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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. 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

Lawliss v. Quellman

Plaintiff sustained a right shoulder injury at work, leading his orthopedic specialist to recommend immediate surgery for a ruptured biceps. However, his employer's workers' compensation carrier disputed the need for surgery and mandated an independent medical examination (IME) by the defendant, an orthopedic specialist. The defendant reported to the carrier that surgery was unnecessary, advocating physical therapy instead. This advice resulted in the carrier denying surgery, and the plaintiff's subsequent physical therapy proved ineffective, as did delayed surgery, allegedly causing an 80% loss of shoulder use. Consequently, plaintiff initiated a medical malpractice action against the defendant, asserting that the negligent advice given during the IME caused the detrimental delay in his treatment. The Supreme Court denied the defendant's motion for summary judgment, a decision which the appellate court affirmed, citing the presence of factual questions regarding an implied physician-patient relationship, negligence, and foreseeable reliance.

medical malpracticeindependent medical examinationphysician-patient relationshipsummary judgmentworkers' compensationappellate decisionorthopedic injurynegligent advicedelayed surgeryloss of use
References
10
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
Case No. MISSING
Regular Panel Decision

Claim of Capon v. Grumman Corp.

William Capon sustained compensable injuries to his left leg in 1970 and 1983. In the latter incident, he fractured his femur, requiring surgery. Following his hospital discharge, Capon began physical therapy with Louis Cress. On April 8, 1983, after a reportedly strenuous therapy session, Capon suffered a fatal heart attack approximately one hour after returning home. His wife, the claimant, applied for workers' compensation benefits. The Workers’ Compensation Board sustained the claim, based on Dr. Irwin Friedman's testimony that the heart attack was causally related to the stress of the physical therapy. The employer appealed, contending that Friedman's testimony lacked substantial evidence. The court found adequate evidentiary support in the physical therapist's report and the claimant's testimony regarding Capon's condition, affirming the Board's decision.

Workers' Compensation BenefitsCausal ConnectionFatal Heart AttackStress-Induced InjuryPhysical Therapy ComplicationsMedical Expert TestimonyAppellate Court ReviewSubstantial Evidence RuleEmployer AppealDecedent's Claim
References
2
Case No. MISSING
Regular Panel Decision

Hansen v. Post

The petitioner, a child protective worker, sought custody of Christopher Post, whose parents, Rose and William Post, had a documented history of child abuse and neglect, leading to the removal of seven other children from their care. Christopher had also been involved in two prior neglect proceedings. The parents exhibited severe deficiencies in parenting skills, an inability to address Christopher's emotional disturbances, and a history of rejecting assistance. After voluntarily placing Christopher with the petitioner, who became his psychological parent, they abruptly cut off contact. The Family Court found extraordinary circumstances, justified judicial intervention, and granted custody to the petitioner, a decision which the appellate court subsequently affirmed.

Custody DisputeParental UnfitnessChild NeglectExtraordinary CircumstancesFamily Court Act Article 6Child Protective ServicesAppealParental RightsPsychological ParentEmotional Disturbance
References
5
Case No. MISSING
Regular Panel Decision

Claim of D'Avilar v. New York University School of Medicine

In August 2005, a claimant sustained a work-related right knee injury requiring surgery and physical therapy. While finishing therapy at the Hospital for Special Surgery on July 28, 2006, she slipped in the cafeteria injuring her left knee and back during a personal errand to buy coffee. A Workers’ Compensation Law Judge initially found these subsequent injuries consequential. However, the Workers’ Compensation Board reversed, ruling the injuries non-compensable due to occurring during a personal pursuit. The Appellate Division affirmed the Board's decision, concluding that the causal connection between the claimant's employment and her off-duty injuries was severed once she engaged in a personal errand.

Workers' CompensationAppellate DivisionConsequential InjuriesPersonal ErrandCausal ConnectionSlip and FallPhysical TherapyBoard DecisionAffirmedScope of Employment
References
5
Case No. MISSING
Regular Panel Decision
Apr 12, 1996

Van Guilder v. Sands Hecht Construction Corp.

This case involves an appeal from a judgment in an action under Labor Law § 240 (1). The judgment, entered April 12, 1996, awarded damages for past pain and suffering and past lost earnings, but zero for future damages. The court unanimously affirmed the judgment. The central issue was whether the trial court correctly instructed the jury on mitigation of damages, specifically regarding the plaintiff's refusal to undergo a myelogram, a test repeatedly recommended by his treating orthopedist for diagnosis and potential surgery. The appellate court found ample evidence to justify the mitigation charge, citing the physician's recommendation and the plaintiff's failure to attend physical therapy or seek employment. The court also affirmed the damage award, finding it reasonable given conflicting medical testimony about a herniated disc and inconsistencies in the plaintiff's testimony about his post-accident lifestyle and efforts to find work.

Labor Law § 240 (1)DamagesMitigation of DamagesMyelogramMedical DiagnosisRefusal of TreatmentPain and SufferingLost EarningsHerniated DiscWorkers' Compensation Board
References
1
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