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Case Law Database

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

Case No. ADJ7162019
Regular
Aug 13, 2010

Abraham Avila vs. Victory Outreach San Bernardino, Guide One Ins. Co.

This case involves a petition for reconsideration filed by the defendant, Victory Outreach San Bernardino, and its insurer, Guide One Ins. Co. The Workers' Compensation Appeals Board has granted this petition. The Board determined that reconsideration is necessary to allow for further study of the factual and legal issues to ensure a just and reasoned decision. Further proceedings may be held pending the issuance of a Decision After Reconsideration.

WORKERS' COMPENSATION APPEALS BOARDPetition for ReconsiderationVICTORY OUTREACH SAN BERNARDINOGUIDE ONE INS. CO.ABRAHAM AVILAOPINION AND ORDERGRANTING PETITIONSTATUTORY TIME CONSTRAINTSFACTUAL AND LEGAL ISSUESJUST AND REASONED DECISION
References
0
Case No. 2013-1427 K C
Regular Panel Decision
Jun 03, 2016

Harvard Med., P.C. v. Tri State Consumers Ins. Co.

This is an appeal by Harvard Medical, P.C., as assignee of Lenford Carty, against Tri State Consumers Ins. Co. The appeal is from an order of the Civil Court of the City of New York, Kings County, entered April 12, 2013, which granted the defendant's motion for summary judgment. The defendant argued that it had fully paid the plaintiff in accordance with the workers' compensation fee schedule for first-party no-fault benefits. The Appellate Term, Second Department, affirmed the Civil Court's order, citing a related case, Renelique, as Assignee of Yvon Delgado v Tri State Consumers Ins. Co.

No-fault benefitsSummary JudgmentAppellate ReviewWorkers' Compensation Fee ScheduleAssignee
References
1
Case No. 2013-2706 Q C
Regular Panel Decision
Sep 19, 2016

NYS Acupuncture, P.C. v. State Farm Mut. Auto. Ins. Co.

This case, NYS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., concerned an appeal from an order of the Civil Court of the City of New York, Queens County. The plaintiff, NYS Acupuncture, P.C., sought assigned first-party no-fault benefits from State Farm, which had moved for summary judgment arguing full payment according to the workers' compensation fee schedule. The Civil Court initially granted State Farm's motion. On appeal, NYS Acupuncture, P.C. contended that the fee schedule reductions were improper. The Appellate Term, Second Department, affirmed the prior ruling, finding that State Farm adequately demonstrated it had fully compensated the plaintiff for acupuncture services based on the applicable workers' compensation fee schedule for services performed by chiropractors, referencing Great Wall Acupuncture, P.C. v Geico Ins. Co.

Workers' Compensation Fee ScheduleNo-Fault BenefitsAcupuncture ServicesChiropractorsSummary JudgmentAppellate ReviewInsurance DisputeFee Schedule ReductionAssigned BenefitsMedical Billing
References
1
Case No. 2011-192 K C
Regular Panel Decision
Dec 19, 2017

Jamaica Dedicated Med. Care, P.C. v. Tri State Consumer Ins. Co.

This case concerns an appeal from an order of the Civil Court of the City of New York, Kings County, which denied defendant Tri State Consumer Ins. Co.'s cross motion for summary judgment. Jamaica Dedicated Medical Care, P.C., as assignee, sought first-party no-fault benefits. Tri State Consumer Ins. Co. contended that it had either properly reimbursed services according to the workers' compensation fee schedule or timely denied others due to lack of medical necessity. The Appellate Term found a triable issue of fact regarding medical necessity and that the defendant failed to establish its workers' compensation fee schedule defense as a matter of law. Consequently, the order denying summary judgment was affirmed.

No-fault benefitsSummary judgmentMedical necessityWorkers' compensation fee scheduleAppellate reviewAssigneeInsurance claimCivil CourtAppellate TermKings County
References
2
Case No. 2017-913 K C
Regular Panel Decision
Aug 02, 2019

Oriental Health Acupuncture, P.C. v. State Farm Mut. Auto. Ins. Co.

This case concerns an appeal initiated by Oriental Health Acupuncture, P.C., acting as the assignee of Carrington, Earnel, against State Farm Mutual Automobile Ins. Co. The appeal originated from an order by the Civil Court of the City of New York, Kings County, which had granted State Farm's motion for summary judgment and dismissed the plaintiff's complaint seeking first-party no-fault benefits. The Civil Court's decision was predicated on the finding that the amounts claimed by the plaintiff exceeded the limits established by the workers' compensation fee schedule. The Appellate Term, Second Department, affirmed the lower court's order. This decision was made in conjunction with a related case, BQE Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., decided concurrently.

