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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 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. 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. ADJ736188 (GOL 0099658)
Regular
Sep 22, 2017

Deanna Power vs. St. John's Regional Medical Center, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case concerns Deanna Power's claim for continued medical treatment, specifically prescription medications Xyrem and Lunesta, for a previous industrial injury. The employer denied authorization for these medications through Utilization Review (UR), and the applicant's subsequent Independent Medical Review (IMR) application was deemed untimely. The trial judge initially ordered continued treatment and directed the Administrative Director to process the IMR appeal, finding it timely. However, the Appeals Board granted reconsideration, finding the trial judge lacked jurisdiction to order treatment when a timely UR decision was issued and the applicant's sole recourse was the IMR process. The matter was returned to the trial level for a determination solely on the timeliness of the IMR appeal, not the medical necessity of the medications.

WCABPetition for ReconsiderationFindings of Fact and AwardXyremLunestaIndependent Medical ReviewIMRUtilization ReviewURprescription medications
References
3
Case No. MISSING
Regular Panel Decision
Sep 15, 1997

Mushatt v. Cayuga Medical Center

Plaintiff appealed a judgment favoring defendants Cayuga Medical Center and the estate of her obstetrician, Frank Flacco, in a medical malpractice case. Plaintiff alleged that negligent care during her son Quandale's birth on August 15, 1990, led to his severe spastic cerebral palsy, mental retardation, and seizure disorder, attributing it to oxygen deprivation caused by a delayed Cesarean section. Defendants argued the oxygen deprivation occurred prior to delivery due to an acute event and chronic condition, and their care met standards. The jury sided with defendants. On appeal, plaintiff challenged the verdict's weight, the application of CPLR 4519 (Dead Man's Statute), the admission of testimony regarding her drug and alcohol use, and a missing witness charge. The Supreme Court Appellate Division affirmed the judgment, finding no errors warranting reversal.

Medical MalpracticeBirth InjuryCerebral PalsyOxygen DeprivationCesarean SectionExpert WitnessDead Man's StatuteCPLR 4519Appellate ReviewNegligence
References
4
Case No. MISSING
Regular Panel Decision

Lutheran Medical Center v. Hereford Insurance

Maher Kiswani, a livery car driver, was injured in an automobile accident and received medical treatment from Lutheran Medical Center. Lutheran, as Kiswani's assignee, sought payment from Hereford Insurance Company, the no-fault carrier, which refused to pay. After an initial arbitration where the Workers' Compensation Board determined Kiswani was not injured in the course of employment (without Hereford's notice), a second arbitration awarded Lutheran no-fault benefits. The Supreme Court, Kings County, vacated this arbitration award, ruling that Hereford should have been notified of the Workers' Compensation Board hearing. The appellate court affirmed the Supreme Court's decision, holding that a party not afforded an opportunity to participate in a Board hearing is not bound by its determination.

Arbitration AwardNo-Fault InsuranceWorkers' Compensation BoardDue ProcessNotice RequirementsVacated Arbitration AwardAppellate ReviewLivery Car DriverAutomobile AccidentMedical Benefits
References
3
Case No. MISSING
Regular Panel Decision

Perez v. Brookdale University Hospital & Medical Center

Eulalia Perez was admitted to Brookdale University Hospital on November 16, 2010, and treated for various medical conditions before being discharged on December 7. She died two days later. Her family, Ivan and Irma Perez, sued Brookdale and other defendants, alleging a violation of the Emergency Medical Treatment and Active Labor Act (EMTALA) and state-law claims of wrongful death and negligence. The court granted Brookdale's motion for summary judgment on the EMTALA claim, determining that the hospital fulfilled its EMTALA duties once Mrs. Perez was stabilized, and any subsequent issues were outside the statute's scope. Consequently, the court declined to exercise supplemental jurisdiction over the state-law claims, leading to the dismissal of all claims against all parties.

EMTALAEmergency Medical Treatment and Active Labor ActMedical MalpracticeNegligenceWrongful DeathSummary JudgmentSupplemental JurisdictionPatient DumpingHospital DischargeFederal Question Jurisdiction
References
8
Case No. MISSING
Regular Panel Decision

Rozewicz v. New York City Health & Hospitals Corp.

