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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

Surgicare Surgical v. National Interstate Insurance

This case addresses whether an insurer complies with New York's 11 NYCRR 68.6 regulation by reimbursing for out-of-state medical services according to the host state's (New Jersey's) no-fault fee schedule. Plaintiff Surgicare Surgical, assignee of an injured party, sought full payment for surgery performed in New Jersey, but defendant National Interstate Insurance Company paid a reduced amount based on New Jersey's fee schedule. The court affirmed the defendant's method, ruling that when medical services are rendered in another jurisdiction with its own fee schedule, the 'permissible' charge under that schedule constitutes the 'prevailing fee' under New York's regulation. The decision emphasized alignment with legislative intent to contain no-fault insurance costs and reduce judicial burden, dismissing the plaintiff's complaint and denying its cross-motion.

No-Fault BenefitsInsurance LawFee Schedule DisputeOut-of-State Medical ServicesNew York RegulationsNew Jersey Fee ScheduleStatutory InterpretationAutomobile AccidentReimbursement DisputeSummary Judgment
References
17
Case No. FRE 0222651
Regular
Jul 15, 2008

CHRISTOPHER HUNT vs. MADERA COUNTY ROAD DEPARTMENT

The Appeals Board granted reconsideration of a WCJ's decision that limited a lien claimant's facility fees to the Official Medical Fee Schedule. The Board found the WCJ erred by not applying the correct *Kunz* standard for determining the reasonableness of outpatient surgery facility fees, which considers factors beyond the fee schedule. The case is remanded for further proceedings to properly develop the record according to *Kunz*.

KunzOfficial Medical Fee Scheduleoutpatient surgery facility feeslien claimantreconsiderationen banc decisionreasonableness of feesusual feegeographical areacontractually negotiated fees
References
5
Case No. ADJ2806916 (SDO 0271727)
Regular
Oct 30, 2013

SOVEIDA MAGANA vs. CENTER FOR EMPLOYMENT TRAINING, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE COMPANY

This case consolidates numerous claims involving unresolved lien claims for ambulatory surgical center facility fees. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision establishing reasonable facility fees by averaging the January 1, 2004, Official Medical Fee Schedule for ASCs with the average amount paid to San Diego hospitals under an older inpatient fee schedule. The Board found this methodology appropriately considered extensive evidence and relevant factors for determining reasonable fees. Defendants' arguments that only the January 1, 2004, OMFS should apply or that SB 863's independent bill review process was mandatory were rejected.

Workers' Compensation Appeals BoardSoveida MaganaCenter for Employment TrainingCalifornia Insurance Guarantee AssociationReliance Insurance CompanyLien ClaimantsPoint Loma Surgical CenterElite Surgical CentersAmbulatory Surgical CenterFacility Fees
References
0
Case No. 2019 NY Slip Op 09078 [178 AD3d 1268]
Regular Panel Decision
Dec 19, 2019

Matter of Donovan v. DOCCS Coxsackie Corr. Facility

Danl D. Donovan, a correction sergeant, sustained a work-related hip injury. His employer, DOCCS Coxsackie Correctional Facility, advanced his wages and sought reimbursement. Following an award for a schedule loss of use, a dispute arose regarding the deduction of attorney fees from the claimant's payment, which the Workers' Compensation Board upheld. While Donovan's appeal was pending before the Appellate Division, the Board issued an amended decision based on a new legal rationale. Consequently, the Appellate Division, Third Department, dismissed the initial appeal as moot.

Workers' CompensationSchedule Loss of UseAttorney Fee DeductionReimbursement DisputeMoot AppealAppellate DivisionWork-related InjuryWage ReimbursementIndependent Medical ExaminerAdministrative Review
References
2
Case No. 2025 NY Slip Op 02248 [237 AD3d 1379]
Regular Panel Decision
Apr 17, 2025

Matter of Jehle v. DOCCS Coxsackie Corr. Facility

William Jehle, a correction officer, sustained a work-related injury, prompting his employer, DOCCS Coxsackie Correctional Facility, to continue paying his full wages. The employer sought reimbursement, and Jehle's attorney filed for counsel fees. The Workers' Compensation Law Judge (WCLJ) established the claim, found a temporary total disability, awarded a credit to the employer for wage reimbursement, and granted counsel fees of $4,300 as a lien against this reimbursement. The Workers' Compensation Board affirmed the WCLJ's decision, deeming the lien proper under Workers' Compensation Law § 24 (2) (b). The Appellate Division, Third Department, further affirmed the Board's decision, holding that an award for previously unawarded benefits constitutes an 'increase' under the law, and that counsel fees are appropriately a lien against the employer's reimbursement, dismissing arguments of the employer subsidizing fees.

Counsel FeesLien on AwardEmployer ReimbursementTemporary Total DisabilityWorkers' Compensation LawAppellate ReviewCorrection OfficerWage ReimbursementStatutory InterpretationClaimant Attorney Fees
References
3
Case No. SBR 0332538
Regular
Mar 28, 2009

RUBY JONES vs. STATE OF CALIFORNIA / DEPARTMENT OF MENTAL HEALTH, STATE COMPENSATION INSURANCE FUND, PREMIER OUTPATIENT SURGERY CENTER, INC.