No-fault benefitsSummary judgmentAppellate reviewWorkers' compensation fee scheduleAutomobile insuranceFirst-party benefitsMedical provider claimAssigned benefitsCivil Court appealAppellate Term decision
References
1
Case No. 2014-2497 Q C
Regular Panel Decision
Oct 27, 2017

Charles Deng Acupuncture, P.C. v. State Farm Mut. Auto. Ins. Co.

This case involves an appeal by Charles Deng Acupuncture, P.C., as assignee of Blake, Christopher, against State Farm Mutual Automobile Ins. Co. The plaintiff sought summary judgment for unpaid first-party no-fault benefits related to acupuncture services, specifically claims billed under CPT codes 97810, 97811, and 99203. The Civil Court partially granted the plaintiff's motion for a reduced amount on one claim and dismissed the rest, also granting the defendant's cross-motion for dismissal. On appeal, the Appellate Term, Second Department, affirmed the Civil Court's order. The court found that State Farm had timely mailed denial of claim forms and had properly paid the services according to the workers' compensation fee schedule for acupuncture services performed by chiropractors.

no-fault benefitsacupuncture servicesworkers' compensation fee schedulesummary judgmentCPT codesmedical billinginsurance disputeappellate reviewtimely mailingdenial of claim
References
2
Case No. No. 12627
Regular Panel Decision
May 06, 1954

American General Ins. Co. v. Bailey

This case concerns an appeal regarding a worker's compensation claim in Texas. Appellee Bailey sought compensation for permanent partial disability following a scaffold incident where he witnessed a co-worker's death and experienced severe fright and an anxiety state, despite sustaining only minor physical bruises. The appellant, American General Ins. Co., challenged the judgment, arguing that Bailey's neurosis, not directly resulting from a physical injury, was not compensable under the Workmen's Compensation Statutes. The Court of Civil Appeals of Texas, Galveston, reversed the trial court's decision, ruling that under Texas law, a neurosis or emotional condition is only compensable if it is a direct consequence of a physical injury, a condition not met in this case.

Workers' CompensationEmotional TraumaNeurosisPhysical InjuryAnxiety StateScaffold AccidentTexas LawMental HealthCompensable InjuryFright
References
2
Case No. 2020-06-0216
Regular Panel Decision
Sep 21, 2020

De Rosa, Debra v. I & MJ Gross Co.

Debra De Rosa, an employee of I & MJ Gross Co., injured her wrist and subsequently sought additional treatment with a new doctor. She contended that the carrier, Nationwide Mutual Ins. Co., failed to offer a panel of physicians or inform her of her right to choose from a list of three doctors. However, I & MJ Gross Co. denied these allegations, asserting that it had twice fulfilled its statutory obligation to offer a physician panel. The Court found the employer's testimony credible regarding the panel offer and noted that Ms. De Rosa accepted treatment from Dr. John Weaver. Dr. Weaver ultimately placed her at maximum medical improvement and stated no further treatment was necessary, leading the Court to deny Ms. De Rosa’s request for additional medical care.

Workers' CompensationMedical TreatmentPhysician PanelCredibility DeterminationWrist InjuryMaximum Medical ImprovementStatutory ObligationEmployee RightsEmployer ResponsibilityMedical Benefits
References
1
Case No. 2014-1535 Q C
Regular Panel Decision
Sep 22, 2017

GBI Acupuncture, P.C. v. GEICO Ins. Co.

The Appellate Term, Second Department, affirmed an order from the Civil Court of the City of New York, Queens County, in a case involving GBI Acupuncture, P.C. and GEICO Ins. Co. GBI Acupuncture, as assignee, sought to recover first-party no-fault benefits, but the Civil Court had denied its motion for summary judgment and partially granted GEICO's cross-motion. The Appellate Term concurred with the Civil Court's findings, holding that GEICO had properly mailed its denial of claim forms. Furthermore, the court found no merit in the plaintiff's arguments concerning the application of the workers' compensation fee schedule in this no-fault benefits dispute.

No-fault benefitsSummary judgmentClaims denialWorkers' compensation fee scheduleAppellate reviewProper mailingCivil courtFirst-party benefitsAssignee claimInsurance dispute
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
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