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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

Government Employees Insurance v. Uptown Health Care Management, Inc.

Plaintiffs GEICO allege a scheme where defendants, including Uptown Health Care Management d/b/a East Tremont, Hisham Elzanaty, Alan Goldenberg, Dr. Hisham Ahmed, and Dr. Jadwiga Pawlowski, fraudulently billed GEICO for millions in services. GEICO contends East Tremont was ineligible for reimbursement under New York's no-fault insurance laws, operating without a legitimate medical director, violating its operating certificate, and paying kickbacks for referrals. The complaint raises six causes of action, including declaratory judgment, RICO violations (18 U.S.C. §§ 1962(c), 1962(d)), common law fraud, aiding and abetting fraud, and unjust enrichment. Defendants moved to dismiss under Rule 12(b)(1) for Burford abstention and Rule 12(b)(6) for failure to state a claim, arguing GEICO's claims would invalidate a DOH license and interfere with state oversight. Citing the similar Allstate Ins. v. Elzanaty action, the court denied defendants' motions, affirming that insurers can challenge fraudulent licensing and conduct under RICO and fraud claims, even if state authorities have approved the facility. The court concluded that such claims do not disrupt New York's regulatory scheme and need not be raised exclusively with the DOH or through an Article 78 proceeding.

Insurance FraudNo-Fault InsuranceRICO ActMedical LicensingHealthcare FraudAbstention DoctrineRule 12(b)(1) MotionRule 12(b)(6) MotionArticle 28 FacilitiesKickbacks
References
21
Case No. MISSING
Regular Panel Decision
Dec 27, 2001

MacRo v. Independent Health Ass'n, Inc.

Plaintiffs Cheryl Macro and Kim Zastrow, insured under a group health contract with Independent Health through the Tonawanda City School District, initiated a class action in state court to challenge Independent Health's modification of infertility treatment coverage. Defendant Independent Health removed the case to federal court, asserting ERISA preemption. Plaintiffs moved to remand, arguing that their claims fell under New York Insurance Law, which is exempt from ERISA preemption by the saving clause, and that their health plan qualified as a 'governmental plan' also exempt from ERISA. The District Court granted the plaintiffs' motion, concluding that the claims were indeed saved from ERISA preemption and that the plan was exempt, thus rendering federal subject matter jurisdiction absent. The court accordingly remanded the case back to New York State Supreme Court.

Infertility CoverageHealth Insurance DisputesERISA PreemptionSaving ClauseGovernmental PlansRemoval to Federal CourtSubject Matter JurisdictionNew York Insurance LawClass Action LitigationEmployee Benefits Plan
References
31
Case No. 2013-1456 K C
Regular Panel Decision
Mar 11, 2016

EMC Health Prods., Inc. v. Allstate Ins. Co.

This case involves an appeal from an order of the Civil Court of the City of New York, Kings County, which had granted the plaintiff's motion for summary judgment. The plaintiff, EMC Health Products, Inc., as an assignee, sought to recover assigned first-party no-fault benefits from Allstate Insurance Company. The Appellate Term affirmed the Civil Court's decision concerning the first and second causes of action, determining that the defendant failed to establish timely mailing of denial of claim forms. However, the court modified the original order by denying summary judgment for the third and fourth causes of action. This modification was based on the defendant successfully raising triable issues of fact regarding timely denial due to lack of medical necessity and claims exceeding the workers' compensation fee schedule.

Summary JudgmentNo-Fault BenefitsFirst-Party BenefitsMedical NecessityWorkers' Compensation Fee ScheduleTimely DenialAppellate ReviewCivil Court OrderAssignee ClaimsInsurance Law
References
3
Case No. 532194
Regular Panel Decision
Nov 10, 2022

In the Matter of the Claim of Marc Trombino

Claimant Marc Trombino, an iron worker, filed a workers' compensation claim in September 2016 for work-related lung conditions, including silicosis and chronic obstructive pulmonary disease, naming FMB Inc. as his employer. The claim was initially indexed against Phoenix Insurance Co., then corrected to Liberty Insurance Corporation after an investigation. Liberty disputed coverage, but a Workers' Compensation Law Judge (WCLJ) found prima facie evidence and established the claim, finding an occupational disease and permanent total disability. Liberty appealed, belatedly raising a lack of policy coverage for the work location. The Board remitted the matter for a hearing on coverage, during which Ace American Insurance Company was put on notice. The WCLJ and subsequently the Board invoked the doctrine of laches, barring Liberty from denying coverage due to its inexcusable delay in raising the defense and the resultant prejudice to Ace American. The Supreme Court, Appellate Division, Third Judicial Department, affirmed the Board's decision.

Workers' CompensationOccupational DiseaseSilicosisChronic Obstructive Pulmonary DiseaseLaches DoctrineInsurance Coverage DisputeAppellate ReviewPrima Facie EvidencePermanent Total DisabilityMedical Expert Testimony
References
7
Case No. 534672
Regular Panel Decision
Jun 01, 2023

In the Matter of the Claim of Delon Nelson

The claimant, Delon A. Nelson, appealed two decisions from the Workers' Compensation Board. The case involved an established claim for work-related injuries, for which the self-insured employer, NYC Health & Hospital Corp., continued to pay claimant's wages during a period of disability. The employer sought reimbursement for these wages against a schedule loss of use award previously made to the claimant. The claimant argued that the employer had waived its right to reimbursement by not requesting it before the award was made or by failing to object to a proposed decision. The Workers' Compensation Board ruled in favor of the employer, finding its reimbursement request timely, and denied claimant's application for reconsideration. The Appellate Division affirmed the Board's decisions, concluding that the employer's earlier filing of a C-669 form constituted a timely request for reimbursement under Workers' Compensation Law § 25 (4) (a), and denying reimbursement would result in unjust enrichment for the claimant.

