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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

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. 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 The Board granted reconsideration, rescinded the C&R, and returned the case to the trial level.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. 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. ADJ19408921, ADJ19408487, ADJ19408920
Regular
Jun 16, 2025

Maria Vazquez vs. Holiday Inn Los Angeles Gateway, Indemnity Insurance Company of North America

Defendant filed a petition to set aside and reconsider an Order Approving Compromise & Release (OACR), claiming applicant's age and Medicare beneficiary status were overlooked in the settlement. The Appeals Board noted procedural irregularities regarding notice of case transmission and the absence of a hearing to establish a complete record concerning the Compromise and Release agreement's adequacy and Medicare interests. As a result, the Board dismissed the petition as premature and returned the matter to the trial level for a hearing to gather necessary evidence.

Order Approving Compromise & ReleaseMedicare Set AsidePetition for ReconsiderationMotion to Set AsideLabor Code Section 590960-Day RuleNotice of TransmissionWorkers' Compensation Medicare Set-Aside Arrangement (WCMSA)Good CauseMutual Mistake of Fact
References
18
Case No. MISSING
Regular Panel Decision

United States ex rel. Takemoto v. Hartford Financial Services Group, Inc.

Relator Dr. Kent Takemoto initiated a qui tam action under the False Claims Act, alleging that various insurance and holding companies violated the Medicare Secondary Payer Act by knowingly avoiding their obligation to reimburse the government for Medicare payments to beneficiaries. Magistrate Judge Jeremiah J. McCarthy recommended dismissing Takemoto's amended complaint with prejudice, finding a failure to state plausible claims under Federal Rule of Civil Procedure 8(a), specifically due to group pleading and speculative allegations regarding defendants' payment obligations. Both Takemoto and the defendants filed objections to this recommendation. Presiding District Judge William M. Skretny reviewed the objections de novo, ultimately accepting the Magistrate Judge's recommendations. Consequently, Takemoto's objections were denied, the motion to dismiss was granted, and his amended complaint was dismissed with prejudice, without prejudice to the United States.

False Claims ActMedicare Secondary Payer ActQui TamPleading StandardsRule 8Rule 9(b)Motion to DismissDismissal with PrejudiceKnowing AvoidanceRelator
References
38
Case No. MISSING
Regular Panel Decision

Onondaga Commercial Dry Wall Corp. v. 150 Clinton Street, Inc.

This case concerns the conflict between two classes of claimants, lienors under Article 2 of the Lien Law and trust beneficiaries under Article 3-A (the United States and the State of New York with tax claims), over a $23,000 balance due from an owner on a contract for the construction of apartment buildings. The fund was deposited into court under Lien Law § 55 in prior lien foreclosure actions. The Special Term initially favored the lienors, denying the U.S.'s application to enjoin foreclosure, but the Appellate Division reversed, granting the injunction and seemingly prioritizing tax claims. The Court of Appeals, interpreting the Lien Law, determined that Article 3-A provisions were intended to supplement, not supersede, older mechanic's lien provisions, especially regarding funds paid into court under section 55. The court held that such funds take the place of the property, making lien claims against them akin to claims against the property itself, which are not subject to tax claims under the statute. Therefore, the court reversed the Appellate Division's order and reinstated the Special Term's order, granting priority to the lienors.

Lien LawTrust FundMechanic's LiensTax ClaimsStatutory InterpretationFund PriorityForeclosure ActionsConstruction ContractArticle 2 Lien LawArticle 3-A Lien Law
References
2
Case No. MISSING
Regular Panel Decision

Barbot v. Frackman

Plaintiffs, identified as beneficiaries of the Local 19-9 Pension Trust, initiated an action alleging violations of the Labor Management Relations Act, 29 U.S.C.A. § 186, stemming from the alleged improper appointment and control of the trustee, Leonard M. Frackman, by Local 199, as well as claims of unreasonable fees and non-compliance with the Welfare and Pension Plan Disclosure Act of 1959. Defendants, including Henry M. Moses and Better Electric Company, moved to dismiss the complaint, challenging the plaintiffs' standing and the court's jurisdiction. The court denied the case's classification as a class action, allowing it to proceed on individual claims. Finding substantial issues of fact regarding the trustee's status and the extent of union control over the trust, the court denied both parties' cross-motions for summary judgment. Furthermore, the plaintiffs' application for a preliminary injunction was denied due to an insufficient showing of probable success or irreparable harm.

Labor Management Relations ActPension Trust LitigationTrustee AccountabilitySummary Judgment DenialPreliminary Injunction DenialClass Action SuitEmployee StandingUnion Control of FundsWelfare and Pension Plan Disclosure ActFederal Civil Procedure
References
12
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. CV 96 3467 (RJD)
Regular Panel Decision
Jun 09, 1997

Gray v. GROVE MFG. CO., DIV. OF KIDDE, INC.

Plaintiffs, including union officials and beneficiaries of Local 14, initiated an action against Grove Manufacturing Company for tortious interference with contract and prima facie tort, also seeking a permanent injunction. The case was removed to the United States District Court, E.D. New York, due to a federal pre-emption claim under section 301 of the Labor Management Relations Act of 1947. The core dispute revolved around Grove's marketing of a 'cherrypicker' crane, allegedly enabling employers to bypass a Collective Bargaining Agreement (CBA) requiring a union member for cranes exceeding a certain lift capacity. The court dismissed the prima facie tort claim, citing inadequate pleading of special damages and insufficient evidence of 'disinterested malevolence.' Furthermore, the court granted summary judgment to Grove on the tortious interference and injunction claims, ruling that these state law claims were pre-empted by LMRA § 301 because their resolution necessitated interpretation of the CBA and implicated fundamental federal labor law principles, including the strong policy favoring arbitration.

Labor LawLMRA Section 301Pre-emptionTortious InterferencePrima Facie TortCollective Bargaining AgreementSummary JudgmentFederal JurisdictionArbitrationUnion
References
27
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
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