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

Case No. 2014-1712 K C
Regular Panel Decision
Dec 08, 2017

Daily Med. Equip. Distrib. Ctr., Inc. v. Global Liberty Ins.

Daily Medical Equipment Distribution Center, Inc., as assignee of Juan Mendoza, appealed an order from the Civil Court concerning no-fault benefits. The Civil Court had held Global Liberty Insurance's motion for summary judgment in abeyance. This abeyance was pending a Workers' Compensation Board determination on Mendoza's eligibility for workers' compensation benefits. The Appellate Term dismissed the appeal, ruling that an order holding a motion in abeyance is not appealable as of right under CPLR 5701 (a) (2). Consequently, the court declined to grant leave to appeal, thus upholding the procedural decision to await the Workers' Compensation Board's findings.

No-Fault BenefitsWorkers' Compensation BoardAppeal DismissedSummary Judgment MotionAbeyanceAppellate ProcedureJurisdictionCivil Procedure Law and RulesFirst-Party BenefitsInsurance Law
References
3
Case No. MISSING
Regular Panel Decision

Yklik Medical Supply, Inc. v. Allstate Insurance

Plaintiff Yklik Medical Supply, Inc., a medical supply provider, sued Allstate Insurance Company to recover $317 in unpaid medical bills for equipment supplied to its assignor, Tammy Agosto. Yklik moved for summary judgment, asserting proper bill submission and Allstate's failure to timely pay or deny the claim. Allstate argued that the charges exceeded the Workers' Compensation fee schedule and that a partial payment had been made. The court found that Yklik established a prima facie case. The central issue was whether Allstate's fee schedule defense was precluded due to its failure to issue a timely denial within 30 days as mandated by Insurance Law § 5106 (a) and 11 NYCRR 65-3.5. The court ruled that since Allstate waited 56 days to send its denial, it was precluded from raising the fee schedule defense, and therefore, summary judgment was granted to the plaintiff.

No-fault insurancesummary judgmenttimely denialfee schedulepreclusion ruleinsurance lawmedical supplybilling practicespersonal injury protectionassignor
References
19
Case No. MISSING
Regular Panel Decision

ABC Medical Management, Inc. v. GEICO General Insurance

The case addresses whether a plaintiff-assignee medical equipment supplier can recover no-fault first-party benefits when a chiropractor, rather than a physician, issued the prescription. Defendant GEICO General Insurance Company moved for summary judgment, arguing that Education Law § 6551 prohibits chiropractors from prescribing such items. The court denied GEICO's motion, ruling that chiropractors are permitted to prescribe TENS units, thermophore devices, and similar medical supplies, as these do not constitute 'drugs or medicines' under the Education Law. Furthermore, the court found that GEICO failed to properly present its medical necessity defense and that the contested issues should be determined by a trier of fact.

No-Fault BenefitsChiropractic PrescriptionMedical EquipmentEducation Law § 6551Summary JudgmentMedical NecessityTENS UnitThermophoreCervical CollarLumbar Support
References
29
Case No. ADJ1316674 (VNO 0500904)
Regular
May 03, 2010

NORMA GARCIA vs. WARNER BROTHERS; Permissibly Self-Insured

Defendant Warner Brothers seeks reconsideration of an award for medical treatment and durable medical equipment liens. The defendant argues the WCJ erred in awarding Vision Quest's lien for durable medical equipment, claiming timely utilization review established it was not necessary. Defendant also disputes Sobol Orthopedic's lien, asserting the awarded physical therapy visits exceeded the statutory cap and that penalties were unwarranted as they timely objected. The Appeals Board granted reconsideration, rescinded the award, and returned the case to the trial level to further develop the record.

Workers' Compensation Appeals BoardSupplemental Findings and AwardPetition for Reconsiderationutilization reviewretrospective URlien disputedurable medical equipmentphysical therapy visit cappenaltiesinterest
References
0
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. ADJ1148042 (RIV 0079139)
Regular
Apr 24, 2012

SARA OCHOA vs. BEL AIRE WINDOW COVERINGS, ZENITH INSURANCE COMPANY

The Appeals Board affirmed the WCJ's decision disallowing a medical lien from Aspen Medical Resources (AMR). AMR failed to prove that the durable medical equipment it provided was reasonably necessary to cure or relieve the applicant's industrial injury, lacking a report from the primary treating physician requesting such equipment. Furthermore, the applicant's treatment occurred outside the defendant's Medical Provider Network (MPN) after proper notification was given, and AMR's argument regarding defective MPN notice was rejected as defects can be cured. The Board also found no error in the admission of defendant's exhibits, as any objection to the proof of service was waived by AMR's failure to timely object.

Medical Provider NetworkMPNLien ClaimantDurable Medical EquipmentReasonable and NecessaryBurden of ProofUtilization ReviewProof of ServiceTimely ObjectionWaiver
References
14
Case No. ADJ8909369
Regular
May 30, 2018

MICHAEL PINEDA vs. COVENANT TRANSPORT, GALLAGHER BASSETT

The Workers' Compensation Appeals Board denied Rehab Solutions' petition for reconsideration regarding a disallowed lien for durable medical equipment. The Board affirmed the WCJ's finding that Rehab Solutions failed to prove the equipment was medically reasonable and necessary, as required by Labor Code § 4600. The lien claimant's arguments about the defendant's procedural non-compliance were unavailing because the primary failure was the lack of evidence supporting the medical necessity of the treatment itself. Consequently, the lien was properly disallowed, and the petition for reconsideration was denied.

Workers' Compensation Appeals BoardRehab Solutionslien claimantdurable medical equipmentmedically reasonable and necessaryLabor Code § 4603.2(b)official medical fee schedulepenaltyMinute OrderStipulation with Request for Award
References
2
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. 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. MISSING
Regular Panel Decision

Rechenberger v. Nassau County Medical Center

Edward Rechenberger suffered hip fractures and underwent two operations at Nassau County Medical Center in May 1982. Following a re-injury and later diagnosis, he learned the surgical hardware was improperly implanted, leading to further operations. Mr. Rechenberger sought leave to serve a late notice of claim against the medical center. The Supreme Court initially denied the motion, but the Appellate Division reversed this decision, finding that the hospital had actual knowledge of the essential facts of the claim within the statutory 90-day period through its own medical records. The court concluded that the delay in serving the notice of claim was not substantially prejudicial to the hospital, and thus, granted the petitioners leave to serve the late notice of claim.

Medical MalpracticeLate Notice of ClaimNassau CountyHip FractureSurgical ErrorContinuous Treatment DoctrineActual NoticePrejudiceAppellate ReviewMunicipal Corporation
References
11
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