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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. 2015-2337 Q C
Regular Panel Decision
May 18, 2018

Sama Physical Therapy, P.C. v. Hereford Ins. Co.

This case concerns an action by Sama Physical Therapy, P.C., as assignee, to recover first-party no-fault benefits from Hereford Insurance Co. The defendant argued that the plaintiff's assignor had been injured during the course of employment. The Civil Court conditionally granted defendant's cross-motion for summary judgment, ordering the plaintiff to file an application with the Workers' Compensation Board within 90 days. Plaintiff failed to comply with this order, and upon renewal, the Civil Court adhered to its prior determination. The Appellate Term, Second Department, affirmed the Civil Court's order, finding that the plaintiff did not demonstrate compliance with the order to make a proper application under the Workers' Compensation Law.

No-Fault BenefitsSummary JudgmentWorkers' Compensation BoardAppellate ReviewConditional GrantFailure to ComplyRenewal MotionInsurance LawAssigneeMedical Provider
References
1
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. ADJ563768 (SBR 0331684), ADJ2410618 (SBR 0338943)
Regular
Mar 22, 2010

JORGE GONZALEZ vs. TOYO TIRE USA, TOKO MARINE PASADENA

Lien claimant Access Health Medical Group seeks full reimbursement for services, arguing the WCJ erred by disallowing most of its lien based on anti-referral laws (Labor Code §§ 139.3, 139.31). Access contends these laws do not apply to in-house referrals for chiropractic, acupuncture, or "work conditioning" services, as these are not "physical therapy." The Appeals Board granted reconsideration, finding the WCJ applied an overly broad definition of physical therapy. The case is returned for further proceedings to determine if the billed services were distinct from physical therapy, or if "work conditioning" constitutes physical therapy under the statute.

Labor Code §§ 139.3Labor Code § 139.31anti-referral lawsin-office referralsphysical therapychiropracticacupuncturework conditioninglien claimantFindings and Order
References
6
Case No. MISSING
Regular Panel Decision
May 06, 1998

Nieves v. Five Boro Air Conditioning & Refrigeration Corp.

Reding Nieves, an employee of United Fire Protection, was injured while installing fire sprinklers at a New York Hall of Science site, which was subcontracted by Five Boro Air Conditioning & Refrigeration Corp. He allegedly tripped over a concealed drop light after stepping off an eight-foot ladder, sustaining an ankle injury. Nieves sued Five Boro under Labor Law § 240 (1), and Five Boro filed a third-party action against United, with the motion court initially granting Nieves summary judgment. However, the appellate court modified this order, denying summary judgment for all parties due to unresolved questions of fact surrounding the accident's cause, including conflicting testimonies. Consequently, the case requires a trial to determine liability and facts, as neither side was entitled to summary judgment.

Elevation-related riskTripping hazardSummary judgmentLabor Law § 240(1)Construction site accidentLadder fallContributory negligenceQuestions of factAppellate DivisionSubcontractor liability
References
11
Case No. 2015-608 Q C
Regular Panel Decision
Dec 19, 2017

Adelaida Physical Therapy, P.C. v. 21st Century Ins. Co.

In this case, Adelaida Physical Therapy, P.C., acting as an assignee, appealed an order from the Civil Court of the City of New York, Queens County. The original order had granted 21st Century Insurance Company's motion for summary judgment, dismissing parts of a complaint seeking first-party no-fault benefits for services billed under specific CPT codes (97010, 97110, and 97124). The Appellate Term, Second Department, reversed the lower court's decision. The appellate court found that 21st Century Insurance Company failed to demonstrate that it had used the correct conversion factor to calculate the reimbursement rate, thus not establishing its defense that the charged fees exceeded the workers' compensation fee schedule. As a result, the branches of the defendant's motion for summary judgment related to those CPT codes were denied.

No-Fault BenefitsCPT CodesSummary JudgmentWorkers' Compensation Fee ScheduleReimbursement RateAppellate ReviewInsurance DisputeCivil ProcedureConversion FactorMedical Billing
References
2
Case No. 2016-198 Q C
Regular Panel Decision
Jun 01, 2018

Comprehensive Care Physical Therapy, P.C. v. Allstate Ins. Co.

