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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

Pig Newton, Inc. v. Boards of Directors of the Motion Picture Industry Pension Plan

Plaintiff Pig Newton, Inc. commenced an action against the Boards of Directors of the Motion Picture Industry Pension Plan, Health Plan, and Individual Account Plan, seeking a declaration that certain provisions of the Plans’ Trust Agreements were invalid and unenforceable. The Defendants counterclaimed for delinquent contributions under ERISA. The core dispute revolved around "Controlling Employee Provisions" in the Trust Agreements, which obligated employers to contribute for Controlling Employees for a specified number of hours and weeks regardless of actual hours worked. Pig Newton argued these provisions were invalid, not properly incorporated, or conflicted with collective bargaining agreements (CBAs). The Court, applying federal common law and an arbitrary and capricious standard of review for the Directors' interpretation, found the provisions valid, properly incorporated, and not in conflict with the CBAs, concluding that Szekely (Pig Newton's sole owner) qualified as a Controlling Employee. Consequently, the Court denied Plaintiff's motion for summary judgment and granted Defendants' cross-motion for summary judgment, dismissing Plaintiff's complaint and awarding Defendants the sought-after contributions, interest, auditors’ fees, and liquidated damages.

ERISAMultiemployer PlanPension PlanHealth PlanDeclaratory JudgmentSummary JudgmentTrust AgreementsCollective Bargaining AgreementsControlling Employee ProvisionsDelinquent Contributions
References
44
Case No. MISSING
Regular Panel Decision

American Prescription Plan, Inc. v. American Postal Workers Union AFL-CIO Health Plan

This case involves appeals and a cross-appeal from an order of the Supreme Court, Nassau County. Defendant American Postal Workers Union, AFL-CIO Health Plan (APWU-HP) appealed the denial of its motion for summary judgment concerning the fourth, fifth, and fourteenth causes of action. Defendant Administrative Consultants, Inc. (ACI) appealed the denial of its motion for summary judgment regarding the tenth and eleventh causes of action. The plaintiff cross-appealed the partial dismissal of the first, third, and sixth causes of action. The appellate court reversed the order for the defendants, granting their motions for summary judgment and dismissing all causes of action asserted against them. The order was affirmed insofar as cross-appealed by the plaintiff, upholding the partial dismissals against the plaintiff.

Summary JudgmentContract DisputeOral RepresentationsStatute of FraudsEquitable EstoppelAppellate ProcedureDismissal of ClaimsBreach of ContractMootness DoctrineAuthority to Contract
References
7
Case No. MISSING
Regular Panel Decision

Sibley-Schreiber v. Oxford Health Plans (N.Y.), Inc.

This class action involves several plaintiffs challenging Oxford Health Plans' denial of insurance coverage for Viagra. Defendants moved to dismiss the complaint, alleging that the plaintiffs failed to exhaust administrative remedies. Plaintiffs countered that pursuing these remedies would have been futile given the defendants' public 'no pay' and 'six pill' policies and the lack of clear appeal processes. The court denied the defendants' motions to dismiss and for summary judgment, concluding that the plaintiffs had made reasonable efforts to seek coverage and that further administrative appeals would have been futile.

ERISAInsurance CoverageHealthcare BenefitsViagraErectile DysfunctionExhaustion of Administrative RemediesFutility DoctrineClass ActionMotion to DismissSummary Judgment
References
16
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. MISSING
Regular Panel Decision
May 14, 2013

Veneruso v. Mount Vernon Neighborhood Health Center

Plaintiff James J. Veneruso, on behalf of Community Choice Health Plan of Westchester Inc. (CCHP), sued Defendant Mount Vernon Neighborhood Health Center to recover 'Surplus Distributions' CCHP made to Mount Vernon. CCHP, a New York not-for-profit corporation, was directed by the New York State Department of Health to terminate operations and commence dissolution. Plaintiff, appointed temporary receiver, sought to recover payments made to Mount Vernon, arguing they were unlawful under New York's Not-for-Profit Corporation Law § 515(a). Defendant removed the case to federal court, asserting federal jurisdiction based on complete preemption, substantial federal question, its status as a federal corporation, and the involvement of federal funds. The court rejected all of Defendant's arguments for federal jurisdiction, finding that the claims were based purely on state law and that federal law was, at best, a potential defense. Consequently, the Plaintiff's motion to remand the case to state court was granted, while the request for attorneys' fees was denied.

MedicaidNon-Profit Corporation LawState Law ClaimsFederal JurisdictionRemoval StatuteComplete PreemptionSubstantial Federal QuestionDeclaratory JudgmentAttorneys' FeesCooperative Federalism
References
76
Case No. MISSING
Regular Panel Decision

Mundo v. Sanus Health Plan of Greater New York

Evelyn A. Mundo, a former employee of Sanus Health Plan, was discharged in 1993 and alleged her termination violated the Americans with Disabilities Act (ADA) because Sanus perceived her inability to tolerate stress as an impairment that substantially limited her ability to work. Sanus moved to dismiss the complaint, arguing that job-related stress is not a disability under the ADA. The court granted Sanus' motion, ruling that an inability to tolerate stressful situations is not an impairment for ADA purposes. Furthermore, Mundo failed to demonstrate that her employer considered her generally unable to work in a broad range of positions, rather than just a specific supervisory role. Consequently, the complaint was dismissed in its entirety, and the court declined to exercise supplemental jurisdiction over any remaining state law claims.

