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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

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
Feb 10, 2017

Mitchell v. SUNY Upstate Medical University

Plaintiff Robbie Mitchell sued SUNY Upstate Medical Center for alleged Title VII violations, including race discrimination and retaliation, after experiencing a series of adverse employment actions. These actions included reassignment, disciplinary notices (NODs), a mandatory medical examination, a formal counseling memorandum, a verbal dispute, and eventual termination. The defendant moved for summary judgment, arguing the plaintiff failed to establish a prima facie case for most claims and that their actions were based on legitimate, non-discriminatory reasons. The court granted summary judgment in favor of SUNY Upstate Medical Center, concluding that the plaintiff failed to provide sufficient evidence of discrimination or that retaliation was the but-for cause of the challenged employment actions, and consequently, the case was closed.

Title VIICivil Rights ActEmployment DiscriminationRetaliationSummary JudgmentAdverse Employment ActionMcDonnell Douglas FrameworkWorkplace ConductDisciplinary ActionPaid Administrative Leave
References
49
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
Oct 14, 2008

Westchester Medical Center v. Lincoln General Insurance

The plaintiff appealed an order from the Supreme Court, Nassau County, which denied its motion for summary judgment to recover no-fault medical benefits. The appellate court reversed the order, granting the plaintiff's motion. The plaintiff successfully demonstrated a prima facie case by showing that statutory billing forms were mailed and received, and the defendant failed to either pay or deny the claim within the 30-day period. The court rejected the defendant's arguments that letters advising of an investigation tolled the statutory period and that the period was tolled pending a no-fault application. Additionally, defenses related to Workers' Compensation benefits or the assignor's failure to appear at an examination under oath were found insufficient to defeat the medical provider's right to benefits.

no-fault insurancemedical benefitssummary judgmentinsurance contractstatutory periodtimely denialworkers' compensationpolicy conditionpreclusion remedyappellate review
References
19
Case No. ADJ8331259
Regular
Dec 21, 2012

MARIELA GOMEZ vs. PROVIDENCE FARMS, LLC, ZENITH INSURANCE COMPANY

The Workers' Compensation Appeals Board denied the defendant's Petition for Reconsideration. The Board adopted the WCJ's report, emphasizing that the defendant's failure to properly notify the applicant about changing treating physicians within the Medical Provider Network (MPN) resulted in a denial of necessary medical treatment. This failure to inform the applicant of her rights, particularly regarding physician selection and dispute resolution processes within the MPN, constituted a neglect or refusal to provide reasonable medical treatment, as established by precedent. Consequently, the applicant was permitted to continue receiving treatment outside the MPN until she could begin care with a designated physician within the network.

Workers' Compensation Appeals BoardProvidence FarmsLLCZenith Insurance CompanyMariela GomezADJ8331259Order Denying ReconsiderationPetition for ReconsiderationMedical TreatmentMedical Provider Network
References
2
Case No. MISSING
Regular Panel Decision

King's Medical Supply Inc. v. Travelers Property Casualty Corp.

The plaintiff, a provider of medical supplies, moved for summary judgment seeking $2,522.86 in unpaid no-fault benefits for equipment provided to its assignors. The defendant insurer had made partial payments, asserting 'reasonable and customary fees' or technical denials, contrary to the plaintiff's interpretation of reimbursement based on 150% of documented cost. The court denied the plaintiff's motion, ruling that the plaintiff failed to establish a prima facie case by providing admissible evidence of the actual 'documented cost' of the medical supplies. The court clarified that while the regulation specifies '150 percent of the documented cost,' insurers cannot unilaterally introduce additional 'reasonable or customary cost' requirements, but the plaintiff's inability to sufficiently document their costs was fatal to their motion.

