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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

Long Island Neurological Assocs., P.C. v. Highmark Blue Shield & Reed Smith LLP

Plaintiff Long Island Neurological Associates, P.C. sued Highmark Blue Shield and Reed Smith LLP for under-reimbursement of surgical services under ERISA. The case involved a 4-year-old patient who received complex out-of-network surgery from Dr. Schneider due to the unavailability of in-network providers. Highmark significantly under-reimbursed the billed amount and denied multiple appeals, failing to provide requested documentation. The patient's parents assigned their rights to the Plaintiff, leading Defendants to move for dismissal, asserting an anti-assignment provision in their Administrative Service Agreement (ASA). The Court denied the motion, ruling that the ASA is not an ERISA plan document and thus its anti-assignment clause is not binding on plan participants, confirming Plaintiff's standing. The Rule 12(b)(6) motion was also denied as abandoned.

ERISAMotion to DismissAnti-assignment clauseAdministrative Service Agreement (ASA)Plan DocumentSubject Matter JurisdictionStandingUnder-reimbursementOut-of-network providerHealth Insurance
References
27
Case No. ADJ1880234 (GOL 0097047)
Regular
Oct 06, 2014

HSING TEREK vs. EMBASSY SUITES/WINDSOR CAPITAL GROUP

In this workers' compensation case, the applicant suffered an admitted industrial injury from a slip and fall as a housekeeper. The defendant sought reconsideration of the findings of total permanent disability and injury to the "psyche, head, internal, and neurological/cognitive impairment." The Appeals Board granted reconsideration to address the ambiguity of the "internal" injury finding, which they found insufficiently specified. While affirming the total permanent disability finding and injury to psyche, head, and neurological/cognitive impairment, the Board rescinded the "internal" injury finding and returned the case for further proceedings to clarify the specific internal systems or conditions injured.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings of Fact and AwardIndustrial InjuryPsycheNeurological/Cognitive ImpairmentTotal Permanent DisabilityApportionmentHousekeeperSlip and Fall
References
1
Case No. ADJ4397000
Regular
Jun 10, 2011

MARIA MERCEDES FELIX vs. SEA DWELLING CREATURES, INC., STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board denied reconsideration, upholding the finding that applicant Maria Mercedes Felix has 0% whole person impairment for her back injury and requires no further medical treatment. This decision was based on the opinion of a qualified medical evaluator (PQME) whose findings were consistent with a prior medical report. The PQME's report concluded that various diagnostic tests were normal and revealed no significant clinical findings, structural alterations, or neurological impairment. Crucially, the Appeals Board clarified that a 3% pain add-on for whole person impairment is legally permissible only to increase an already established impairment rating, which was not the case here as the initial rating was zero.

Workers' Compensation Appeals BoardReconsideration deniedExpert medical evidencePanel Qualified Medical Evaluator (PQME)American Medical Association Guides (AMA Guides)Permanent ImpairmentWhole Person Impairment (WPI)DRE Lumbar Category IMedical treatmentPain add-on
References
2
Case No. MISSING
Regular Panel Decision

the Claim of Brigandi v. Town & Country Linoleum & Carpet

This case involves an appeal by an employer and its compensation carrier against decisions made by the Workers’ Compensation Board. The decedent, a carpet layer, died from cardiac arrest during work, with an autopsy revealing underlying coronary atherosclerotic disease. His widow was awarded death benefits. The employer’s carrier sought reimbursement from the Special Disability Fund under Workers’ Compensation Law § 15 (8), asserting a preexisting permanent physical impairment. However, the Board determined that there was no evidence that the decedent’s heart condition hindered his job potential before his death, thus releasing the Special Disability Fund from liability and holding the compensation carrier responsible. The employer's subsequent application for reconsideration was denied by the Board, leading to these appeals. The appellate court affirmed the Board's decisions, concluding that the Board rationally found no proof that the decedent's heart disease impaired his job potential, a necessary condition for reimbursement under WCL § 15 (8) (d).

Special Disability FundPreexisting Permanent ImpairmentCardiac ArrestCoronary Atherosclerotic DiseaseDeath Benefits ClaimEmployer ReimbursementCarrier LiabilityBoard Decision ReviewAppellate AffirmationMedical Evidence Interpretation
References
2
Case No. MISSING
Regular Panel Decision

In re Anonymous

This case concerns an adoption proceeding in Nassau County for a neurologically handicapped child. The petitioners, an approved adoptive family, sought to finalize the adoption. Former foster parents, the intervenors, challenged this, claiming a statutory preference for adoption due to their long-term care of the child. The court found that the intervenors had previously declined to adopt the child and failed to take affirmative steps to gain statutory preference while the child was in their care. The decision emphasized that intervention rights apply to current foster parents in custody disputes, and ultimately, the court prioritized the child's best interests by granting the petitioners' adoption application.

AdoptionFoster CareChild WelfareNeurological HandicapBest Interests of ChildInterventionStatutory PreferenceSocial Services LawAgency Discretion
References
3
Case No. MISSING
Regular Panel Decision

Claim of Milner v. Country Developers, Inc.

