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Case Law Database

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

Case No. MISSING
Regular Panel Decision

Yklik Medical Supply, Inc. v. Allstate Insurance

Plaintiff Yklik Medical Supply, Inc., a medical supply provider, sued Allstate Insurance Company to recover $317 in unpaid medical bills for equipment supplied to its assignor, Tammy Agosto. Yklik moved for summary judgment, asserting proper bill submission and Allstate's failure to timely pay or deny the claim. Allstate argued that the charges exceeded the Workers' Compensation fee schedule and that a partial payment had been made. The court found that Yklik established a prima facie case. The central issue was whether Allstate's fee schedule defense was precluded due to its failure to issue a timely denial within 30 days as mandated by Insurance Law § 5106 (a) and 11 NYCRR 65-3.5. The court ruled that since Allstate waited 56 days to send its denial, it was precluded from raising the fee schedule defense, and therefore, summary judgment was granted to the plaintiff.

No-fault insurancesummary judgmenttimely denialfee schedulepreclusion ruleinsurance lawmedical supplybilling practicespersonal injury protectionassignor
References
19
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. 25 NY3d 907
Regular Panel Decision
2015-XX-XX

Government Employees Insurance v. Avanguard Medical Group, PLLC

This case addresses whether no-fault insurance carriers are obligated to pay facility fees to New York State-accredited office-based surgery (OBS) centers for the use of their premises and support services. The court concluded that neither existing statutes nor regulations mandate such payments. Plaintiffs, a group of GEICO insurers, successfully sought a declaratory judgment that they are not legally required to reimburse Avanguard Medical Group, PLLC, for OBS facility fees, totaling over $1.3 million. The decision affirmed the Appellate Division's ruling, emphasizing that OBS facility fees are not explicitly covered by statute or fee schedules, nor do they fall under reimbursable "professional health services" as per 11 NYCRR 68.5. The court highlighted the distinct regulatory frameworks for OBS centers compared to hospitals and ambulatory surgery centers, declining to mandate policy changes best left to the legislature.

No-Fault InsuranceOffice-Based Surgery (OBS)Facility FeesInsurance LawBasic Economic LossFee SchedulesWorkers' Compensation BoardDepartment of Financial ServicesStatutory InterpretationRegulatory Framework
References
16
Case No. MISSING
Regular Panel Decision

Jesa Medical Supply, Inc. v. GEICO Insurance

Plaintiff commenced this action against GEICO to recover first-party no-fault benefits for medical services totaling $796.46. GEICO denied the claims, citing lack of medical necessity and charges exceeding the workers' compensation fee schedule. The court granted summary judgment to the plaintiff for $16.46, finding GEICO failed to provide sufficient evidence for its fee schedule defense on that specific amount. Conversely, the court denied plaintiff's motion for the $780 claim and dismissed that cause of action, accepting GEICO's timely mailed denial and an admissible peer review report by Dr. Andrew R. Miller establishing lack of medical necessity. The court also ruled that defects in the defendant's attorney affirmation did not warrant summary judgment for the plaintiff.

no-fault benefitsmedical necessityfee schedulesummary judgmentpeer reviewelectronic signatureinsurance claimsNew York Civil Courtmedical provider reimbursementtimely denial
References
15
Case No. 2014-1081 K C
Regular Panel Decision
Oct 05, 2016

High Quality Med. Supplies, Inc. v. Mercury Ins. Group

This case involves an appeal concerning assigned first-party no-fault benefits sought by High Quality Medical Supplies, Inc., as assignee of Charles Botwee. The defendant, Mercury Ins. Group, appealed an order from the Civil Court that denied its motion for summary judgment to dismiss the complaint. Mercury Ins. Group contended that billing for durable medical equipment not listed in a fee schedule is not compensable. However, the Appellate Term affirmed the lower court's decision, citing 11 NYCRR 68.5, which specifically permits reimbursement for healthcare services not explicitly covered by fee schedules, thereby rejecting the defendant's argument.

No-Fault BenefitsFirst-Party BenefitsDurable Medical EquipmentFee ScheduleSummary JudgmentAppellate TermAssigned BenefitsInsurance LawReimbursementCivil Court
References
3
Case No. 2017-2088 K C
Regular Panel Decision
Oct 25, 2019

Quality Comprehensive Med. Care, P.C. v. New York Cent. Mut. Fire Ins. Co.