Wage ReimbursementWorkers' Compensation BenefitsSchedule Loss of UseAdvance PaymentsEmployer Reimbursement ClaimTimeliness of ClaimUnjust EnrichmentAppellate ReviewBoard DecisionsPermanent Partial Disability
References
13
Case No. ADJ1857578
Regular
Jun 23, 2009

MIRNA LICEA vs. MINSON CORPORATION, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for PHICO INSURANCE COMPANY in liquidation

This case involves a lien claim by Missirian Orthopedic Medical Group, assigned to KM Financial Services, for medical treatment provided to Mirna Licea. The California Insurance Guarantee Association (CIGA), representing the insolvent insurer Phico Insurance Company, denied the lien based on Insurance Code § 1063.1(c)(9), which excludes claims by assignees. The Workers' Compensation Appeals Board denied reconsideration, affirming that the statute clearly prohibits payment to assignees, including medical providers who have assigned their accounts receivable. The Board relied on *Baxter Healthcare Corp. v. CIGA* for the principle that assigned claims are not "covered claims" under the Guarantee Act.

Workers' Compensation Appeals BoardCalifornia Insurance Guarantee AssociationCIGAPhico Insurance Companyliquidationinsolvent insurerlien claimantassigneecovered claimInsurance Code 1063.1(c)(9)
References
4
Case No. 2000 WL 178191
Regular Panel Decision

Selby v. Principal Mutual Life Insurance

Adrian and Jill Selby sued Principal Life Insurance Company, alleging various errors in processing their health insurance claims. They challenged Principal's interpretation of an infertility treatment exclusion and its claims review procedures under ERISA. The court considered motions for class certification for four proposed classes. Class I, addressing Principal's online claims review process for altering diagnoses, was certified. Classes II and III, concerning medically necessary infertility treatments and New York Insurance Law violations respectively, were not certified for class-wide adjudication, though individual claims were permitted. Class IV, challenging the sufficiency of claim denial letters, was not certified immediately due to the named plaintiffs' lack of standing for injunctive relief, but conditional certification was offered upon identification of a new suitable plaintiff.

ERISAClass ActionHealth InsuranceClaims DenialInfertility ExclusionOnline ReviewMedical BenefitsStandingFederal Rules of Civil Procedure Rule 23Benefit Plans
References
23
Case No. MISSING
Regular Panel Decision

Fulton Boiler Works, Inc. v. American Motorists Insurance

Fulton Boiler Works, Inc., filed an action against several insurance companies regarding defense and indemnification for thousands of asbestos claims. The court addressed multiple pending motions for summary judgment, focusing on the proper allocation of indemnity costs among the liable parties, Fulton's obligation for uninsured years, the applicability of equitable estoppel against insurers, and Travelers' specific obligations concerning notice of claims and disclaimers. The court ruled that a pro rata allocation of indemnity costs is appropriate, with Fulton liable for periods it was uninsured. Equitable estoppel was deemed inapplicable to bar insurers from seeking contribution, and Travelers was found to have received proper notice for many claims and is barred from disclaiming coverage due to untimely disclaimers. This order, along with a previous one, sets the 'ground rules' for resolving past, pending, and future asbestos claims.

Asbestos LiabilityInsurance Coverage DisputeIndemnity AllocationSummary JudgmentEquitable EstoppelNotice ProvisionsDisclaimer of CoveragePro Rata AllocationInjury-in-factComprehensive General Liability Policy
References
23
Case No. 2013-1470 K C
Regular Panel Decision
Mar 16, 2016

Ultimate Health Prods., Inc. v. Hereford Ins. Co.

This case concerns an appeal by Ultimate Health Products, Inc., as assignee of Paul Luckner, against Hereford Insurance Co. The plaintiff sought to recover assigned first-party no-fault benefits. The Civil Court of the City of New York, Kings County, had previously denied the plaintiff's motion for summary judgment and granted the defendant's cross motion, dismissing the complaint. The defendant successfully argued that the policy in question was a workers' compensation insurance policy, not an automobile insurance policy, thus establishing a lack of coverage for no-fault benefits. The Appellate Term affirmed the Civil Court's order, reiterating that a lack of coverage defense is not precluded by issues of propriety or timeliness of a denial of claim form.

No-Fault BenefitsWorkers' Compensation PolicyAutomobile InsuranceSummary JudgmentLack of Coverage DefenseAppellate ReviewAssigned BenefitsInsurance Policy InterpretationCivil Court OrderFirst-Party Benefits
References
2
Case No. ADJ1403614 (SAC 0279198), ADJ1512320 (SAC 0297907), ADJ3378464 (SAC 0279199), ADJ3737011 (SAC 0279196), ADJ4501288 (SAC 0279197)
Regular
Jul 07, 2014

SHARON SUNDMAN SCHULTZ vs. SUTTER ROSEVILLE MEDICAL CENTER, SUTTER HEALTH, CALIFORNIA INSURANCE GUARANTY ASSOCIATION, FREMONT INDEMNITY COMPANY

The Workers' Compensation Appeals Board (WCAB) affirmed a prior order requiring the California Insurance Guarantee Association (CIGA) to reimburse Sutter Health. CIGA argued that the reimbursement claim, stemming from a stipulation with an insolvent insurer, was not a "covered claim" under Insurance Code section 1063.1. The WCAB adopted the WCJ's report and recommendation, denying CIGA's reconsideration request. Therefore, CIGA remains obligated to reimburse Sutter Health as per the original stipulation.

Workers' Compensation Appeals BoardCIGASutter HealthFremont Indemnity Companyliquidationcovered claimsInsurance Code section 1063.1stipulationinsolvent insurance carrierreconsideration
References
0
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