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Case Law Database

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

Case No. 2017-1180 K C
Regular Panel Decision
Aug 02, 2019

Merrick Med., P.C. v. A Cent. Ins. Co.

The case of Merrick Med., P.C. v A Central Ins. Co. concerned a provider's action to recover assigned first-party no-fault benefits from an insurer. The defendant insurer, A Central Insurance Company, moved for summary judgment to dismiss the complaint, asserting that a portion of the claim exceeded the workers' compensation fee schedule and other claims lacked medical necessity. Initially, the Civil Court denied the defendant's motion in part, making CPLR 3212 (g) findings. However, the Appellate Term, Second Department, modified the Civil Court's order. The appellate court concluded that the defendant's motion for summary judgment dismissing the complaint should have been entirely granted, as the specific claim was properly paid under the fee schedule, and the remaining claims were successfully challenged on medical necessity grounds by the defendant, which the plaintiff failed to rebut.

No-fault benefitsSummary judgment motionWorkers' compensation fee scheduleMedical necessity defenseAppellate Term decisionInsurance litigationAssignee claimCivil procedurePeer review reportIndependent medical examination
References
3
Case No. ADJ6724203
Regular
Mar 29, 2013

Med-Legal LLC vs.

The Workers' Compensation Appeals Board granted Med-Legal LLC's Petition for Reconsideration, rescinding the dismissal of its lien. Med-Legal claimed its representative was present at the lien conference and never received the Notice of Intention to Dismiss. Due to unclear hearing minutes and conflicting address information, the Board found the record regarding the conference unclear. The case is returned to the trial level for further proceedings to determine the lien's compensability.

Med-Legal LLCPetition for ReconsiderationOrder of Dismissallien conferenceNotice of Intention to DismissMinutes of Hearingrescindedreturned to trial levelillegible recordszip code discrepancy
References
0
Case No. ADJ7902535
Regular
Dec 02, 2013

MARIA SANCHEZ vs. TARGET CORPORATION

In this workers' compensation case, the Appeals Board denied California Imaging Solutions' petition for reconsideration. The Board also dismissed AR Med Management's petition for reconsideration on behalf of Dr. Saghafi and Spectrum Medical Supply because it was not timely filed. Even if timely, the AR Med Management petition would have been denied on its merits. The Board adopted the findings of the administrative law judge in both instances.

Workers' Compensation Appeals BoardPetition for ReconsiderationAR Med ManagementCalifornia Imaging SolutionsWCJ Reporttimely-filedmeritsSpectrum Medical SupplyDr. SaghafiTarget Corporation
References
0
Case No. 2022 NY Slip Op 03327 [205 AD3d 548]
Regular Panel Decision
May 19, 2022

Newman v. Mount Sinai Med. Ctr., Inc.

Plaintiff Aja Newman appealed two orders related to discovery in her lawsuit against Mount Sinai for negligent hiring, retention, and supervision, stemming from sexual assaults committed by defendant Dr. David Newman on her and three other patients. The Supreme Court had denied Newman's motions to compel discovery regarding the identities of the other patients and hospital workers, and granted Mount Sinai's cross-motion for a protective order, citing quality assurance and HIPAA privileges. The Appellate Division reversed both orders, ruling that Mount Sinai failed to prove entitlement to the quality assurance privilege for all requested documents and that the doctor-patient privilege does not cover incidents of abuse. The court also clarified that HIPAA regulations allow for disclosure subject to a qualified protective order. The Appellate Division granted Newman's motions, directing Mount Sinai to disclose patient identities under a protective order, provide identities of Newman's coworkers, produce party statements from ordinary business records, and prepare a privilege log for quality assurance materials for in camera review, remanding the matter for further proceedings.

Discovery DisputeNegligent HiringNegligent SupervisionQuality Assurance PrivilegeHIPAADoctor-Patient PrivilegeSexual AssaultPatient ConfidentialityProtective OrderPrivilege Log
References
13
Case No. 2013-1461 K C
Regular Panel Decision
Mar 16, 2016

Performance Plus Med., P.C. v. Nationwide Ins.

This case involves an appeal by Performance Plus Medical, P.C., acting as an assignee, against Nationwide Ins. The plaintiff sought to recover assigned first-party no-fault benefits. The Civil Court had previously granted the defendant's motion for summary judgment, leading to the dismissal of the complaint. The Appellate Term affirmed this order, ruling that the defendant's timely verification request tolled the insurer's time to pay or deny the claim, thus rendering the plaintiff's action premature due to a failure to respond to the request. Additionally, the court found that the defendant had successfully demonstrated a prima facie case for denying claims related to the first cause of action based on the workers' compensation fee schedule, which the plaintiff failed to rebut.

No-fault benefitsSummary judgmentVerification requestInsurer's time to payPremature actionWorkers' compensation fee scheduleAppellate reviewCivil Court orderFirst-party benefitsAssigned claims
References
2
Case No. 2014-827 Q C
Regular Panel Decision
Sep 22, 2017

Compas Med., P.C. v. 21st Century Ins. Co.

