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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

Sexton v. Medicare

Plaintiff Kevin Sexton sued the Secretary of the United States Department of Health and Human Services (HHS) to prevent direct reimbursement for Medicare payments made after he was injured in an accident. Sexton argued that Medicare should pursue the primary insurer, American Transit Insurance Company, or the medical providers, rather than him. HHS moved to dismiss the case, asserting a lack of subject matter jurisdiction due to Sexton's failure to demonstrate an actual or imminent injury and to exhaust administrative remedies. The court granted HHS's motion, dismissing the complaint with prejudice. It ruled that Sexton lacked standing because Medicare had not yet formally demanded reimbursement from him, and its right to recover from a beneficiary only accrues after the beneficiary receives a primary payment, making his alleged injury purely speculative.

MedicareMedicare Secondary Payer ActMSP ActSubject Matter JurisdictionMotion to DismissStandingRipeness DoctrineConditional PaymentsReimbursement ClaimPrimary Payer
References
26
Case No. MISSING
Regular Panel Decision

Ferlazzo v. 18th Avenue Hardware, Inc.

Plaintiff Marie Ferlazzo moved to extinguish liens and subrogation rights asserted by Oxford Health Plan and The Rawlings Company, LLC against her personal injury settlement proceeds. Oxford, administering a Medicare Advantage plan, sought reimbursement for medical expenses. Ferlazzo contended that General Obligations Law § 5-335 (a) barred such claims as Oxford lacked a statutory right of reimbursement. The court examined the Medicare Secondary Payer Act and the Medicare Advantage Program, concluding that unlike Medicare, private Medicare Advantage insurers only have contractual, not statutory, rights to reimbursement. Citing federal precedents, the court ruled that Oxford's claim was subject to state law and not entitled to recovery from the settlement. Consequently, the court granted Ferlazzo's motion to extinguish the liens and subrogation rights.

Personal InjurySubrogationMedicare AdvantageHealth Insurance LienSettlement ProceedsGeneral Obligations LawStatutory InterpretationContractual RightsFederal PreemptionPrivate Insurer
References
4
Case No. ADJ3544094 (SAC 0351694) ADJ2331078 (SAC 0354152)
Regular
May 11, 2009

NORMA HODGES vs. CLARCOR, INC., ST. PAUL TRAVELERS

Defendant seeks reconsideration of an approved Compromise and Release (C&R) for alleged knee and back injuries due to a dispute over the applicant's Medicare eligibility. The C&R contained a provision stating the applicant was not Medicare eligible, but the defendant later learned she was listed as an active beneficiary. The Board granted reconsideration, rescinded the C&R, and returned the case to the trial level. This action allows for further proceedings to resolve the factual conflict regarding Medicare status and address any necessary Medicare set-asides.

Order Approving Compromise and ReleasePetition for ReconsiderationMedicare Secondary Payer lawsQualified Medical EvaluatorGood CauseFraudMutual Mistake of FactDuressUndue InfluenceRescind
References
10
Case No. MISSING
Regular Panel Decision

Rankin-Fulcher v. Duane Morris, LLP

Plaintiff Elizabeth Rankin-Fulcher sued her former employer, Duane Morris LLP, for reimbursement of COBRA payments, alleging the firm failed to inform her of Medicare eligibility upon termination. Defendant moved to dismiss, asserting no such duty existed and that plaintiff received adequate notice. The court found that defendant's COBRA notification and subsequent communications sufficiently highlighted Medicare eligibility. It further ruled that ERISA plan administrators have no statutory or common-law obligation to individually inform terminated employees aged 65 or older about Medicare as a preferable alternative, as Medicare eligibility is considered common knowledge and the responsibility of HHS. Consequently, the court granted the defendant's motion to dismiss.

ERISACOBRAMedicare EligibilityEmployee BenefitsDuty to NotifyFiduciary DutyHealth InsuranceMotion to DismissStatutory InterpretationPlan Administrator
References
11
Case No. MISSING
Regular Panel Decision

LEFEVRE v. Niagara Mohawk Power Corp.

Plaintiffs, former employees of Niagara Mohawk Power Corporation, filed a putative class action alleging age discrimination under the Age Discrimination in Employment Act of 1967 (ADEA). They challenged amendments to the company's health benefit plans, arguing that Medicare-eligible retirees were required to pay greater dollar amounts and percentages of total premiums for the same coverage compared to non-Medicare eligible retirees. Defendants moved for summary judgment. The court found that the plans were exempt from ADEA prohibitions due to their coordination with Medicare and also fell within the ADEA's 'equal benefit' safe harbor, as the actual benefits received were the same regardless of Medicare eligibility. Consequently, the court granted summary judgment for the defendants and dismissed the complaint.