The Appellate Term, Second Department, reviewed an appeal concerning assigned first-party no-fault benefits. The plaintiff, Quality Comprehensive Medical Care, P.C., appealed a Civil Court order that granted summary judgment to the defendant, New York Central Mutual Fire Insurance Company, dismissing the complaint. The defendant had denied claims asserting a lack of medical necessity and excessive fees. The appellate court determined that the defendant did not establish a lack of medical necessity. However, it agreed that fees exceeding $425.88 per claim surpassed the allowed amount under the workers' compensation fee schedule. Therefore, the Civil Court's order was modified to dismiss only the portion of the complaint seeking recovery in excess of $425.88 per claim, and the order was affirmed as modified.

No-fault benefitsMedical necessityWorkers' compensation fee scheduleSummary judgmentAppellate reviewInsurance claimsFee disputeAssigned benefitsCivil CourtKings County
References
4
Case No. MISSING
Regular Panel Decision

Cornell Medical, P.C. v. Mercury Casualty Co.

This appellate decision addresses an action by healthcare providers seeking assigned first-party no-fault benefits. The defendant moved for summary judgment to dismiss the complaint and to amend its answer to include a counterclaim for unjust enrichment, citing alleged overcharges based on workers' compensation fee schedules. The Civil Court initially denied both branches of the defendant's motion due to preclusion. On appeal, the order was modified. Summary judgment was granted to the defendant, dismissing the first, second, seventh, and eighth causes of action, and a portion of the third cause of action, primarily because the claims were fully paid with interest and attorney's fees exceeded fee schedules. However, the appellate court affirmed the denial of the defendant's motion to amend its answer for a counterclaim, finding it lacked merit due to preclusion. The denial of summary judgment concerning medical necessity for other parts of the third cause of action was also affirmed, as an issue of fact existed.

no-fault insurancesummary judgmentfee schedule overpaymentattorney's feesCPLR 3025(b)preclusion doctrinemedical necessityappellate reviewCivil Courtunjust enrichment
References
6
Case No. MISSING
Regular Panel Decision

Surgicare Surgical v. National Interstate Insurance

This case addresses whether an insurer complies with New York's 11 NYCRR 68.6 regulation by reimbursing for out-of-state medical services according to the host state's (New Jersey's) no-fault fee schedule. Plaintiff Surgicare Surgical, assignee of an injured party, sought full payment for surgery performed in New Jersey, but defendant National Interstate Insurance Company paid a reduced amount based on New Jersey's fee schedule. The court affirmed the defendant's method, ruling that when medical services are rendered in another jurisdiction with its own fee schedule, the 'permissible' charge under that schedule constitutes the 'prevailing fee' under New York's regulation. The decision emphasized alignment with legislative intent to contain no-fault insurance costs and reduce judicial burden, dismissing the plaintiff's complaint and denying its cross-motion.

No-Fault BenefitsInsurance LawFee Schedule DisputeOut-of-State Medical ServicesNew York RegulationsNew Jersey Fee ScheduleStatutory InterpretationAutomobile AccidentReimbursement DisputeSummary Judgment
References
17
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. SBR 0320298
Regular
Jun 13, 2008

DANILO DeGUZMAN vs. LOMA LINDA UNIVERSITY MEDICAL CLINIC, LOMA LINDA RISK MANAGEMENT

This case concerns a dispute over the reasonable value of medical services provided by West Coast Spine Restoration Center. The Workers' Compensation Appeals Board granted reconsideration and rescinded the prior decision, finding that the defendant properly paid the lien claimant's fees according to the Official Medical Fee Schedule. The Board determined that the lien claimant failed to meet its burden of proof to justify charges exceeding the OMFS for work hardening and functional capacity evaluations.

Workers' Compensation Appeals BoardLoma Linda University Medical CenterLoma Linda Risk ManagementDanilo DeGuzmanIndustrial InjuryRegistered NurseWork HardeningFunctional Capacity EvaluationOfficial Medical Fee ScheduleOMFS
References
1
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