Summary JudgmentNo-Fault BenefitsMedical SuppliesMedical EquipmentInsurance LawDocumented CostPrima Facie CaseReimbursementRegulation InterpretationProvider Costs
References
13
Case No. ADJ6552734
Regular
Apr 02, 2015

Diane Garibay-Jimenez vs. Santa Barbara Medical Foundation Clinic, Zurich American Insurance

This case concerns a denied request for left ulnar nerve decompression surgery. The Administrative Law Judge (WCJ) upheld the denial, finding the applicant failed to provide necessary Agreed Medical Examiner (AME) reports to the Independent Medical Review (IMR), making a further review unreasonable. However, the Workers' Compensation Appeals Board (WCAB) granted reconsideration, rescinding the WCJ's order. The WCAB found the defendant failed to comply with Labor Code section 4610.5(l) by not providing all relevant medical records to IMR, thus invalidating the prior IMR determination. The matter was returned for a new IMR application, holding the defendant responsible for submitting complete records.

Workers' Compensation Appeals BoardDiane Garibay-JimenezSanta Barbara Medical Foundation ClinicZurich American InsuranceADJ6552734Opinion and Order Granting Petition for ReconsiderationExpedited Findings of Fact and OrderAdministrative Law JudgeIndependent Medical ReviewUtilization Review
References
0
Case No. MISSING
Regular Panel Decision
Jul 23, 1976

Lichtenstein v. Montefiore Hospital & Medical Center

This appeal concerns a wrongful death action filed by Ruth Lichtenstein against Montefiore Hospital and Medical Center. The plaintiff alleged the hospital's negligence in allowing her husband, Gary Lichtenstein, to escape from an open psychiatric unit, leading to his suicide. The appellate court found no evidence of negligence on the hospital's part regarding the patient's escape, overturning the prior verdict which awarded $400,000 in damages. The court deemed the damages excessive and ordered a new trial, providing guidance on issues like the inference of suicide and proximate cause.

Wrongful DeathNegligenceHospital LiabilityPsychiatric PatientSuicideElopementOpen Psychiatric UnitProximate CauseDamagesExcessive Verdict
References
7
Case No. MISSING
Regular Panel Decision
Mar 09, 2001

Convenient Medical Care, P.C. v. Medical Business Associates, Inc.

Plaintiff, a professional medical corporation, entered into a billing services contract with defendant, a medical billing service provider, in early 1997. The agreement was terminated by plaintiff in 1998 due to alleged failures by the defendant in timely billing worker's compensation patients and delays in returning billing records. Defendant subsequently moved for summary judgment on its counterclaims for breach of contract and an account stated, which the Supreme Court denied. On appeal, the appellate court modified the lower court's order, reversing the denial of summary judgment for defendant's breach of contract counterclaim and granting summary judgment to the defendant on the issue of liability. The court found plaintiff's arguments and evidence insufficient to defeat the defendant's prima facie showing for summary judgment, but denied summary judgment for an account stated due to discrepancies in claimed amounts.

Breach of ContractSummary JudgmentMedical Billing ServicesNegligenceCounterclaimsAppellate ReviewContract TerminationWorker's Compensation PatientsEvidentiary ProofMerger Clause
References
10
Case No. MISSING
Regular Panel Decision
Jun 19, 2001

Carman v. Abter

A nurse employed by a medical center providing dialysis services alleged she contracted HIV after a needle stick injury sustained while drawing blood from a patient. She filed a medical malpractice action against the medical center, a salaried physician (Dr. Ma) employed by a nephrology group associated with the center, and an independent infectious disease consultant (Dr. Abter) used by the group. The Supreme Court initially dismissed the complaint against all defendants, applying the Workers' Compensation Law's "fellow employee rule." On appeal, the judgment was modified. The appellate court affirmed the dismissal for the medical center and Dr. Ma, concluding their services to the plaintiff were employment-related and not available to the general public. However, the complaint against Dr. Abter was reinstated, as the fellow-employee rule was found not to apply to him given his status as an independent consultant.

Medical malpracticeHIV exposureNeedle stick injuryWorkers' CompensationFellow employee ruleIndependent contractorPhysician negligenceEmployer liabilityAppellate reviewNew York law
References
1
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