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Case Law Database

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

Case No. MISSING
Regular Panel Decision
May 29, 2009

Kilmetis v. Creative Pool & Spa, Inc.

The plaintiff, an employee of Complete Construction Alternatives, Inc., sustained personal injuries on October 3, 2006, after falling from a scaffold while finishing siding on a garage roof. He initiated a personal injury action against Creative Pool and Spa, Inc., alleging a violation of Labor Law § 240 (1) and asserting Creative Pool was the general contractor. The Supreme Court of Nassau County denied the plaintiff's motion for summary judgment and granted the defendant's cross-motion, dismissing the complaint. On appeal, the order was affirmed, with the court finding that Creative Pool was neither a general contractor nor an agent for liability under Labor Law § 240 (1) concerning the plaintiff's work. This decision was based on evidence that Creative Pool did not supervise or control the plaintiff's work, provided no equipment, and was not present at the site on the accident date.

Personal InjuryScaffold AccidentConstruction Site SafetyLabor Law § 240(1)Summary JudgmentGeneral Contractor LiabilityAgent LiabilityAppellate ReviewNew York LawWorkplace Accident
References
12
Case No. 2014-1124 K C
Regular Panel Decision
Jul 21, 2017

Natural Therapy Acupuncture, P.C. v. Nationwide Ins.

The Appellate Term, Second Department, affirmed an order of the Civil Court of the City of New York, Kings County, which had granted summary judgment to Nationwide Ins. The case involved Natural Therapy Acupuncture, P.C.'s action to recover assigned first-party no-fault benefits. Nationwide Ins. successfully argued that it properly reimbursed the plaintiff for acupuncture services using the workers' compensation fee schedule applicable to chiropractors providing similar services. The appellate court found sufficient proof of timely mailing of claim denials and full payment according to the fee schedule. A new contention raised by the plaintiff for the first time on appeal was not considered by the court.

no-fault insuranceacupuncture servicesworkers' compensation fee schedulesummary judgmentappellate reviewclaim denialtimely mailingreimbursementmedical servicesfirst-party benefits
References
4
Case No. 2017-635 K C
Regular Panel Decision
Aug 02, 2019

Natural Therapy Acupuncture, P.C. v. GEICO Ins. Co.

In this case, Natural Therapy Acupuncture, P.C., acting as assignee, sought to recover no-fault benefits from GEICO Ins. Co. The Civil Court initially denied GEICO's cross-motion for summary judgment to dismiss claims concerning unpaid benefits. On appeal, the Appellate Term, Second Department, reversed the lower court's decision. The Appellate Term found that GEICO had timely denied the claims and correctly applied the workers' compensation fee schedule for the services in question. Consequently, GEICO's cross-motion for summary judgment was granted, dismissing the plaintiff's claims.

No-Fault BenefitsSummary JudgmentWorkers' Compensation Fee ScheduleAppellate ReviewInsurance ClaimsTimely DenialAssigned ClaimsMedical Provider ReimbursementCivil CourtAppellate Term Decision
References
2
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. 2017-407 K C
Regular Panel Decision
Jul 12, 2019

Apple Massage Therapy, P.C. v. 21st Century Ins. Co.

This case concerns an appeal by Apple Massage Therapy, P.C., as an assignee, against 21st Century Ins. Co. The plaintiff sought to recover assigned first-party no-fault benefits. The appeal challenged an order from the Civil Court of the City of New York, Kings County, which had granted the defendant's motion for summary judgment, thereby dismissing the complaint. The appellate court found that the defendant adequately demonstrated the proper mailing of denial of claim forms and the correct application of the workers' compensation fee schedule for determining benefits. Consequently, the appellate court affirmed the Civil Court's order.

No-Fault BenefitsSummary JudgmentAppellate ReviewDenial of ClaimWorkers' Compensation Fee ScheduleInsurance LawCivil ProcedureAssignee ClaimMailing PresumptionMedical Provider
References
1
Case No. 2014-769 Q C
Regular Panel Decision
Mar 18, 2016

Natural Therapy Acupuncture, P.C. v. American Tr. Ins. Co.

The plaintiff, Natural Therapy Acupuncture, P.C., acting as an assignee of Christopher Icheke, initiated an action to recover assigned first-party no-fault benefits from American Transit Ins. Co. The plaintiff moved for summary judgment, while the defendant cross-moved for summary judgment, asserting that all claims had been timely and properly paid in accordance with the workers' compensation fee schedule. The Civil Court denied the plaintiff's motion and granted the defendant's cross-motion, dismissing the complaint. On appeal, the Appellate Term affirmed the Civil Court's order, concluding that the defendant had successfully demonstrated full payment under the workers' compensation fee schedule, and the plaintiff failed to raise a triable issue of fact.

No-fault benefitsSummary judgmentWorkers' compensation fee scheduleAppellate reviewInsurance claimsAssignee rightsCivil Court decisionTimely paymentMedical servicesAcupuncture services
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. 2015-1078 K C
Regular Panel Decision
Jan 20, 2017

Bronx Acupuncture Therapy, P.C. v. Hereford Ins. Co.

This case involves Bronx Acupuncture Therapy, P.C., as assignee of Niurka Mejia, appealing an order from the Civil Court of the City of New York, Kings County. The defendant, Hereford Ins. Co., had moved for summary judgment, arguing full payment according to workers' compensation fee schedules. The Civil Court granted the motion, dismissing claims for services billed under codes 97039 (unlisted modality) and 99199 (unlisted special service). The Appellate Term reversed this decision, finding that the defendant failed to request additional verification within 15 business days for these "By Report" designated codes, as required by 11 NYCRR 65-3.5 (b). Therefore, the defendant was not entitled to summary judgment.

No-Fault BenefitsSummary JudgmentAppellate TermWorkers' Compensation Fee ScheduleUnlisted Medical CodesVerification of ClaimsMoxibustionAcupressureInsurance DisputeHealthcare Provider Reimbursement
References
2
Case No. MISSING
Regular Panel Decision

Best Quality Swimming Pool Service, Inc. v. Pross

This case concerns a breach of contract action for swimming pool construction. The defendant sought to dismiss the plaintiffs' complaint, arguing that one of the plaintiff corporations, Swim World Pool and Spa, Inc., lacked the required Nassau County home improvement license. Plaintiffs, Best Quality Swimming Pool Service, Inc. and Swim World Pool and Spa, Inc., both owned by Jairo Arango, operated together, with Best Quality holding the necessary license. The court denied the defendant's motion to dismiss, finding that denying payment would be an excessive penalty given that Best Quality was licensed, aligning with the rationale of Marraccini v Ryan. Additionally, the court granted the plaintiffs' cross-motion to amend their complaint to include the licensing details for Best Quality Swimming Pool Service, Inc.

Home Improvement LicenseCorporate LiabilityBreach of ContractMotion to DismissAmended ComplaintNassau County Administrative CodeCPLR 3015(e)Licensing RequirementsCorporate VeilSubstantial Compliance
References
8
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