Age DiscriminationADEARetiree Health BenefitsMedicare CoordinationSummary JudgmentEmployee Benefit PlansDiscrimination LawStatutory ExemptionEqual Benefit PrincipleClass Action
References
4
Case No. ADJ839435
Regular
Jun 21, 2010

HILARIO TORRES vs. WERNER HOLDING COMPANY, INC., EMPLOYERS SELF INSURANCE SERVICES, INC.

The Workers' Compensation Appeals Board (WCAB) granted reconsideration to rescind an approved Compromise and Release (C&R) agreement. The defendant argued the C&R failed to address Medicare interests, a federal requirement. The WCAB agreed that this oversight could jeopardize the applicant's future Medicare benefits. Therefore, the WCAB rescinded the order and returned the case for further proceedings to allow parties to address Medicare obligations.

Compromise and ReleaseMedicare Secondary PayerPetition for ReconsiderationOrder Approving Compromise and ReleaseRescind OrderSerious and Willful MisconductWorkers' Compensation Appeals BoardIndustrial InjuryLadder FabricatorIndustrial Accident
References
11
Case No. ADJ7889661
Regular
Jan 28, 2014

CONYANILL, STATE OF CALIFORNIA, CDCR - INMATE CLAIMS vs. STATE COMPENSATION INSURANCE FUND/STATE CONTRACT SERVICES

In this case, the defendant sought to set aside an Order Approving Compromise and Release (OAC&R) due to a mutual mistake in omitting a Medicare Set-Aside (MSA) provision. The Appeals Board granted reconsideration and rescinded the OAC&R. The matter was returned to the trial level to determine the parties' intent regarding the MSA and ensure compliance with Medicare regulations. This action was taken to provide the WCJ an opportunity to properly address Medicare's interests.

Petition for ReconsiderationOrder Approving Compromise and ReleasePetition to Set AsideMutual MistakeMedicare Set-AsideMSARescindAgreed Medical ExaminerWCJAppeals Board
References
3
Case No. ADJ2214463 (VNO 0522433)
Regular
Feb 19, 2009

RICARDO DUARTE PONCE vs. ROSS STORES, INC., SEDGWICK CLAIMS MANAGEMENT SERVICES

The Appeals Board granted reconsideration to set aside the Order Approving Compromise and Release (OACR). The defendant sought to vacate the OACR because the parties' settlement agreement, which included a Medicare Set Aside (MSA) allocation, was contingent on approval by the Centers for Medicare Services (CMS) that was never obtained. Since the applicant was a Medicare beneficiary and the settlement exceeded $25,000, federal regulations require CMS approval of the MSA. The Board rescinded the OACR and returned the matter for further proceedings.

Medicare Set AsideMSA allocationCenters for Medicare ServicesCMS approvalCompromise and ReleaseOACRPetition for ReconsiderationRescind OrderGood CauseEquitable Grounds
References
8
Case No. MISSING
Regular Panel Decision

Tahir v. Progressive Casualty Insurance

This case addresses a no-fault health services provider's claims for compensation for current perception threshold (CPT) and sensory nerve conduction threshold (sNCT) testing. The defendant insurer argued these tests were not compensable under Medicare and constituted provider fraud. The court rejected the Medicare defense, clarifying that New York's no-fault statute relies on workers' compensation fee schedules, not Medicare standards. Furthermore, the court categorized the fraud defense as a medical necessity issue, requiring timely assertion with supporting evidence. Finding the insurer failed to meet its burden, the court ruled in favor of the plaintiff, entitling them to attorney fees and statutory interest.

No-fault insuranceCPT testingsNCT testingMedical necessityProvider fraudMedicare compensationWorkers' compensation fee schedulesElectrodiagnostic testSensory neuropathyChiropractic services
References
26
Case No. 2025 NY Slip Op 03690
Regular Panel Decision
Jun 18, 2025

Matter of Bentkowski v. City of New York

The City of New York implemented a new Medicare Advantage plan (Aetna MAP) for retirees, replacing their previous Medicare supplemental options, in an effort to reduce costs. Petitioners, a group of retirees and an organization, challenged this change, arguing that the City was bound by a promise to provide lifetime Medicare supplemental coverage under the doctrine of promissory estoppel and violated Administrative Code § 12-126 (b) (1). The Supreme Court and Appellate Division initially sided with the petitioners. However, the Court of Appeals reversed, concluding that the City's Summary Program Descriptions (SPDs) were descriptive, not a clear and unambiguous promise of specific lifetime health benefits, and found no violation of the Administrative Code or the Moratorium Law. The case was remitted to Supreme Court for further proceedings on remaining causes of action.

Promissory EstoppelHealth Insurance BenefitsRetiree BenefitsMedicare Advantage PlansMedigap PlansCollective BargainingAdministrative Code § 12-126Moratorium LawMunicipal EmployeesLifetime Coverage
References
10
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