The Appeals Board granted reconsideration, rescinded the prior order, and returned the case for further proceedings on the reasonableness of Premier Outpatient Surgery Center's (POSC) $\$16,578.00$ lien claim for surgical services. While POSC was properly licensed as a surgical clinic and did not require a fictitious-name permit, the Appeals Board found the record insufficient to establish the reasonableness of the charged fee, noting a significant disparity between the billed amount and what was paid based on Medicare rates. The Board also rescinded the award of attorney's fees to POSC's counsel, finding no basis for such an award under Labor Code sections 5811 or 5813.

Workers' Compensation Appeals BoardRuby JonesState Compensation Insurance FundPremier Outpatient Surgery Centerfictitious-name permitMedical Board of CaliforniaDepartment of Health Servicessurgical clinic licenseoutpatient settingreasonable fee
References
6
Case No. MISSING
Regular Panel Decision
Jun 30, 2010

John Giugliano, DC, P.C. v. Merchants Mutual Insurance

Plaintiff John Giugliano, DC, EC., as assignee of Laura Hebenstreit, initiated this action to recover first party no-fault benefits from defendant Merchants Mutual Ins. Co. The core dispute, following a trial on June 30, 2010, centered on the plaintiff's billing practices under the New York Workers' Compensation Medical Fee Schedule, specifically regarding the use of surgical CPT codes for chiropractic procedures. Defendant argued against the use of surgical codes and duplicate billing for a specific CPT code, while plaintiff maintained these practices were justified because the procedures were not listed under the chiropractic fee schedule and involved distinct treatment areas. The court ultimately ruled in favor of the plaintiff, concluding that the procedures were properly billed according to the Fee Schedule, thereby entitling the plaintiff to reimbursement.

No-Fault BenefitsChiropractic BillingWorkers' Compensation Fee ScheduleCPT CodesSurgical ProceduresCo-Surgeon BillingInsurance ReimbursementMedical Fee Schedule DisputesSpinal ManipulationMandibular Fracture
References
2
Case No. OAK 0293725
Regular
May 22, 2008

MARGARITA CHAVEZ vs. WESTERN NATIONAL PROPERTIES, STATE COMPENSATION INSURANCE FUND

The Workers' Compensation Appeals Board granted reconsideration and rescinded the initial denial of the lien claim by Bay Surgery Center (BSC). BSC's claim for facility fees was initially denied because it allegedly failed to prove it operated as an "outpatient setting" and thus was exempt from needing a fictitious business name permit. The Board found that BSC presented sufficient evidence of its "surgical clinic" license to meet its initial burden, thereby establishing it as an "outpatient setting" for purposes of the lien claim, and remanded the case for further proceedings on the reasonableness of the fees.

Workers' Compensation Appeals BoardLien claimantOutpatient settingFictitious Business Name permitSurgical clinic licenseDepartment of Health ServicesFacility feeMedical BoardLicensed physicianReasonable fee
References
9
Case No. 531543
Regular Panel Decision
Jan 07, 2021

Matter of Gilliam v. Doccs Wende Corr. Facility

Claimant Wanda Gilliam, a correction officer, sustained work-related injuries to her right hip and left shoulder in May 2017. Following various medical evaluations, including conflicting opinions from orthopedist Michael Grant and independent examiner Louis Nunez regarding schedule loss of use (SLU), a Workers' Compensation Law Judge initially awarded a 60% SLU of her left arm and 57.5% SLU of her right leg. Upon administrative review, the Workers' Compensation Board modified this decision, crediting Nunez's evaluation, and awarded a 30% SLU for her left arm while making no SLU award for her right leg, and also reduced the attorney's fee. The Appellate Division, Third Department, affirmed the Board's decision, determining that it was supported by substantial evidence, particularly in resolving conflicting medical opinions and exercising discretion regarding counsel fees. The court found no abuse of discretion in the reduction of attorney's fees, noting the limited period of representation.

Workers' CompensationSchedule Loss of Use (SLU)Left Arm InjuryRight Leg InjuryOrthopedic ExaminationMedical Opinion ConflictAppellate ReviewAttorney FeesDiscretionary AwardSubstantial Evidence
References
17
Case No. 25 NY3d 907
Regular Panel Decision
2015-XX-XX

Government Employees Insurance v. Avanguard Medical Group, PLLC

This case addresses whether no-fault insurance carriers are obligated to pay facility fees to New York State-accredited office-based surgery (OBS) centers for the use of their premises and support services. The court concluded that neither existing statutes nor regulations mandate such payments. Plaintiffs, a group of GEICO insurers, successfully sought a declaratory judgment that they are not legally required to reimburse Avanguard Medical Group, PLLC, for OBS facility fees, totaling over $1.3 million. The decision affirmed the Appellate Division's ruling, emphasizing that OBS facility fees are not explicitly covered by statute or fee schedules, nor do they fall under reimbursable "professional health services" as per 11 NYCRR 68.5. The court highlighted the distinct regulatory frameworks for OBS centers compared to hospitals and ambulatory surgery centers, declining to mandate policy changes best left to the legislature.

No-Fault InsuranceOffice-Based Surgery (OBS)Facility FeesInsurance LawBasic Economic LossFee SchedulesWorkers' Compensation BoardDepartment of Financial ServicesStatutory InterpretationRegulatory Framework
References
16
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