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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. 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
Sep 12, 2001

Claim of Oberson v. Bureau of Ferry Aviation & Transportation

The claimant was terminated from his employment as a marine oiler after a physical altercation with his supervisor in January 1993. He sought workers' compensation benefits, claiming a compensable psychological injury from the altercation. A Workers’ Compensation Law Judge disallowed the claim due to the claimant's failure to timely notify the employer of his injury. The Workers’ Compensation Board affirmed this decision, which was subsequently affirmed on appeal. Although the employer had actual knowledge of the altercation and termination, there was no indication they had actual knowledge of a psychological injury stemming from the altercation until 1999, approximately six years later. The Board's determination that the employer did not have timely notice and was prejudiced by the delay was supported by substantial evidence.

Workers' Compensation NoticePsychological Injury ClaimTimeliness of NoticeEmployer PrejudiceActual KnowledgeWorkplace AltercationEmployment TerminationWorkers' Compensation Board AffirmationAppellate ReviewStatutory Interpretation
References
6
Case No. ADJ15544152
Regular
May 02, 2025

TALIBAH COFFEE vs. COUNTY OF LOS ANGELES, SEDGWICK

Applicant, Talibah Coffee, sought reconsideration of a finding that her claimed industrial injury was non-compensable due to her being the initial physical aggressor in an altercation. The Workers' Compensation Appeals Board reviewed the applicant's petition, the defendant's answer, and the WCJ's report. The Board concurred with the WCJ's analysis, which found that the applicant's act of physically touching and moving a cameraman's equipment constituted the initial physical aggression, thereby barring compensation under Labor Code section 3600(a)(7). Consequently, the Petition for Reconsideration was denied.

Initial physical aggressorLabor Code section 3600(a)(7)Deputy Probation Officer IIaltercationphysical conductreal and present threat of bodily harmPetition for ReconsiderationWCJReport and Recommendationinjury AOE/COE
References
3
Case No. ADJ10762593
Regular
Feb 06, 2023

NICHOLAS KOBE vs. CITY OF LOS ANGELES, AIMS

The Workers' Compensation Appeals Board denied the City of Los Angeles' petition for reconsideration, upholding the finding that firefighter Nicholas Kobe's TMJ/myofascial pain injury was compensable. The Board adopted the judge's report, which determined that the applicant was not the initial physical aggressor in an altercation with a fellow firefighter, as the initial physical contact was initiated by the other firefighter. Therefore, Labor Code §3600(a)(7) did not bar the claim, and the applicant was awarded temporary and permanent disability benefits. The defense exclusively argued the initial physical aggressor defense, which the Board found inapplicable based on the facts.

Initial physical aggressor defenseLabor Code §3600(a)(7)TMJ/myofascial painPanel Qualified Medical EvaluatorNina Nattiv DDSfirefighter injurytemporary disabilitypermanent disabilitywage calculationattorney fees
References
11
Case No. MISSING
Regular Panel Decision
Nov 14, 1991

Pellach v. Pellach

The Supreme Court modified an earlier order denying plaintiff's motion to reopen a maintenance and support hearing and compel defendant's physical examination. The record before the Special Referee was reopened, allowing the plaintiff to subpoena defendant's bank account records due to alleged discovery of new information and previous attorney refusal. However, the court affirmed the denial of the physical examination request, noting the defendant's prior adjudication of permanent disability by the Workers’ Compensation Board. The delay in the divorce action, pending since 1988, was largely attributed to the defendant's frequent changes of attorneys.

DivorceMaintenanceSupportFinancial DisclosureBank AccountsPhysical ExaminationWorkers' CompensationJudicial DiscretionAppellate ReviewReopening Record
References
1
Case No. ADJ10903154
Regular
Apr 01, 2020

JEHUDA KNOBLER vs. LOS ANGELES UNIFIED SCHOOL DISTRICT, SEDGWICK CLAIMS MANAGEMENT SERVICES

This case involves a teacher claiming workers' compensation for PTSD after a student altercation. The Board overturned the initial finding, now recognizing the PTSD as arising out of and occurring in the course of employment. However, they affirmed the finding that the applicant was the initial physical aggressor under Labor Code section 3600(a)(7). This disqualifies him from receiving compensation benefits due to his role in initiating the physical confrontation.

AOE/COEinitial physical aggressorLabor Code section 3600(a)(7)posttraumatic stress disorderphysical altercationPQME reportstudent altercationwitness statementsadministrative leavetrier of fact
References
0
Case No. ADJ1132942
Regular
Jun 04, 2009

James Lewis vs. Compton Unified School District, Hazelrigg Risk Management Services

The Workers' Compensation Appeals Board granted reconsideration, reversing a prior finding that James Lewis was not the initial physical aggressor in an altercation. The Board found that Lewis's actions, including throwing tools at a co-worker and attempting to move the co-worker's truck, initiated the physical confrontation. Consequently, Lewis's claim for injury benefits is barred under Labor Code section 3600(a)(7).

Workers' Compensation Appeals BoardInitial Physical AggressorLabor Code section 3600(a)(7)AltercationFindings of FactReconsiderationOpinion and OrderAffirmative DefensesEmploymentInjury
References
0
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