This opinion addresses a complex medical malpractice case involving the death of Mrs. Rosewicz, a Jehovah's Witness, who refused blood transfusions due to religious beliefs. Justice Lehner explores three categories of relevant legal precedents: government benefit denials for religious refusal of treatment, tortfeasor liability and mitigation of damages, and malpractice claims where a patient refused life-saving treatment on religious grounds. The court declines to charge the jury on mitigation of damages, deeming it inappropriate for this specific case. Instead, the judge rules that the jury will be instructed on the principles of assumption of risk and comparative fault, allowing for the apportionment of liability between the defendant's alleged negligence and the decedent's refusal of blood transfusions, consistent with decisions in Shorter v Drury and Corlett v Caserta.

Medical MalpracticeReligious FreedomBlood Transfusion RefusalJehovah's WitnessAssumption of RiskComparative FaultMitigation of DamagesWrongful DeathJury InstructionsNegligence
References
12
Case No. MISSING
Regular Panel Decision

Claim of Evevsky v. Liberty Mutual Group

This case involves an appeal from a Workers’ Compensation Board decision regarding a claimant's unauthorized medical treatment. The claimant, who sustained neck and shoulder injuries in 1993, had her case reopened in 2001 after the employer's carrier objected to her request for authorized massage therapy. Both the Workers’ Compensation Law Judge and the Board determined that the treatment was not authorized under Workers’ Compensation Law § 13-b, as the massage therapist was not Board-authorized nor supervised by an authorized physician. The appellate court reviewed the Board's decision, affirming that there was no legal basis to overturn the finding. The court also considered and dismissed the claimant's constitutional arguments as being without merit.

Workers' CompensationMedical TreatmentMassage TherapyAuthorizationBoard DecisionAppellate ReviewStatutory InterpretationPhysician SupervisionConstitutionalityPermanent Partial Disability
References
3
Case No. ADJ10168011
Regular
Sep 25, 2017

BELINDA GO vs. SUTTER SOLANO MEDICAL CENTER

This case involved an applicant who self-procured cervical spine surgery after her employer denied authorization, which was upheld by an Independent Medical Review. Despite the denial, the Workers' Compensation Appeals Board (WCAB) denied the employer's petition for reconsideration. The WCAB affirmed that injured workers are entitled to temporary and permanent disability for reasonable, self-procured medical treatment, even if initially unauthorized. The Board found the self-procured surgery was reasonable due to its positive outcome, and the Permanent Qualified Medical Evaluator's findings supported the disability award. The WCAB clarified that utilization review and independent medical review processes do not preclude temporary disability indemnity for self-procured treatment deemed reasonable.

Workers' Compensation Appeals BoardPetition for ReconsiderationUtilization Review (UR)Independent Medical Review (IMR)Self-Procured SurgeryTemporary Disability IndemnityPermanent DisabilityPanel Qualified Medical Evaluator (PQME)Medical Treatment DisputesLabor Code Section 4600
References
14
Case No. ADJ638016 (VNO 0518817)
Regular
Mar 22, 2011

Roger Schleifstein vs. Leslie's Pool Supply, ST. PAUL'S TRAVELERS INSURANCE

This case concerns a lien claim by Grossman Medical Group for $188,310.89 in unpaid medical treatment expenses following an industrial injury. The WCAB affirmed the WCJ's decision disallowing the lien, finding Grossman Medical failed to prove its charges exceeded the Official Medical Fee Schedule (OMFS) due to extraordinary circumstances. Applicant's private health insurer, CIGNA, had already paid a significant portion of the bill, and the Appeals Board held that the statutory changes eliminating the exception for billing above OMFS in disputed claims applied. The dissenting opinion argued that Grossman Medical met its burden by demonstrating reasonable and customary fees supported by comparable cases, particularly where treatment was extensive.

Lien claimantGrossman Medical GroupOfficial Medical Fee ScheduleOMFSusual and customary feesextraordinary circumstancesreasonablenesslabor codeappeals boardcompromise and release
References
5
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