CompFox Logo
AboutWorkflowFeaturesPricingCase LawInsights

Updated Daily

Case Law Database

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

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. 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. ADJ344700
Regular
Jan 13, 2011

MARTHA GATLIN BANUELOS vs. LIVHOME, INC., as administered by CRUM FORSTER, CENTRAL ORTHOPEDIC MEDICAL GROUP, RONALD KVITNE, M.D. PHYSICIAN PARTNER

The Workers' Compensation Appeals Board (WCAB) dismissed the lien claimant's petition for reconsideration, finding they were not aggrieved by the decision awarding them full reimbursement for medical services. The defendant's petition for reconsideration was denied as the WCAB adopted the judge's reasoning for upholding the award. The WCAB affirmed the judge's finding that the lien claimant was entitled to $11,508.79 less any penalty or interest, despite an objection to an unsigned bill. This decision resolved disputes regarding the reasonableness of medical charges following an industrial injury.

Workers' Compensation Appeals BoardLien ClaimantPetition for ReconsiderationDefendant's PetitionAmended Findings and AwardOfficial Medical Fee ScheduleLabor Code section 5900Admissibility of EvidenceExhibit 1Itemized Bill
References
0
Case No. ADJ8969504
Regular
Sep 12, 2016

GLADYS PAZ, vs. TECH FLEX; SEABRIGHT INSURANCE COMPANY, TRI-COUNTY MEDICAL GROUP

This case concerns the timeliness of a lien claim filed by Tri-County Medical Group for services rendered to applicant Gladys Paz. The lien was filed on October 19, 2015, more than 18 months after the last date of service on December 23, 2013. The Appeals Board affirmed the WCJ's decision that the lien is barred by the 18-month limitation period in Labor Code section 4903.5(a) for services provided on or after July 1, 2013. The Board found that the amended statute applied and lien claimant had a reasonable time to file within 18 months of their last service date.

Workers' Compensation Appeals BoardLien ClaimantLabor Code Section 4903.5(a)Statute of LimitationsReconsiderationFindings and OrderAdministrative Law JudgeContinuous ServicesEffective DateRetroactive Application
References
11
Case No. MISSING
Regular Panel Decision
Sep 16, 1992

Pica v. Montefiore Medical Group

The Supreme Court, Bronx County, dismissed a personal injury action brought by an employee of Montefiore Hospital and Medical Center against Montefiore Medical Group. The dismissal was based on the affirmative defense of Workers' Compensation. The plaintiff failed to demonstrate that Montefiore Medical Group was a separate legal entity from Montefiore Hospital and Medical Center, whose employee controlled her work. Consequently, the court found recovery barred under Workers' Compensation Law § 11. The appellate court unanimously affirmed the dismissal.

Workers' CompensationPersonal InjuryEmployer LiabilityCorporate VeilExclusive RemedyAffirmative DefenseAppellate DecisionMotion to DismissSummary JudgmentBronx County
References
3
Case No. 2022 NY Slip Op 02801 [204 AD3d 1016]
Regular Panel Decision
Apr 27, 2022

Matter of Panos v. Mid Hudson Med. Group, P.C.

Spyros Panos was terminated from Mid-Hudson Medical Group (MHMG) for submitting fraudulent medical bills and subsequently pleaded guilty to healthcare fraud. Panos initiated an action for breach of contract against MHMG, which proceeded to arbitration. The arbitrator applied the faithless servant doctrine and granted MHMG's motion for summary judgment, dismissing Panos's claims. Panos then sought to vacate the arbitration award in the Supreme Court, Dutchess County, but the court denied his petition and dismissed the proceeding. On appeal, the Appellate Division affirmed the lower court's judgment, concluding that Panos failed to demonstrate that the arbitrator manifestly disregarded the law.

Arbitration awardVacaturFaithless servant doctrineBreach of contractSummary judgmentHealth care fraudAppellate reviewJudicial reviewEmployment agreementFiduciary duty
References
18
Case No. ADJ10373550
Regular
Apr 25, 2019

EVALINA AGUILAR-RIVAS vs. K&H SUBWAY, INC., dba AAA SUBWAY INVESTMENT GROUP, INC.; EMPLOYERS ASSURANCE COMPANY

The Workers' Compensation Appeals Board affirmed a prior decision denying recovery for three lien claimants: Kohanim Chiropractic, Metropolitan Health Group, and SoCal Interpreting. The lien claimants failed to prove their medical services or interpreting services were reasonable and necessary under the Medical Treatment Utilization Schedule (MTUS), as required by Labor Code section 5402(c). Specifically, they did not demonstrate that the treatment was consistent with MTUS guidelines or that interpreter invoices were properly submitted to the defendant. Therefore, the Board concluded the lien claimants did not meet their burden of proof for reimbursement.

