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Case Law Database

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. MISSING
Regular Panel Decision
Nov 05, 2014

Shoshanah B. v. Lela G.

This case involves an appeal from a Family Court order concerning child therapy and visitation. The original order, entered on November 5, 2014, permitted the respondent (custodial parent) to enroll the parties' child in therapy and temporarily suspended the petitioner's Wednesday overnight visits. The Appellate Division modified the order, affirming the respondent's right to enroll the child in therapy but vacating the suspension of the petitioner's Wednesday overnight visits. The court found that while the respondent acted appropriately in seeking therapy for the child due to emotional distress, the Family Court erred in modifying the visitation schedule without a proper hearing, as there was no showing of an immediate emergency. The ruling underscores the requirement for a hearing when modifying custody or visitation orders, even on a temporary basis.

Family LawChild CustodyVisitation RightsChild TherapyParental RightsCustody Agreement ModificationJudicial Hearing OfficerAppellate ReviewDue ProcessEmergency Order
References
8
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. ADJ8266885
Regular
Jan 20, 2016

DAYSI PATRICIA MOLINA ROMERO vs. CALIFORNIA PIZZA KITCHEN, TRAVELERS DIAMOND BAR

This case involves a lien claim by Mario Arroyo, D.C., for chiropractic and physical therapy services provided to an injured worker. The Workers' Compensation Appeals Board (WCAB) granted reconsideration and rescinded the original findings. The WCAB held that "visits" must be distinguished by the type of treatment rendered, allowing for separate reimbursement caps for chiropractic and physical therapy visits. Further development of the record is required to determine the nature of services provided and whether Arroyo is entitled to reimbursement for physical therapy beyond the 24 chiropractic visits already paid.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and OrderLien ClaimantChiropractic VisitsPhysical TherapyLabor Code Section 4604.5(c)(1)Bill ReviewerCumulative TraumaIndustrial Injury
References
2
Case No. MISSING
Regular Panel Decision

Raychelle J. v. Kendell K.

This case involves an appeal from a Family Court order in Broome County, which modified a prior custody and visitation arrangement between unmarried parents. The mother initiated proceedings after the father physically assaulted one of their sons and the mother during a dispute. The Family Court determined the father committed a family offense, issued an order of protection, granted the mother sole custody, and ordered supervised visitation for the father. The father appealed, challenging only the supervised visitation restriction. The appellate court affirmed the Family Court's decision, citing the father's history of temper outbursts, inappropriate use of corporal punishment, and his refusal to participate in therapy, concluding that supervised visitation was in the children's best interests.

Custody modificationSupervised visitationFamily offense findingCorporal punishmentChild safetyParental conductBest interests of childrenAppellate reviewFamily Court discretionDomestic violence
References
7
Case No. ADJ4647589
Regular
Dec 10, 2019

ORIS PAYTON vs. CAL EXPO FAIRGROUNDS, CALIFORNIA FAIR SERVICES AUTHORITY

The Workers' Compensation Appeals Board (WCAB) denied the applicant's petition for reconsideration. The applicant sought further physical therapy beyond the statutory limit of 24 visits. The WCAB adopted the Workers' Compensation Administrative Law Judge's report, which concluded that the WCAB lacks the authority to challenge the constitutionality of a statute, including Labor Code section 4604.5, which limits physical therapy visits. Therefore, the applicant's request for treatment exceeding the statutory allowance was denied.

Workers' Compensation Appeals BoardPetition for ReconsiderationAdministrative Law JudgeFindings and AwardIndustrial InjuryCumulative Work ActivitiesMedical TreatmentPhysical TherapyStipulationsAgreed Medical Examiner
References
3
Case No. MISSING
Regular Panel Decision
Jul 27, 2009

Ciccone v. Ciccone

In a visitation proceeding, the father appealed an order from the Family Court, Kings County, which granted the mother’s petition for supervised visitation with their daughter. The Family Court's decision was affirmed on appeal. The court found that despite the mother's history of mental health problems and a past admission of physically abusing an adult son, her condition had significantly improved through voluntary mental health treatment and she showed remorse. The decision to award monthly supervised visits was supported by a court-appointed forensic psychologist, a social worker who supervised visits, and the attorney for the child. The Family Court also considered a finding of a family offense against the mother but determined it did not establish that supervised visitation would be detrimental to the child's welfare, especially since experts reported the mother acted appropriately with the child during visits.

Visitation rightsFamily lawChild custodyParental rightsSupervised visitationMental healthParental fitnessBest interest of the childAppellate reviewEvidentiary basis
References
9
Case No. ADJ10265190
Regular
Jun 12, 2017

HANAN MEGALLA vs. COUNTY OF SAN BERNARDINO

This case involves a worker who sustained severe injuries from gunshot wounds and sought additional physical therapy. The defendant employer argued that the request was untimely and beyond the post-surgical treatment period, and that the applicant failed to establish medical necessity. The Workers' Compensation Appeals Board denied the employer's petition for reconsideration, upholding the finding that the employer failed to timely and effectively serve the Utilization Review denial. The Board found the additional physical therapy was reasonable and necessary, and that the request fell within the permissible 24-visit limitation after the post-surgical period concluded.

Workers' Compensation Appeals BoardUtilization ReviewService of DeterminationReconsiderationMedical TreatmentFindings and AwardWCJApplicantDefendantSan Bernardino County
References
3
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