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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
May 14, 2014

Forest Rehabilitation Medicine PC v. Allstate Insurance

Plaintiff Forest Rehabilitation Medicine PC sued defendant Allstate to recover $3,490 for no-fault medical benefits provided to assignor Tracy Fertitta. The core issue was the medical necessity of "Calmare pain therapy" (scrambler therapy), a novel treatment. The court conducted a bench trial, hearing expert testimony from both sides. Dr. Ayman Hadhoud, for the defense, argued the treatment was not medically necessary, not cost-effective, and essentially a form of physical therapy. Dr. Jack D’Angelo, for the plaintiff, countered that the therapy, though new, had FDA approval, was used by the military, and reduced the assignor's pain levels. Applying the Frye standard, the court found the evidence regarding Calmare scrambler therapy reliable and ruled it was medically necessary for Ms. Fertitta's pain management. Consequently, judgment was awarded to the plaintiff, Forest Rehabilitation Medicine PC, for $3,490 plus attorney's fees and interest.

No-Fault InsuranceMedical NecessityCalmare Pain TherapyScrambler TherapyNovel TreatmentFrye StandardExpert TestimonyPain ManagementFDA ApprovalCervical Radiculopathy
References
14
Case No. 13-08-00351-CV
Regular Panel Decision
Aug 31, 2009

Mitch Burkhart and Christine Burkhart v. Sedgwick Claim Management Services, Inc. and Concentra Integrated Services, and rgv/nueces Rehabilitation D/B/A Innovative Physical and Occupational Therapy

Mitch Burkhart sustained a foot and ankle injury while training for his employer, Verizon Communications. Verizon's workers' compensation claims were administered by Sedgwick Claim Management Services, Inc., who, along with Concentra Integrated Services, arranged a Functional Capacity Evaluation (FCE) for Burkhart with RGV/Nueces Rehabilitation d/b/a Innovative Physical and Occupational Therapy. The Burkharts alleged that the FCE aggravated Mitch's injury, causing permanent damage. They sued Sedgwick, Concentra, and Innovative, claiming negligence, civil conspiracy, assault, fraud, and breach of the duty of good faith and fair dealing. The trial court dismissed the case against Innovative for an inadequate expert report and granted summary judgment to Sedgwick and Concentra, citing the exclusive remedy provision of the Texas Workers' Compensation Act. The appellate court affirmed the trial court's judgment, concluding that Mitch's aggravation injury was an 'extension injury' covered by the exclusive remedy provision of the TWCA.

Workers' CompensationFunctional Capacity EvaluationExclusive RemedyAggravation InjurySummary JudgmentMedical Expert ReportHealth Care LiabilityCivil ConspiracyBreach of Duty of Good Faith and Fair DealingTexas Court of Appeals
References
23
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. ADJ9501859
Regular
May 13, 2015

, Jose Chavez, vs. , Miracle Farms, d/b/a Golden Valley Farms; Star Insurance Company, Administered By Meadowbrook Insurance Group,

The applicant suffered a low back injury and claims additional injuries, with a Physical Medicine and Rehabilitation physician as his primary treating doctor. The WCJ incorrectly ordered a Spine-MNB QME panel, overriding the parties' requests and the primary physician's specialty. The Appeals Board dismissed the applicant's reconsideration petition as untimely for a non-final order. They granted removal, rescinded the WCJ's order, and substituted their own, directing the Medical Unit to issue a QME panel in Physical Medicine and Rehabilitation.

Workers' Compensation Appeals BoardPetition for ReconsiderationPetition for RemovalFindings and OrderQualified Medical EvaluatorQME PanelPhysical Medicine and RehabilitationSpine-MNBOrthopedic PanelPrimary Treating Physician
References
5
Case No. NO. 03-05-00031-CV
Regular Panel Decision
Dec 08, 2005

Texas Department of Assistive and Rehabilitative Services, Successor in Interest to the Former Texas Rehabilitation Commission v. Richard Howard

Richard Howard, a unit manager at the Texas Department of Assistive and Rehabilitative Services, reported alleged illegal practices to the State Auditor’s Office (SAO). Howard claimed his superiors retaliated against him by rating him below standard on performance appraisals and denying promotions and merit pay increases. He sued under the Whistleblower Act, and a jury awarded him damages, costs, and attorney's fees. The Department appealed, challenging the sufficiency of evidence regarding Howard's good faith report, appropriate authority, causation, and damages. The Court of Appeals affirmed the trial court's judgment, finding sufficient evidence to support the jury's verdict that Howard made a good faith report to an appropriate authority and that his report caused the adverse actions.

Whistleblower ActRetaliationPublic EmployeeState Auditor’s OfficePerformance AppraisalMerit PayPromotion DenialDamagesCausationGood Faith Report
References
20
Case No. MISSING
Regular Panel Decision

Doctor of Medicine in the House, P.C. v. Allstate Ins.

