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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. MISSING
Regular Panel Decision
Oct 26, 2015

Matter of Newbill v. Town of Hempstead

Claimant, a sanitation crew chief, injured his right ankle and foot at work and was awarded disability benefits. His self-insured employer paid his full weekly wages during a period of disability and timely sought reimbursement for these advanced payments. A Workers’ Compensation Law Judge granted the employer's reimbursement request against a 20% schedule loss of use award for the right foot. The Board affirmed this decision, and the claimant appealed, arguing that reimbursement should not cover periods where no compensation awards were initially made. The court affirmed the Board's decision, reiterating that an employer is entitled to full reimbursement from a schedule loss of use award for advanced wages paid during disability, as schedule awards are not allocable to specific periods of lost work.

Schedule Loss of UseReimbursementAdvanced Wage PaymentsDisability BenefitsEmployer RightsAppellate ReviewWorkers’ Compensation BoardStatutory InterpretationPermanent Partial DisabilityTimely Claim
References
10
Case No. MISSING
Regular Panel Decision

Claim of Guarascio v. Spargo Wire Co.

The claimant, a truck driver, suffered work-related back and shoulder injuries in October 1995. The employer’s workers’ compensation carrier paid benefits. In 2000, the carrier sought reimbursement from the Special Disability Fund under Workers’ Compensation Law § 15 (8) (d) for these payments. A Workers’ Compensation Law Judge (WCLJ) established the claim in 2002 and later found the claimant permanently partially disabled, ruling on apportionment but deferring the reimbursement issue. The WCLJ subsequently found the carrier’s request for reimbursement timely. The Workers’ Compensation Board affirmed this decision. This appeal concerns the Board’s ruling that the carrier’s C-250 claim for reimbursement was timely filed within the statutory 52-week period, despite the underlying claim documents being posted by the Board in 2000.

ReimbursementSpecial Disability FundTimeliness of ClaimPermanent Partial DisabilityWorkers' Compensation LawPreexisting ImpairmentWork-related InjuryC-250 ClaimStatute of LimitationsAppellate Review
References
3
Case No. MISSING
Regular Panel Decision

Claim of Simpson v. Glen Aubrey Fire Co.

A volunteer fireman suffered an acute lumbosacral strain requiring frequent hospital and doctor visits. He sought reimbursement for 290 miles of travel expenses. The Workers' Compensation Board approved reimbursement at 20 cents per mile, leading to this appeal. The court examined whether travel expenses for medical treatment are reimbursable under the Volunteer Firemen’s Benefit Law and Workers’ Compensation Law. It concluded that access to medical treatment implies the financial means to obtain it, upholding the humanitarian goals of the legislation.

Volunteer FiremanLumbosacral StrainMileage ReimbursementTravel ExpensesMedical TreatmentWorkers' Compensation LawVolunteer Firemen's Benefit LawStatutory InterpretationRemedial LawLiberal Construction
References
2
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

Poupard v. Mohonasen Central School District

The claimant, a librarian, sustained an employment-related injury. Following her injury, she received full salary for 27 weeks under a collective bargaining agreement, and then used 23 days of accumulated sick leave. The employer sought reimbursement for these advance payments. The referee and the Workers’ Compensation Board initially granted the full reimbursement. On appeal, the court modified the decision, holding that wages paid from accumulated sick leave, acquired through a collective bargaining agreement, are compulsory payments and thus not reimbursable under Workers’ Compensation Law § 25 (subd 4, par [a]). The matter was remitted for further proceedings consistent with this ruling, with costs awarded to the claimant.

Workers' CompensationReimbursementSick LeaveCollective Bargaining AgreementAdvance PaymentsOccupational DisabilityStatutory LimitationsAppellate ReviewEmployment InjuryReferee Decision
References
5
Case No. MISSING
Regular Panel Decision

Claim of Domanico v. Woodmere Fire District

This case involves an appeal from a decision by the Workers’ Compensation Board, filed April 4, 2005, which denied an employer's request for reimbursement of wages paid to a claimant during a period of disability. The court examined whether a June 24, 2004 notice, issued by the self-insured employer, Woodmere Fire District, containing language about reimbursement, was sufficient as a request under Workers’ Compensation Law § 25 (4) (a). The court found the notice to be sufficient in form. However, a critical issue remained regarding the timeliness of this request; specifically, whether it was filed prior to the compensation award made at the January 7, 2005 hearing. Due to this unresolved issue, the court reversed the Board's decision and remitted the matter for further proceedings to determine the timeliness of the reimbursement request.

Workers' Compensation ReimbursementEmployer Wage ReimbursementDisability WagesTimeliness of Reimbursement RequestWorkers' Compensation LawBoard Decision AppealJudicial ReversalRemittal for Further ProceedingsNew York Workers' CompensationStatutory Interpretation
References
5
Case No. MISSING
Regular Panel Decision

Claim of Perrin v. Builders Resource, Inc.

The case concerns an appeal from a Workers' Compensation Board decision regarding the reimbursement rate for home health aide services provided to a claimant by their sister. Initially, the carrier denied payment but was later directed to pay. The Workers’ Compensation Law Judge set the reimbursement rate at $12 per hour for services starting in 2011, which the Board affirmed. The claimant appealed, solely challenging this rate. The court dismissed the appeal, ruling that the claimant was not an aggrieved party concerning the reimbursement rate, as the dispute was between the care provider (the sister) and the carrier. The court affirmed that the claimant received the care sought and could not raise issues on behalf of the care provider.

Workers' CompensationHome Health Aide ServicesReimbursement RateAppeal DismissalAggrieved PartyCare ProviderWorkers' Compensation BoardAppellate ProcedureNew York LawCarrier Liability
References
4
Case No. MISSING
Regular Panel Decision

Claim of Foti-Crawford v. Buffalo General Hospital

A registered nurse sustained a back injury in July 1991 while concurrently employed by Buffalo General Hospital and Supplemental Health Care, leading to permanent partial disability. The Workers’ Compensation Board awarded benefits of $153.36 per week and ruled that the Special Disability Fund should reimburse the hospital's carrier for most of these benefits under Workers’ Compensation Law § 14 (6). The Fund appealed, contending that reimbursement was unwarranted as the benefits did not exceed the maximum amount the hospital would have paid without concurrent employment. The court affirmed the Board's decision, finding its interpretation rational, especially given the claimant returned to work for the primary employer.

Workers' CompensationConcurrent EmploymentSpecial Disability FundReimbursementPermanent Partial DisabilityAverage Weekly WageAppellate ReviewBack InjuryNurseWorkers' Compensation Law
References
2
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