The Special Disability Fund appealed decisions by the Workmen’s Compensation Board which imposed liability on the Fund for a claimant's injuries. The Board found that the employer, Country Developers, continued to employ the claimant, a carpenter, with knowledge of his pre-existing permanent physical impairment, triggering liability under subdivision 8 of section 15 of the Workmen’s Compensation Law. The claimant suffered a fracture of the nose and a hip dislocation in 1964, having a history of three ruptured disc surgeries and other conditions. The appeal centered on whether the employer had sufficient knowledge of the claimant’s permanent condition. Testimony from the employer’s foreman, Mr. Pahlck, indicated awareness of the claimant's back issues, including wearing a back brace and being favored by co-workers. The court affirmed the Board’s decision, reiterating that employer knowledge is a question of fact for the Board, and its findings, if supported by substantial evidence, will not be disturbed.

Workers' Compensation LawSpecial Disability FundEmployer LiabilityPre-existing Permanent ImpairmentEmployer KnowledgeSubstantial EvidencePermanent Partial DisabilityFracture of NoseHip DislocationRuptured Discs
References
3
Case No. MISSING
Regular Panel Decision

Nye v. IBM Corp.

This case concerns an appeal from Workers' Compensation Board decisions regarding the apportionment of a claimant's permanent total disability. The claimant, a maintenance worker, sustained neck injuries in 1993, having a history of prior neck surgeries. The Board initially apportioned his disability, attributing 70% to the work-related injury and 30% to a noncompensable preexisting condition. The appellate court reversed these decisions, finding the apportionment unsupported. Evidence showed the claimant was fully employed and capable of performing his duties despite the prior condition, with medical testimony indicating no neurological impairments or work limitations before the 1993 injury.

Workers' CompensationApportionmentPreexisting ConditionPermanent Total DisabilityMedical EvidenceCausal RelationshipBoard ReviewAppealReversalJudicial Review
References
8
Case No. ADJ14053925
Regular
May 16, 2025

AMIR BAIGMORADI vs. NEP GROUP, INC.; FEDERAL INSURANCE COMPANY

The Workers' Compensation Appeals Board (WCAB) denied the Defendant's Petition for Reconsideration, upholding the Workers' Compensation Administrative Law Judge's (WCJ) Findings of Fact, Award & Order. The WCAB affirmed the WCJ's decision to admit the neuropsychological consultative reports of Fernando Gonzalez, Ph.D., deeming them substantial medical evidence. The Board further agreed with Dr. Gonzalez's method of adding impairment ratings for the applicant's neurological and psychiatric conditions, citing the synergistic effects on daily living activities. Additionally, the WCAB concluded that the applicant's injury, resulting from being crushed by an LED screen, constituted a "violent act" under Labor Code § 4660.1(c)(2)(A), entitling him to an increased psychiatric permanent disability rating.

Workers' Compensation Appeals BoardPetition for ReconsiderationLabor Code section 5909Electronic Adjudication Management SystemAdmissibility of medical reportsValdez v. Workers' Comp. Appeals Bd.Batten v. Workers' Comp. Appeals Bd.Qualified Medical EvaluatorSubstantial evidenceVigil v. County of Kern
References
19
Case No. ADJ3057272 (RDG 0125821)
Regular
Dec 03, 2010

FIDEL NAZARENO vs. OLD DURHAM WOOD COMPANY, STATE COMPENSATION INSURANCE FUND

This case involves a defendant's petition for reconsideration of a permanent disability award, arguing the Agreed Medical Evaluator's (AME) impairment rating was inconsistent with AMA Guides. The Appeals Board granted reconsideration, rescinded the award, and returned the matter for further development of the record. Issues include the DEU rater improperly separating AME's combined whole person impairment and the AME needing to clarify his reasoning on grip loss and potential overlap with other impairments. The AME will also re-evaluate impairment without referencing prior DEU ratings.

WORKERS' COMPENSATION APPEALS BOARDAgreed Medical EvaluatorAMEpermanent disabilityAMA GuidesDEU raterrating instructionswhole person impairmentFindings and AwardPetition for Reconsideration
References
1
Case No. ADJ7927652
Regular
Oct 25, 2016

Bozenna Kasperowicz vs. Metropolitan State Hospital, State Compensation Insurance Fund

This case involves an industrial injury to the applicant, a psychiatric technician, sustained on June 14, 2011, from a patient strike to the head. The Workers' Compensation Appeals Board (WCAB) granted reconsideration to address disputes over psychiatric impairment and a sleep disorder rating. The WCAB affirmed the original award but reduced the permanent disability rating from 76% to 70% by excluding the sleep dysfunction impairment. The WCAB found Dr. O'Brien's opinion on psychiatric impairment more persuasive than conflicting medical evaluations and determined Dr. Matos's opinion on sleep impairment lacked substantial medical evidence due to staleness.

WCABReconsiderationPsychiatric ImpairmentWhole Person ImpairmentGAF ScoreSleep DisorderSubstantial Medical EvidencePermanent DisabilityQualified Medical EvaluatorInsomnia
References
0
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