This case involves an appeal from an order of the Civil Court regarding a provider's action to recover assigned first-party no-fault benefits. Plaintiff, Compas Medical, P.C., sought summary judgment, while defendant, 21st Century Insurance Company, cross-moved for summary judgment to dismiss several causes of action. The Appellate Term modified the Civil Court's order by denying the defendant's cross-motion to dismiss the fourth cause of action, noting the defendant's failure to establish a timely denial. However, the plaintiff also failed to prove entitlement to summary judgment on this claim. The court affirmed the dismissal of the first and fifth causes of action, finding that the defendant had adequately paid for services according to the workers' compensation fee schedule. A triable issue of fact was identified concerning whether the defendant received the claims for the remaining causes of action.

No-fault benefitsSummary judgmentTimely denialFee schedule defenseWorkers' compensationAppellate reviewCivil Court orderCauses of actionInsurance claimsProcedural appeal
References
5
Case No. 2015-2418 K C
Regular Panel Decision
May 25, 2018

Remedial Med. Care, P.C. v. Park Ins. Co.

This case involves an appeal from an order of the Civil Court concerning first-party no-fault benefits. The defendant, Park Insurance Co., sought summary judgment to dismiss the complaint filed by Remedial Medical Care, P.C., as assignee of Thomas Brown. The Civil Court initially denied the motion but found that the defendant had established timely mailing of denials. The Appellate Term modified the order, granting summary judgment to the defendant for a bill of services rendered on August 23, 2012, as it was paid according to the workers' compensation fee schedule. However, for the remaining bills, the defendant failed to prove timely mailing of IME scheduling letters, thus failing to demonstrate that the IMEs were properly scheduled or that the assignor failed to appear. Therefore, the denial of summary judgment for the remaining claims was affirmed.

Summary JudgmentNo-Fault BenefitsIndependent Medical Examination (IME)Timely MailingWorkers' Compensation Fee ScheduleAppellate TermCivil CourtDenial of ClaimFirst-Party BenefitsInsurance Law
References
3
Case No. 2020 NY Slip Op 07280 [189 AD3d 439]
Regular Panel Decision
Dec 03, 2020

Lumbermens Mut. Cas. Co. v. A B Med. Servs., PLLC

This case concerns an appeal regarding the payment of no-fault benefits. Plaintiff insurers initiated an action seeking a declaration that they had no obligation to pay benefits to defendant A B Medical Services, PLLC, for services rendered by various medical professionals. The Supreme Court, New York County, ruled in favor of the plaintiffs, determining that the medical providers were independent contractors and not employees of the defendant. This distinction was crucial as it violated 11 NYCRR 65-3.11 (a), which limits no-fault medical billing to employees of the provider. The Appellate Division, First Department, unanimously affirmed this decision, finding insufficient evidence of an employer-employee relationship based on factors like the degree of control, work flexibility, and benefits.

No-fault benefitsIndependent contractorEmployer-employee relationshipMedical billing11 NYCRR 65-3.11(a)Appellate reviewDegree of controlW-2 formsMalpractice insuranceStaffing services
References
2
Case No. 2014-1040 K C
Regular Panel Decision
Jul 14, 2017

TAM Med. Supply Corp. v. Country Wide Ins. Co.

This case involves an appeal concerning a claim for first-party no-fault benefits. The Civil Court initially denied the plaintiff-provider's motion for summary judgment and granted the defendant-insurer's cross-motion for summary judgment. The Appellate Term modified this order, finding that a discrepancy in the defendant's affidavit prevented a summary judgment dismissal based on late notice of the accident. However, the plaintiff had failed to comply with discovery demands, leading the Appellate Term to grant the defendant's alternative request to compel discovery responses and an examination before trial from the plaintiff within specified timeframes.

No-fault benefitsSummary judgmentDiscoveryInterrogatoriesExamination before trialTimely denialLate notice of accidentCPLR 3126Appellate TermCivil Court
References
6
Case No. 2014-1595 Q C
Regular Panel Decision
Sep 22, 2017

Compas Med., P.C. v. American Tr. Ins. Co.

This case involves an appeal from an order of the Civil Court of the City of New York, Queens County. The plaintiff, Compas Medical, P.C., as assignee, sought summary judgment for first-party no-fault benefits, while the defendant, American Transit Ins. Co., cross-moved for summary judgment to dismiss the complaint. The Civil Court initially denied parts of plaintiff's motion and granted parts of defendant's cross-motion, dismissing the third through seventh causes of action. On appeal, the Appellate Term affirmed the denial of plaintiff's summary judgment on the second through seventh causes of action. However, it modified the order by denying the branches of defendant's cross-motion that sought to dismiss the third through seventh causes of action, citing triable issues of fact regarding verification receipt and payment in accordance with the workers' compensation fee schedule.

No-Fault BenefitsSummary JudgmentAppellate ReviewTriable Issues of FactVerification of ClaimInsurance ClaimMotion to DismissMedical ProviderAssigneeWorkers' Compensation Fee Schedule
References
5
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