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

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
Oct 14, 2008

Westchester Medical Center v. Lincoln General Insurance

The plaintiff appealed an order from the Supreme Court, Nassau County, which denied its motion for summary judgment to recover no-fault medical benefits. The appellate court reversed the order, granting the plaintiff's motion. The plaintiff successfully demonstrated a prima facie case by showing that statutory billing forms were mailed and received, and the defendant failed to either pay or deny the claim within the 30-day period. The court rejected the defendant's arguments that letters advising of an investigation tolled the statutory period and that the period was tolled pending a no-fault application. Additionally, defenses related to Workers' Compensation benefits or the assignor's failure to appear at an examination under oath were found insufficient to defeat the medical provider's right to benefits.

no-fault insurancemedical benefitssummary judgmentinsurance contractstatutory periodtimely denialworkers' compensationpolicy conditionpreclusion remedyappellate review
References
19
Case No. MISSING
Regular Panel Decision

Claim of Vanostrand v. Felchar Manufacturing Corp.

The case involves an appeal from a Workers’ Compensation Board decision concerning a claimant found to have defrauded employers and carriers by overstating mileage and making false statements about her physical condition. The Board ruled that Workers’ Compensation Law § 114-a, which bars future wage replacement benefits for such violations, does not preclude the claimant from receiving future mileage expenses or medical coverage. The Appellate Division, Third Department, affirmed this decision, citing its previous ruling in Matter of Rodriguez v Burn-Brite Metals Co., which established that the penalties under Workers’ Compensation Law § 114-a are limited to wage replacement benefits and do not extend to medical benefits. The court also found no error in the Board's tacit refusal to require the claimant to directly repay the mileage overpayments to the subject carriers.

Workers' Compensation Law § 114-aMedical BenefitsMileage ExpensesFraudulent MisrepresentationStatutory InterpretationAppellate DecisionWage Replacement BenefitsBoard Decision ReviewAffirmative RulingLegal Precedent
References
2
Case No. ADJ2270634 (VNO 0521616)
Regular
Aug 03, 2018

SHEVON THOMAS vs. POMONA VALLEY HOSPITAL MEDICAL CENTER, Administered by ADMINSURE, INC., SUBSEQUENT INJURIES BENEFITS TRUST FUND

This case concerns an applicant seeking benefits from the Subsequent Injuries Benefits Trust Fund (SIBTF) following a 2005 industrial injury that resulted in a 69% permanent disability and a substantial settlement. The applicant's claim for SIBTF benefits was denied because she failed to establish a prior "labor disabling" permanent disability that existed before the 2005 injury. The Appeals Board upheld the denial, finding that the applicant's evidence of prior symptoms, including a doctor's speculative impairment ratings, lacked substantial medical evidence and did not meet the strict requirements for establishing a pre-existing, labor-disabling condition. The Board emphasized that post-injury medical opinions, especially those based on hypotheticals and inadequate history, cannot retroactively establish a prior disability for SIBTF eligibility.

Subsequent Injuries Benefits Trust FundSIBTFlabor disablingpermanent partial disabilityLabor Code section 4751SB 899apportionmentpreexisting disabilityAMA Guides impairment ratingsretrospective prophylactic work restrictions
References
8
Case No. 19 Misc 3d 1104(A), 2008 NY Slip Op 50546(U)
Regular Panel Decision

Westchester Medical Center v. American Transit Insurance

This case involves an appeal in an action to recover no-fault medical payments. The plaintiff, Westchester Medical Center (WMC), as assignee of Daphne McPherson, sought summary judgment against American Transit Insurance Company, arguing that the defendant failed to timely pay or deny benefits. The Supreme Court initially granted WMC summary judgment. However, the appellate court reversed this judgment, finding that the defendant had presented a prima facie case for a timely request for additional verification, which effectively tolled the period for denying the claim. The defendant's denial was based on the premise that McPherson might be entitled to workers' compensation benefits. While reversing the summary judgment for WMC, the appellate court declined the defendant's request for summary judgment or referral to the Workers' Compensation Board due to insufficient evidence from the defendant regarding workers' compensation eligibility.

