care Reform Act (HCRA) funds from People Care Incorporated. The core issue was whether HRA possessed the authority to audit and recover these HCRA funds, established as a distinct Medicaid reimbursement program for worker recruitment and retention, from personal care service providers. The Court found that neither Public Health Law § 2807-v (1) (bb) nor the Memorandum of Understanding between the Department of Health (DOH) and HRA delegated such auditing and recoupment powers to HRA. It rejected HRA's arguments that HCRA funds were merely a subset of general Medicaid funds subject to its existing contractual audit authority, or that DOH's actions constituted ratification of HRA's authority. Consequently, the Court upheld the injunction preventing HRA from recouping the disputed HCRA funds from People Care.

Administrative LawMedicaid ReimbursementAuditing AuthorityStatutory ConstructionInter-agency AgreementsHealthcare Reform ActPersonal Care ServicesGovernment ContractsCPLR Article 78Delegation of Power
References
8
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