WCABReconsiderationLien ClaimantsMedical-Legal CostsSelf-Procured TreatmentLabor Code Section 5402(c)Utilization ReviewDelay PeriodBurden of ProofMedical Treatment Guidelines
References
1
Case No. ADJ8094646
Regular
Jan 17, 2014

ALEJANDRINA BARRETO vs. OUT OF THE SHELL, SOUTHERN INSURANCE COMPANY, REPUBLIC INDEMNITY COMPANY, PHARMAFINANCE, LLC, HEALTHCARE FINANCE MANAGEMENT, LLC

This case involves lien claimants PharmaFinance and Healthcare Finance Management, and their representatives Landmark Medical Management and Brian Hall, who sought reconsideration of a decision disallowing their liens for medical treatment. The Appeals Board granted reconsideration solely to notice its intention to impose sanctions of up to $2,500 against the lien claimants and their representatives. This action is due to a pattern of allegedly filing petitions containing false statements about not receiving notices, which violates the Board's Rules of Practice and Procedure and Labor Code Section 5813. The Board found these claims not persuasive and indicative of a tactic to avoid responsibility.

Workers' Compensation Appeals BoardPetition for ReconsiderationSanctionsLien ClaimantsHearing RepresentativesIndustrial InjuryFindings and OrderCompromise and ReleaseNotice of IntentionLabor Code section 5813
References
0
Case No. ADJ3871980 (SBR 0332495) ADJ1578450 (SBR 0333829) ADJ7125261
Regular
Nov 05, 2010

ANITA BAKER vs. SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP, PSI, Adjusted and Administered By KAISER PERMANENTE MEDICAL GROUP

This case involves Anita Baker's workers' compensation claim against Southern California Permanente Medical Group. The Workers' Compensation Appeals Board denied reconsideration of the judge's decision. The primary dispute centered on the calculation of diminished future earning capacity, with the applicant arguing for a calculation based on actual lost earnings and the defendant relying on statutory guidelines and expert testimony. The Board adopted the judge's report, which found in favor of the applicant regarding the calculation of permanent disability, incorporating aspects of both expert opinions and considering the applicant's specific circumstances.

Workers Compensation Appeals BoardSouthern California Permanente Medical GroupKaiser Permanente Medical GroupPetition for ReconsiderationWorkers' Compensation Administrative Law JudgeOgilvie v. City and County of San Franciscodiminished future earning capacityFindings and Awardcontinuous traumabilateral upper extremities
References
1
Case No. ADJ9336762
Regular
Mar 17, 2025

Ramiro Hernandez vs. Riverside Landscape & Irrigation Inc., California Insurance Guarantee Association

The Appeals Board considered petitions for reconsideration from lien claimants RMS Medical Group and Basso Pharmacy regarding a WCJ's Findings and Order from December 11, 2024, which denied their lien claims related to applicant Ramiro Hernandez's industrial injury. The Board denied Basso Pharmacy's petition, upholding the finding that Basso Pharmacy was not properly licensed. Conversely, the Board granted RMS Medical Group's petition, ruling that their medical-legal services, performed by the primary treating physician Dr. Gottschalk, are compensable as a medical-legal expense, even with an AME in the case. Consequently, the matter was returned to the trial level for the WCJ to determine the reasonable value of RMS Medical Group's services.

Workers Compensation Appeals BoardRamiro HernandezRiverside Landscape & Irrigation Inc.California Insurance Guarantee AssociationIntercareCastlepoint InsuranceRMS Medical GroupBasso PharmacyPrimary Treating PhysicianMedical-Legal Reports
References
1
Showing 1-10 of 11,923 results

Ready to streamline your practice?

Apply these legal strategies instantly. CompFox helps you find decisions, analyze reports, and draft pleadings in minutes.

CompFox Logo

The AI standard for workers' compensation professionals. Faster research, deeper analysis, better outcomes.

Product

  • Platform
  • Workflow
  • Features
  • Pricing

Solutions

  • Defense Firms
  • Applicants' Attorneys
  • Insurance carriers
  • Medical Providers

Company

  • About
  • Insights
  • Case Law

Legal

  • Privacy
  • Terms
  • Trust
  • Cookies
  • Subscription

© 2026 CompFox Inc. All rights reserved.

Systems Operational