No-fault medical paymentsInsurance disputeSummary judgment reversalTimely denialAdditional verificationWorkers' compensation eligibilityAppellate DivisionAssignee claimMotor vehicle accidentCivil Practice Law and Rules
References
6
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. ADJ9445538
Regular
Oct 05, 2017

WENDY LEUNG vs. HUNTINGTON MEDICAL FOUNDATION, SUBSEQUENT INJURIES BENEFIT TRUST FUND

The Workers' Compensation Appeals Board denied Wendy Leung's petition for reconsideration of the administrative law judge's decision. The judge found no substantial medical evidence to support a subsequent compensable industrial permanent disability claim sufficient for benefits from the Subsequent Injuries Benefit Trust Fund (SIBTF). Leung contended she met SIBTF eligibility by claiming a prior $43\%$ permanent disability, a subsequent injury, and a resulting combined disability exceeding $70\%$. However, the Board agreed that Leung failed to prove industrial causation for her subsequent injury with reasonable medical probability.

Subsequent Injuries Benefit Trust FundLabor Code Section 4751cumulative injurypermanent disabilityreasonable medical probabilityindustrial causationapportionmentQualified Medical Evaluator (QME)Agreed Medical Evaluator (AME)Workers' Compensation Appeals Board (WCAB)
References
2
Case No. MISSING
Regular Panel Decision

Claim of Nicpon v. Zelasko Construction, Inc.

This case involves a workers' compensation claim where the claimant sustained a lower back injury in 2003 and was subsequently classified with a permanent partial disability. A key event was the claimant's settlement of a third-party action in 2008 for $240,000, which included the employer waiving liens and agreeing to cover future medical costs in exchange for the claimant's waiver of future indemnity benefits. Subsequently, in 2011, the employer attempted to transfer liability for these future medical expenses to the Special Fund for Reopened Cases under Workers' Compensation Law § 25-a. The Workers’ Compensation Board initially found the Special Fund liable, reversing a prior Workers’ Compensation Law Judge's finding. However, the Appellate Division reversed the Board's decision, ruling that the third-party settlement constituted a lump-sum payment for the purposes of Workers' Compensation Law § 25-a, thereby preventing the transfer of liability for future medical benefits to the Special Fund. The case was remitted to the Board for the specific calculation of the date of the last payment of compensation.

Workers’ CompensationPermanent Partial DisabilityThird-Party SettlementSpecial Fund for Reopened CasesLump Sum PaymentIndemnity Benefits WaiverFuture Medical ExpensesStatutory InterpretationAppellate ReviewRemittal
References
6
Case No. MISSING
Regular Panel Decision

Schonholz v. Long Island Jewish Medical Center

Plaintiff Gleniss Schonholz sued her former employer, Long Island Jewish Medical Center (LIJ), and several individual defendants under ERISA, seeking severance benefits. Schonholz alleged that LIJ wrongfully denied her severance benefits after requesting her resignation and promising benefits under a May 1991 plan, which she claims was revoked after her employment termination or not in writing. She also brought a promissory estoppel claim and claims against individual defendants for breach of fiduciary duty, seeking punitive damages. The court denied defendants' motion to dismiss the ERISA claim, finding plaintiff adequately alleged non-payment of benefits under a plan in effect at her termination or an invalid unwritten revocation. However, the court granted the motion to dismiss the promissory estoppel claim with leave to amend, as plaintiff failed to allege actual reliance. Claims against individual defendants for breach of fiduciary duty and for punitive damages were dismissed with prejudice, as fiduciary duties run to the plan, not individuals, and punitive damages are generally unavailable under ERISA. Cross-motions for Rule 11 sanctions were also denied.

ERISAEmployee BenefitsSeverance PayMotion to DismissPromissory EstoppelFiduciary DutyPunitive DamagesRule 11 SanctionsEmployment LawWelfare Plan
References
39
Case No. ADJ4465666 (OAK 0286384) ADJ2738204 (OAK 0277457)
Regular
Jun 22, 2012

NAQUISHA HENSLEY vs. A.C. TRANSIT DISTRICT, SUBSEQUENT INJURIES BENEFITS TRUST FUND

The Appeals Board granted reconsideration, rescinding the WCJ's decision that denied the employer reimbursement for a $10,200 mistaken payment. The Board found the applicant should have known the payment was an error, given its identical amount to a previous settlement check from the Subsequent Injuries Benefits Trust Fund. While the employer's adjuster was negligent, the Board exercised its discretion to allow the employer a credit of $10,200 against future workers' compensation benefits rather than ordering direct reimbursement due to the time lapse and applicant's spending of the funds. This credit includes future medical treatment, acknowledging the employer's fault in the overpayment.

Workers' Compensation Appeals BoardA.C. Transit DistrictSubsequent Injuries Benefits Trust FundPetition for ReconsiderationFindings And OrdersErroneous PaymentReimbursementCreditStipulated AwardsCompromise and Release
References
9
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