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

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. 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. 2015-1094 K C
Regular Panel Decision
Dec 22, 2017

V.S. Care Acupuncture, P.C. v. NY Cent. Mut. Fire Ins. Co.

This case involves an appeal brought by NY Central Mutual Fire Ins. Co. against V.S. Care Acupuncture, P.C., an assignee, concerning first-party no-fault benefits. The defendant appealed an order from the Civil Court that denied its motion for summary judgment to dismiss claims for services rendered between October 2009 and February 2010. The Appellate Term found that the defendant had properly mailed denial of claim forms and established that the amounts sought by the plaintiff exceeded the applicable workers' compensation fee schedule. Consequently, the Appellate Term reversed the lower court's order and granted the defendant's motion for summary judgment, dismissing the relevant parts of the complaint.

No-Fault BenefitsSummary JudgmentAppellate ReviewFee Schedule DefenseDenial of ClaimWorkers' Compensation Fee ScheduleInsurance LawFirst-Party BenefitsAssignee RightsCivil Court Order
References
1
Case No. 2018-1176 K C
Regular Panel Decision
Nov 01, 2019

Y.A.M. Med. Supply, Inc. v. Global Liberty Ins. Co. of NY

This case involves an appeal from an order of the Civil Court of the City of New York, Kings County, which denied the defendant's cross-motion to hold the action in abeyance. The defendant, Global Liberty Ins. Co. of NY, sought to pause the proceedings pending a determination by the Workers' Compensation Board regarding the plaintiff's assignor's eligibility for workers' compensation benefits. The plaintiff, Y.A.M. Medical Supply, Inc., is a provider seeking assigned first-party no-fault benefits. The Appellate Term affirmed the Civil Court's decision, ruling that the defense of workers' compensation eligibility is subject to preclusion if not timely raised, and the defendant failed to demonstrate a timely denial of the plaintiff's claims.

No-Fault BenefitsWorkers' Compensation LawCross MotionAction in AbeyancePreclusion DefenseTimely DenialAppellate TermCivil CourtFirst-Party BenefitsAssignee
References
2
Case No. 2017-905 K C
Regular Panel Decision
Aug 02, 2019

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

This case involves an appeal by BQE Acupuncture, P.C. against State Farm Mutual Automobile Ins. Co. after the Civil Court granted State Farm's motion for summary judgment and denied BQE Acupuncture's cross-motion. BQE Acupuncture sought to recover assigned first-party no-fault benefits, but State Farm asserted that the amounts claimed exceeded the workers' compensation fee schedule. The Appellate Term, Second Department, affirmed the Civil Court's order. The court reiterated its prior holding that insurers may properly utilize the workers' compensation fee schedule for acupuncture services performed by chiropractors when determining reimbursement for licensed acupuncturists.

No-Fault BenefitsAcupuncture ServicesWorkers' Compensation Fee ScheduleSummary JudgmentAppellate ReviewInsurance DisputeFee ReductionChiropractic ServicesAssigned BenefitsCivil Court Decision
References
2
Case No. 2015-1339 K C
Regular Panel Decision
Dec 19, 2017

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

This case concerns an appeal by GBI Acupuncture, P.C. from a Civil Court order granting State Farm Mutual Automobile Ins. Co.'s motion for summary judgment. The Appellate Term found that State Farm's denial of claim forms for the first four causes of action were untimely, thus reversing that portion of the lower court's decision. However, with respect to the fifth through eighth causes of action, the court affirmed State Farm's practice of using the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine payment for licensed acupuncturists. The order was therefore modified by denying summary judgment for the first four causes of action, and otherwise affirmed. The case cites previous rulings on timely verification requests and the application of workers' compensation fee schedules.

No-fault benefitsSummary judgmentTimely denialVerification requestsFee scheduleAcupuncture servicesChiropractorsWorkers' compensation fee scheduleAppellate reviewCivil Court order
References
2
Case No. 2014-2225 K C
Regular Panel Decision
Oct 27, 2017

Acupuncture Approach, P.C. v. NY Cent. Mut. Fire Ins. Co.

This case concerns an appeal from an order of the Civil Court of the City of New York, Kings County, relating to assigned first-party no-fault benefits. Acupuncture Approach, P.C., as assignee, sought to recover sums from NY Central Mutual Fire Ins. Co. The defendant moved for summary judgment, arguing timely payment according to the workers' compensation fee schedule for some claims, and lack of medical necessity for others. The plaintiff cross-moved for summary judgment. The Appellate Term modified the Civil Court's order, denying the defendant's motion for summary judgment on claims totaling $3,495, $2,695, and $1,965, due to the defendant's failure to demonstrate timely denial. The Appellate Term affirmed the reduction of the amount in controversy for other claims and the denial of the plaintiff's cross-motion.

No-Fault BenefitsSummary JudgmentAppellate ReviewInsurance ClaimsWorkers' Compensation Fee ScheduleMedical NecessityTimely DenialCivil Court OrderAssignee ClaimsPreclusion
References
4
Case No. 2015-2415 K C
Regular Panel Decision
May 18, 2018

Valdan Acupuncture, P.C. v. NY Cent. Mut. Fire Ins. Co.

In an action by Valdan Acupuncture, P.C., as assignee of Daequan Woods, to recover assigned first-party no-fault benefits, the defendant, NY Central Mutual Fire Ins. Co., moved for summary judgment. The Civil Court denied parts of the defendant's motion. On appeal, the Appellate Term, Second Department, reversed the Civil Court's order in part. The appellate court granted the defendant's motion for summary judgment regarding a $883.80 claim, confirming the assignor's failure to appear for independent medical examinations (IMEs) and proper mailing of IME scheduling letters. However, for other claims, the IME no-show defense was deemed not preserved, leading to a remittal of those remaining branches of the motion to the Civil Court for a new determination based on alternative grounds. The decision was reversed in part, with a partial grant of summary judgment to the defendant and remittal for further proceedings.

No-fault benefitsIndependent Medical Examination (IME)Summary judgmentAppellate reviewAssignor's failure to appearDenial of benefitsMedical claimsCivil CourtKings CountyInsurance dispute
References
3
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. 2015-2389 S C
Regular Panel Decision
Apr 13, 2017

Thomas Dow, D.C., P.C. v. New York Cent. Mut. Fire Ins. Co.

This case involves an appeal from an order of the District Court of Suffolk County concerning a provider's action to recover assigned first-party no-fault benefits. The defendant, New York Central Mutual Fire Ins. Co., moved for summary judgment, asserting that the amount sought by the plaintiff exceeded the workers' compensation fee schedule. The District Court initially denied this motion, citing the defendant's failure to establish timely denial of claims. However, the Appellate Term reversed this decision, finding that the defendant had indeed timely mailed its denial forms and made a prima facie showing that the charges were in excess of the permitted fee schedule. The plaintiff failed to provide admissible evidence to counter the defendant's fee schedule defense. Consequently, the Appellate Term granted the defendant's motion for summary judgment.

No-Fault BenefitsSummary JudgmentWorkers' Compensation Fee ScheduleTimely DenialAppellate TermSuffolk CountyInsurance LawAssigned BenefitsMedical ProviderPrima Facie Showing
References
2
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