This case concerns a provider, Comprehensive Care Physical Therapy, P.C., seeking no-fault benefits from Allstate Insurance Company. The Civil Court initially denied the plaintiff's summary judgment motion and granted the defendant's cross-motion, dismissing the complaint based on the assignor's failure to appear for independent medical examinations (IMEs) and claims exceeding the fee schedule. On appeal, the Appellate Term modified this order, finding that Allstate failed to provide sufficient proof of timely denial form mailing, thereby precluding its defenses regarding IMEs and the fee schedule. Consequently, Allstate's cross-motion for summary judgment was denied, reversing that part of the lower court's decision. However, the Appellate Term affirmed the denial of the plaintiff's summary judgment motion, as the plaintiff also failed to establish their claims.

no-fault insurancesummary judgmentindependent medical examinationstimely denialinsurance defenseappellate reviewmedical billingassignee rightsprocedural requirementsfee schedule
References
5
Case No. 46885/05, 47943/05, 47945/05
Regular Panel Decision

Robert Physical Therapy, P.C. v. State Farm Mutual Automobile Insurance

This case involves three consolidated claims for first-party no-fault benefits related to physical therapy services. The plaintiff's assignors received physical therapy, and the defendant, an insurer, denied some claims due to disputes over billing codes. The central legal issues concerned whether a physical therapist could utilize billing codes from the medicine fee schedule when such services were not explicitly in the physical medicine schedule, and if range of motion and muscle testing could be billed separately from evaluation and management on the same day. The court determined that physical therapists are not confined to the physical medicine section and can use codes from any section of the medical fee schedule. Furthermore, the defendant failed to provide sufficient evidence to justify its denials regarding separate billing for range of motion and muscle testing. Consequently, the court ruled in favor of the plaintiff, awarding judgment for all disputed amounts.

Physical Therapy BillingNo-Fault BenefitsMedical Fee ScheduleCPT CodesWorkers' Compensation RegulationsEvaluation and Management ServicesRange of Motion TestingMuscle TestingProvider SpecialtyBilling Disputes
References
4
Case No. MISSING
Regular Panel Decision

New York State Ass'n for Retarded Children, Inc. v. Rockefeller

Plaintiffs, representing residents of the Willowbrook State School for the Mentally Retarded, sought judicial intervention to improve inhumane living conditions. The court found severe overcrowding, chronic understaffing of medical and care personnel, and inadequate facilities, leading to a hazardous environment. While denying a broad constitutional 'right to treatment,' the court affirmed the residents' 'right to protection from harm.' Consequently, the court issued a preliminary injunction mandating specific actions, including immediate hiring of additional ward attendants, nurses, physical therapists, and physicians, repair of inoperable toilets, prohibition of seclusion, and securing a contract with an accredited hospital for acute medical services. The court also reserved the power to adjust salaries to attract necessary staff.

Mentally Retarded RightsInstitutional CareProtection From HarmPreliminary InjunctionStaffing ShortagesFacility ConditionsCivil Rights LitigationDue Process ConcernsEighth AmendmentState Funding
References
68
Case No. MISSING
Regular Panel Decision

Claim of Ransiear v. Lewis County Welfare Department

The claimant, a head maintenance man for Lewis County Welfare Department, sustained two independent accidents in September 1962, injuring his left arm, shoulder, and neck, and subsequently developed a psychiatric condition. His employment was terminated shortly after the accidents. The Workmen’s Compensation Board found both physical and mental disabilities causally related to the accidents. Lewis County and its Welfare Department appealed these decisions, arguing a lack of substantial evidence. The court affirmed the board's findings, noting that conflicting medical testimony regarding physical injuries presented a question of fact for the board, and the psychiatric evidence, including an impartial psychiatrist's report, sufficiently supported the causal relationship between the accidents and the psychiatric condition.

Workers' CompensationCausationPsychiatric DisabilityPhysical InjuryMedical Expert TestimonyAppeal DecisionBoard FindingsSubstantial Evidence StandardEmployment-Related InjurySprained Shoulder
References
5
Case No. MISSING
Regular Panel Decision

Spraker v. Watts

The case involves an appeal by the mother from a Family Court order, entered August 12, 2005, which granted the father's application to modify a prior custody order. The father sought physical custody, alleging the mother's unstable living conditions, frequent moves, and inadequate care for their 13-year-old son, who has ADHD and a learning disability. The Family Court awarded physical custody to the father, finding the mother's lifestyle detrimental and the father's disciplinary approach more effective, while also imposing conditions on the father regarding alcohol consumption. The appellate court affirmed, concluding that the Family Court's determination was supported by a sound and substantial basis in the record, upholding the modification based on a sufficient change in circumstances and the child's best interests.

Custody disputeparental responsibilitieschild welfarejudicial reviewfamily lawappellate decisionspecial needs childparental alcohol userelocation issueshome environment stability
References
5
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