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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

Employers' Mutual Liability Insurance v. McLellan

This motion, brought by a plaintiff insurance carrier and Flying Tigers, Inc., sought to stay payment to defendant John Johnstone. The payment was awarded by Deputy Commissioner McLellan under the Longshoremen’s and Harbor Workers’ Compensation Act for the death of James M. Johnstone. Plaintiffs argued that the Deputy Commissioner's findings on dependency and jurisdiction were erroneous and that they would suffer irreparable harm without a stay due to no provision for repayment under the Act. However, the court found the application inadequate, citing insufficient facts, rebutted dependency claims, and legally insufficient assertions of irreparable injury. Consequently, the motion for a stay of payment was denied.

Longshoremen's and Harbor Workers' Compensation ActWorkers' CompensationStay of PaymentPreliminary InjunctionIrreparable HarmDependencyJurisdictionCompensation AwardPenalty for Non-PaymentInsurance Carrier
References
8
Case No. MISSING
Regular Panel Decision

Williams v. Glass

The petitioner, a paternal grandmother, sought foster care payments for three children who had been in her custody since July 30, 1988, following their placement by the Department of Social Services (DSS). DSS initially provided payments until July 29, 1988, but subsequently denied further funding, asserting that the foster care placement had automatically terminated. The court, in reviewing the Commissioner's determination, held that under the Interstate Compact on the Placement of Children (Social Services Law § 374-a), DSS, as the sending agency, retained jurisdiction and financial responsibility for the children. The court found that the voluntary 'discharge' of the children to the grandmother was an insufficient basis to terminate DSS's ongoing supervisory and financial responsibilities. Consequently, the Commissioner's determination denying foster care payments was annulled, and the petition seeking such payments was granted.

Foster careInterstate CompactSocial Services LawCPLR article 78Judicial reviewAnnulmentChild custodyFinancial responsibilityAgency responsibilityNew York law
References
4
Case No. MISSING
Regular Panel Decision

Claim of Joslin v. City of Albany Fire Department

The claimant appealed a Workers’ Compensation Board decision regarding the method of payment for his hearing loss benefits, specifically challenging the biweekly installment plan. The claimant argued that Workers’ Compensation Law § 49-bb, which governs occupational loss of hearing claims, mandated a different payment method. The court rejected this contention, asserting that Workers’ Compensation Law § 15 (3) (m), which covers schedule awards for hearing losses generally, and § 49-cc, which directs occupational loss of hearing compensation to align with § 15 (3), govern the payment. Consequently, the court affirmed that the claimant was entitled to biweekly scheduled payments, consistent with other schedule loss awards.

Hearing lossWorkers' CompensationOccupational diseaseSchedule awardBiweekly paymentsStatutory interpretationAppealCompensation benefitsWorkers' Compensation Board
References
2
Case No. MISSING
Regular Panel Decision
Jun 20, 1986

Claim of Foglia v. New York City Housing Authority

The claimant, a New York City Housing Authority police officer, sustained a compensable knee injury in 1974. The case was reopened in 1983 due to increased disability, and the Special Fund for Reopened Cases was put on notice for potential liability under Workers' Compensation Law § 25-a. The issue was whether there was an advance payment of compensation, which would relieve the Special Fund from liability. The claimant testified that he retired in 1983 but had been on limited duty performing clerical work at full salary since 1982 due to his injury. The Workers' Compensation Board determined that these full salary payments for lighter work constituted an advance payment of compensation. The court affirmed the Board's decision, finding substantial evidence to support the determination that an advance payment of compensation relieved the Special Fund from liability.

Workers' Compensation BoardAdvance PaymentSpecial FundReopened CasesDisabilitySchedule LossPolice OfficerLimited DutySubstantial EvidenceFactual Determination
References
2
Case No. MISSING
Regular Panel Decision

Claim of Marchese v. New York State Department of Correctional Services

Claimant, injured in October 1997, initially received full wages from their employer, then workers' compensation benefits after employment termination. Following an award of benefits in February 2000, a dispute arose regarding the payment of claimant's counsel fee. The Workers’ Compensation Board ruled that the fee should be paid in installments from continuing payments to the claimant, rather than from the portion reimbursing the employer. Claimant appealed this decision, arguing that continuing payments were subject to adjustment and thus not an award of compensation. The Appellate Division affirmed the Board's decision, emphasizing the Board's broad discretion under Workers’ Compensation Law § 24 and finding no unfairness in the payment method, as the award was sufficient to cover both employer reimbursement and the attorneys' lien.

Attorney FeesWorkers' Compensation LawLien on CompensationContinuing PaymentsBoard DiscretionAppellate ReviewEmployer ReimbursementAward Payment MethodStatutory InterpretationCounsel Fee
References
2
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

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
Jun 14, 2005

Claim of Horton v. Salt

Claimant appealed a Workers' Compensation Board decision that reduced penalties against the employer and its carrier for late benefit payments. The Workers' Compensation Law Judge initially assessed a penalty of 20% of the late payments plus six $300 assessments. The Board agreed on late payments but reduced the penalty to only one $300 assessment, interpreting Workers’ Compensation Law § 25 (1) (e) as allowing a single $300 assessment per "instance" of application. The Court found the Board's interpretation not irrational but noted its inconsistency with prior Board decisions on similar facts without providing an explanation. Consequently, the Court reversed the Board's decision and remitted the matter for further proceedings.

Workers' CompensationLate Payment PenaltiesStatutory InterpretationAdministrative LawAgency PrecedentArbitrary and CapriciousJudicial ReviewRemandWorkers' Compensation BoardEmployer Obligations
References
6
Case No. ADJ3687516
Regular
Jan 26, 2012

RAMONA ANAYA, JUAN JOSE GONZALEZ, JESUS CERVANTES, JULIE ANN CABEZA, WALTER CRABTREE vs. PORT HUENEME UNIFIED SCHOOL DISTRICT, J. M. SMUCKERS, SPECIALTY RISK SERVICES, AMERICAN TECHNOLOGIES, INC., AIG DOMESTIC CLAIMS, INC., GHL ENTERPRISES, CIGA, INTERCARE INSURANCE SERVICES, INC., PAULA INSURANCE COMPANY, MARY HEALTH OF THE SICK, REDISED INSURANCE, CRAWFY AND COMPANY, M.R. AUTOMOTIVE, CIGA, Administrative inTERCARE INSURANCE SERVICES, HIH AMERICA COMPENSATION

The Workers' Compensation Appeals Board denied Attorney M. Francesca Hannan's request for a waiver of fees or a payment plan for reporter's transcripts. Hannan sought the transcripts to support allegations of bias by a Workers' Compensation Judge and claimed financial hardship and limited time for preparation. The Board found no legal basis for the fee waiver or payment plan under applicable rules and statutes, though it affirmed Hannan's right to obtain the transcripts upon payment.

WCABPetitionReporter's TranscriptFee WaiverPayment PlanGovernment Code 68632Administrative Director Rule 9990Appeals Board Rule 10740AnayaLien Trial
References
0
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