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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

ABC Medical Management, Inc. v. GEICO General Insurance

The case addresses whether a plaintiff-assignee medical equipment supplier can recover no-fault first-party benefits when a chiropractor, rather than a physician, issued the prescription. Defendant GEICO General Insurance Company moved for summary judgment, arguing that Education Law § 6551 prohibits chiropractors from prescribing such items. The court denied GEICO's motion, ruling that chiropractors are permitted to prescribe TENS units, thermophore devices, and similar medical supplies, as these do not constitute 'drugs or medicines' under the Education Law. Furthermore, the court found that GEICO failed to properly present its medical necessity defense and that the contested issues should be determined by a trier of fact.

No-Fault BenefitsChiropractic PrescriptionMedical EquipmentEducation Law § 6551Summary JudgmentMedical NecessityTENS UnitThermophoreCervical CollarLumbar Support
References
29
Case No. MISSING
Regular Panel Decision

Claim of Casiano v. CCIP/Union Settlement Home Care

In March 2001, claimant sustained a work-related back injury. Neurosurgeon Richard J. Radna recommended and performed decompression surgery despite the workers' compensation carrier denying preauthorization for the procedure. Both a Workers’ Compensation Law Judge and the Workers’ Compensation Board subsequently ruled that the surgery was not medically necessary, thereby absolving the carrier of liability for its cost. Claimant and Radna appealed this determination to the appellate court. Radna's appeal was dismissed due to lack of standing, and the Board's decision was affirmed, as it was within its purview to resolve the conflicting medical evidence presented by Radna and the carrier's neurosurgeon regarding the necessity of the surgery.

Workers' Compensation LawMedical NecessitySurgical ProcedurePreauthorization DenialNeurological InjuryConflicting Medical OpinionsAppellate ReviewStanding IssueCarrier LiabilityBack Injury
References
3
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. 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

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. 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

Rechenberger v. Nassau County Medical Center

Edward Rechenberger suffered hip fractures and underwent two operations at Nassau County Medical Center in May 1982. Following a re-injury and later diagnosis, he learned the surgical hardware was improperly implanted, leading to further operations. Mr. Rechenberger sought leave to serve a late notice of claim against the medical center. The Supreme Court initially denied the motion, but the Appellate Division reversed this decision, finding that the hospital had actual knowledge of the essential facts of the claim within the statutory 90-day period through its own medical records. The court concluded that the delay in serving the notice of claim was not substantially prejudicial to the hospital, and thus, granted the petitioners leave to serve the late notice of claim.

Medical MalpracticeLate Notice of ClaimNassau CountyHip FractureSurgical ErrorContinuous Treatment DoctrineActual NoticePrejudiceAppellate ReviewMunicipal Corporation
References
11
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
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