This case concerns a medical service provider plaintiff seeking $1,876.76 in no-fault claim benefits. The defendant insurance company denied the claim, citing that the fees were excessive under the workers’ compensation fee schedule and that prior reimbursements had exhausted the daily 8-unit limit for physical medicine procedures. The central legal question involved interpreting paragraph 11 of the Official New York Workers’ Compensation Medical Fee Schedule, Physical Medicine (2010), specifically whether the 8-unit limit applied per provider or cumulatively across all claimants. The court ruled in favor of the plaintiff, clarifying that the 8-unit rule is an individual provider fee limitation and not an exhaustion regulation for all claimants, distinguishing it from the $50,000 basic economic loss limit.

No-Fault BenefitsWorkers' Compensation Fee ScheduleMedical Reimbursement8-unit RuleFee Schedule InterpretationInsurance LawPhysical MedicineStatutory InterpretationClaim DenialExcessive Billing
References
9
Case No. MISSING
Regular Panel Decision

Texas Department of Assistive and Rehabilitative Services, Successor in Interest to the Former Texas Rehabilitation Commission v. Richard Howard

Richard Howard, a unit manager with the Texas Department of Assistive and Rehabilitative Services, reported several alleged legal violations by his employer to the State Auditor’s Office. Howard subsequently experienced retaliation, including denial of promotions and merit pay increases, which he attributed to his whistleblowing activities. He successfully sued the department under the Whistleblower Act, and a jury awarded him damages. The Department appealed the verdict, challenging the sufficiency of the evidence on multiple grounds, including good faith reporting, appropriate authority, causation, and damages. The appellate court affirmed the trial court's judgment, concluding that the evidence was legally and factually sufficient to support the jury's findings.

Whistleblower ActPublic Employee RetaliationPerformance EvaluationEmployment DiscriminationState Auditor's OfficeGood Faith ReportCausal LinkEconomic DamagesAppellate ReviewJury Verdict
References
20
Case No. MISSING
Regular Panel Decision
Dec 21, 1995

In re Jordan Rehabilitation Service, Inc.

Jordan Rehabilitation Service, Inc., providing medical and vocational rehabilitative services, appealed a decision by the Unemployment Insurance Appeal Board. The Board assessed additional unemployment insurance contributions, finding that specialists hired by Jordan were employees, not independent contractors, between 1989 and 1991. The court reviewed whether there was substantial evidence to support the Board's conclusion of an employer-employee relationship. Key factors included Jordan's control over recruitment, screening, compensation, billing, and contractual restrictions on specialists. Ultimately, the court affirmed the Board's decision, determining that Jordan exercised sufficient overall control to establish an employer-employee relationship and thus was liable for the contributions.

Unemployment InsuranceEmployer-Employee RelationshipIndependent ContractorRehabilitation ServicesLabor LawSubstantial EvidenceControl TestJudicial ReviewAdministrative Law JudgeDepartment of Labor
References
8
Case No. MISSING
Regular Panel Decision

Valley Rehabilitation and Medical Offices, P.C. v. Cash

Plaintiff, Valley Rehabilitation, sought $10,010.56 from defendant Lynda Cash for physical therapy, claiming breach of contract and an account stated based on an agreement where Cash would be liable if her workers' compensation claim failed. However, Cash received a $12,500 workers' compensation settlement, fulfilling the conditions of the agreement. The court found that Valley Rehabilitation failed to comply with Workers’ Compensation Board rules, including obtaining authorization for services over $500 and properly filing documentation. Consequently, the court ruled that the medical provider must collect fees from the employer/carrier, not the claimant. Furthermore, the defendant's timely objections prevented the establishment of an account stated. Therefore, the plaintiff's claim was barred, and the action was dismissed with prejudice.

Workers' CompensationMedical BillingAccount StatedBreach of ContractStatutory ComplianceMedical ProviderInjured WorkerLump-Sum SettlementAuthorization RequirementsNew York Law
References
4
Case No. 2024 NY Slip Op 00599 [224 AD3d 428]
Regular Panel Decision
Feb 06, 2024

Matter of New Millennium Pain & Spine Medicine, P.C. v. Garrison Prop. & Cas. Ins. Co.

This case involves two appeals by New Millennium Pain & Spine Medicine, P.C. against Garrison Property & Casualty Insurance Company and GEICO Casualty Company. New Millennium sought to vacate master arbitration awards that denied its claims for no-fault benefits for medical services. The Supreme Court denied these applications. The Appellate Division, First Department, affirmed the Supreme Court's decisions, stating that an arbitrator's award will not be set aside unless it is irrational. The court also addressed the argument regarding a 20% wage offset in no-fault benefits, finding it unavailing under Insurance Law § 5102 (b). Ultimately, New Millennium was not entitled to attorneys' fees as it was not the prevailing party.

No-fault benefitsarbitration awardvacaturinsurance lawwage offsetappellate reviewmedical servicesno-fault policy exhaustionattorneys' feesCPLR Article 75
References
8
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