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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

Claim of Vanostrand v. Felchar Manufacturing Corp.

The case involves an appeal from a Workers’ Compensation Board decision concerning a claimant found to have defrauded employers and carriers by overstating mileage and making false statements about her physical condition. The Board ruled that Workers’ Compensation Law § 114-a, which bars future wage replacement benefits for such violations, does not preclude the claimant from receiving future mileage expenses or medical coverage. The Appellate Division, Third Department, affirmed this decision, citing its previous ruling in Matter of Rodriguez v Burn-Brite Metals Co., which established that the penalties under Workers’ Compensation Law § 114-a are limited to wage replacement benefits and do not extend to medical benefits. The court also found no error in the Board's tacit refusal to require the claimant to directly repay the mileage overpayments to the subject carriers.

Workers' Compensation Law § 114-aMedical BenefitsMileage ExpensesFraudulent MisrepresentationStatutory InterpretationAppellate DecisionWage Replacement BenefitsBoard Decision ReviewAffirmative RulingLegal Precedent
References
2
Case No. MISSING
Regular Panel Decision

Claim of Simpson v. Glen Aubrey Fire Co.

A volunteer fireman suffered an acute lumbosacral strain requiring frequent hospital and doctor visits. He sought reimbursement for 290 miles of travel expenses. The Workers' Compensation Board approved reimbursement at 20 cents per mile, leading to this appeal. The court examined whether travel expenses for medical treatment are reimbursable under the Volunteer Firemen’s Benefit Law and Workers’ Compensation Law. It concluded that access to medical treatment implies the financial means to obtain it, upholding the humanitarian goals of the legislation.

Volunteer FiremanLumbosacral StrainMileage ReimbursementTravel ExpensesMedical TreatmentWorkers' Compensation LawVolunteer Firemen's Benefit LawStatutory InterpretationRemedial LawLiberal Construction
References
2
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. ADJ1171761 (RDG 0076230) ADJ3401110 (RDG 0077725)
Regular
Dec 10, 2012

HAROLD HOUSTON vs. CITY OF REDDING

The Workers' Compensation Appeals Board granted the City of Redding's petition for reconsideration regarding a prior award of medical mileage reimbursement to Harold Houston. While affirming the award of medical mileage, the Board amended the Findings of Fact to clarify that no past interest is due. Interest on the medical mileage will only accrue from the date the amount becomes determined and payable, as per Labor Code section 5800. The case was returned to the trial level for further proceedings to determine the specific amount owed.

Workers' Compensation Appeals BoardCity of ReddingHarold HoustonPetition for ReconsiderationFindings Award and OrderCompromise & Releasemedical mileagefuture medical treatmentLabor Code section 5800accrued interest
References
0
Case No. ADJ1047594 (VNO 0549852)
Regular
Dec 22, 2016

Diane De Los Reyes vs. Mediscan, Zurich American Insurance Company

In this case, the applicant, Diane De Los Reyes, sought reimbursement for self-procured medical treatment related to her work-induced Reactive Airway Disease and Anxiety Disorder. The Appeals Board found that some of the applicant's self-procured treatment was likely industrial and reversed the WCJ's finding that all such treatment was non-industrial. The Board therefore rescinded the original order and returned the matter to the WCJ for further proceedings to determine the extent of reimbursable self-procured medical treatment and associated penalties. The applicant's entitlement to reimbursement for medical mileage and penalties thereon was affirmed.

Workers' Compensation Appeals BoardReconsiderationAgreed Medical EvaluatorReactive Airway DiseaseAnxiety DisorderSelf-procured Medical TreatmentReimbursementPenaltiesMedical MileageLabor Code § 4600(a)
References
9
Case No. ADJ91 04682
Regular
Mar 15, 2016

NOEL CERVANTES vs. UCLA MEDICAL CENTER, SEDGWICK CLAIMS MANAGEMENT SERVICES

The Workers' Compensation Appeals Board (WCAB) granted reconsideration and awarded lien claimant Liberty Life Assurance reimbursement for $3,940.85 in short-term disability payments. The WCAB found that the lien claimant provided sufficient notice of its payments to UCLA Medical Center before UCLA paid overlapping temporary disability benefits. Legibility of a reimbursement agreement was deemed irrelevant when the parties stipulated to the payments made. Therefore, UCLA Medical Center was ordered to reimburse Liberty Life Assurance for these benefits under Labor Code section 4903.1.

Labor Code section 4903.1(a)Lien claimantPetition for ReconsiderationGroup disability policyReimbursement AgreementOverlapping disability paymentsNotice of lienTemporary disability benefitsShort-term disability paymentsCompromise and Release Agreement
References
1
Case No. ADJ1323942
Regular
Jan 25, 2010

JANN WASHINGTON vs. DAVIS COMPANIES, FIREMAN'S FUND

The Workers' Compensation Appeals Board granted reconsideration to address the applicant's medical mileage reimbursement. The Board amended the prior award to allow reimbursement for travel between the applicant's Nevada residence and her California treating physician. The employer failed to prove that equally effective treatment was available closer to the applicant's residence, thus their objection to the extended mileage was denied. The specific amount of reimbursement is to be determined by the parties, with jurisdiction reserved for dispute resolution.

Workers' Compensation Appeals BoardIndustrial InjuryUpper ExtremitiesMedical TreatmentMedical MileageReconsiderationResidenceGeographic AreaTreating PhysicianEmployer Burden
References
1
Case No. CV-23-1692, CV-24-0559
Regular Panel Decision
Feb 06, 2025

In the Matter of the Claim of Kaydee Capers

Kaydee Capers, a registered nurse, sustained work-related injuries in August 2020, leading to a workers' compensation claim established for her right hand, wrist, and third finger. Her treating physician determined she reached maximum medical improvement with a 17.5% schedule loss of use (SLU) of the right wrist. The employer, Jacobi Medical Center, sought reimbursement for wages paid to Capers during her disability period, objecting to a proposed conciliation decision. The Workers' Compensation Board ultimately ruled that the employer was entitled to reimbursement, finding their request timely filed before a final SLU award was made, pursuant to Workers' Compensation Law § 25 (4) (c). Capers appealed this decision, arguing an abuse of discretion by the Board. The Supreme Court, Appellate Division, Third Judicial Department, affirmed the Board's amended decision, concluding that the employer's reimbursement request was indeed timely.

Workers' CompensationSchedule Loss of UseEmployer ReimbursementAdvance Wage PaymentsTimely FilingAppellate ReviewMedical ImpairmentMaximum Medical ImprovementDisability BenefitsWages Paid
References
5
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. 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
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