ADADisability DiscriminationPerceived DisabilityJob-Related StressMotion to DismissFederal Rule of Civil Procedure 12(b)(6)Major Life ActivityWorkingAmericans with Disabilities ActRehabilitation Act
References
26
Case No. 2022 NY Slip Op 07383 [211 AD3d 1616]
Regular Panel Decision
Dec 23, 2022

Williams v. Kaleida Health

Dr. Aston B. Williams, a physician with medical staff privileges at Kaleida Health, sought a medical exemption from a COVID-19 vaccine mandate, which was subsequently denied. As a result of noncompliance, his privileges at Buffalo General Medical Center were suspended. Williams initiated legal action, requesting injunctive relief to prevent the revocation of his privileges. Kaleida Health moved to dismiss the complaint. The Supreme Court denied Williams's motion for an injunction and partially granted Kaleida Health's motion, dismissing the complaint without prejudice. The Appellate Division, Fourth Department, affirmed this decision, determining that Public Health Law § 2801-c provides the exclusive remedy for alleged violations of § 2801-b (1), necessitating Williams to first pursue his claim before the Public Health and Health Planning Counsel.

COVID-19 vaccine mandatemedical staff privilegesinjunctionPublic Health Lawexclusive remedyPHHPCadministrative remediesdismissal without prejudicehealth care workersemployer-employee dispute
References
4
Case No. MISSING
Regular Panel Decision
Jun 21, 2000

Hector v. Wal-Mart Group Health Plan

Plaintiff Garfield Hector sued Wal-Mart Associates Health and Welfare Plan after being denied coverage for medical bills resulting from an automobile accident. Plaintiff alleged timely claim submission in May 1995, while the defendant disputed this, claiming submission in April/May 1999, which exceeded the plan's 12-month limit. The defendant moved for summary judgment, arguing that the plaintiff failed to exhaust administrative remedies as required by the Plan, and also failed to submit the claim within the stipulated timeframe and commence the lawsuit within two years. The plaintiff failed to oppose the motion or appear for oral argument. The court found that the plaintiff did not exhaust the administrative review procedures mandated by the Plan, which explicitly requires pursuing these remedies before initiating legal action. Consequently, the court granted the defendant's motion for summary judgment and dismissed the plaintiff's complaint.

ERISAEmployee BenefitsHealth PlanClaim ExhaustionSummary Judgment MotionPlan AdministrationDenial of BenefitsTimely FilingFederal JurisdictionProcedural Dismissal
References
10
Case No. MISSING
Regular Panel Decision

In re Robert Plan Corp.

Kenneth Kirschenbaum, the Chapter 7 Trustee for The Robert Plan Corporation and The Robert Plan of New York Corporation, sought court approval for fee awards for himself and his professionals for administering an ERISA plan. The U.S. Department of Labor (DOL) objected, asserting the court lacked jurisdiction to award fees from Plan assets and had specific objections to the reasonableness of the fees. The court affirmed its core jurisdiction over the Trustee's actions as Plan administrator and his professionals' compensation, regardless of whether payments came from Plan or estate assets, citing previous rulings. The court analyzed whether Bankruptcy Code §§ 326 and 330 conflicted with ERISA statutes concerning fiduciary compensation, concluding no substantive conflict existed and the Bankruptcy Code's specific compensation scheme governed. Ultimately, the court largely overruled DOL's objections and granted the fee applications for the Trustee, K & K, Witz, and Whitfield, deeming the requested amounts reasonable and compliant with the Bankruptcy Code. The awards are payable from the Plan's Pguy Account, with any shortfall covered by the Debtors' estate.

Bankruptcy LawERISAChapter 7 TrusteeFee ApplicationPlan AdministrationJurisdictionReasonable CompensationStatutory ConstructionDepartment of LaborFiduciary Duties
References
50
Case No. MISSING
Regular Panel Decision

Ames v. Group Health Inc.

Plaintiffs, including trustees John Ames and Michael Pantony of the United Welfare Fund-Welfare Division (UWF) and participant Fred Tremarcke, sued Group Health Incorporated (GHI) under ERISA and HIPAA. They alleged GHI illegally discriminated against Tremarcke by denying his health coverage after he went on disability leave, arguing it violated HIPAA's anti-discrimination provisions and breached the insurance policy. Tremarcke's employer, Classic Chevrolet, continued making health contributions on his behalf, and a 'Side Letter of Understanding' with his union attempted to maintain his 'active employee' status. The court ultimately ruled in favor of GHI, finding that Tremarcke did not meet the eligibility requirements of the UWF-GHI plan, which required working over 20 hours per week, and that the 'Side Letter' could not unilaterally alter GHI's contractual obligations. Consequently, the plaintiffs' motion for partial summary judgment was denied, and the defendant's motion for partial summary judgment was granted, dismissing the second and third causes of action.

ERISAHIPAACOBRAHealth InsuranceDisability BenefitsSummary JudgmentFiduciary DutyBreach of ContractMulti-employer FundCollective Bargaining Agreement
References
6
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