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

Case No. 2018 NY Slip Op 07432 [166 AD3d 621]
Regular Panel Decision
Nov 07, 2018

Matter of Progressive Advanced Ins. Co. v. New York City Tr. Auth.

This case involves an appeal by Progressive Advanced Insurance Company (Progressive) against the New York City Transit Authority (NYCTA) concerning an arbitration award. The dispute arose under Insurance Law § 5105 regarding a loss transfer claim, where NYCTA sought reimbursement from Progressive for workers' compensation benefits paid to its employee after a collision involving Progressive's insured. The central issue was whether a 20% no-fault offset applied to the workers' compensation wages, with the arbitrator ruling it did not, as a one-third offset had already been applied. Progressive's petition to vacate the award was denied by the Supreme Court, Queens County. The Appellate Division affirmed this denial, concluding that the arbitrator's determination was supported by a reasonable hypothesis and was not arbitrary or capricious.

Arbitration AwardLoss TransferInsurance LawWorkers' Compensation BenefitsNo-Fault OffsetAppellate ReviewStatutory InterpretationEvidentiary SupportArbitrary and CapriciousReasonable Hypothesis
References
9
Case No. MISSING
Regular Panel Decision

Progressive Casualty Insurance v. New York State Insurance Fund

Zimone Brown, a sanitation worker insured by the New York State Insurance Fund (NYSIF), was injured after being struck by an automobile insured by Progressive Casualty Insurance Company (Progressive). The NYSIF sought reimbursement of workers’ compensation benefits from Progressive through arbitration, citing Insurance Law § 5105. Progressive contended that the garbage truck was not 'involved' in the accident as statutorily required. Although the arbitration panel sided with NYSIF, the Supreme Court denied Progressive's petition to vacate the award. This appellate court reversed the Supreme Court's decision, finding no evidentiary support or rational basis for the arbitrators' determination, thus granting Progressive's petition and vacating the arbitration award.

Arbitration Award VacaturInsurance LawWorkers' Compensation BenefitsLoss Transfer ProvisionsStatutory InterpretationMotor Vehicle AccidentEvidentiary SupportArbitrary and CapriciousJudicial ScrutinyCPLR Article 75
References
15
Case No. MISSING
Regular Panel Decision

Progressive Transportation Services, Inc. v. County of Essex

Progressive Transportation Services, Inc. sued Essex County, James Pierce, and Clifford Donaldson, asserting a 42 U.S.C. § 1983 civil rights claim for First Amendment retaliation and a state law claim for breach of contract. Progressive claimed the County retaliated against it by rejecting bids and withholding funds after Progressive combined transportation routes for efficiency, arguing this was a matter of public concern regarding taxpayer money and fuel usage. The Court determined that Progressive's speech, made in the context of contract negotiations to secure payment, was primarily an issue of economic self-interest and not a matter of public concern protected by the First Amendment. Consequently, the Court granted the defendants' motion for summary judgment, dismissing the federal claim with prejudice. The state law breach of contract claim was dismissed without prejudice, as the court declined to exercise supplemental jurisdiction after the dismissal of the federal claim.

42 U.S.C. Section 1983Civil RightsBreach of ContractFirst Amendment RetaliationSummary JudgmentGovernment ContractsFreedom of SpeechPublic Concern DoctrineSupplemental JurisdictionGovernmental Waste
References
16
Case No. MISSING
Regular Panel Decision

Progressive Northern Insurance Co. v. Sentry Insurance A Mutual Co.

Progressive Northern Insurance Company initiated an arbitration against Sentry Insurance A Mutual Company to recover first-party benefits paid to its insured following an automobile accident. After an initial arbitration claim (priority-of-payment) was denied, Progressive commenced a second arbitration based on a loss-transfer claim for the same reimbursement. Sentry raised the affirmative defense of res judicata, which the arbitrator upheld, denying Progressive's claim. Progressive then petitioned the Supreme Court, Nassau County, to vacate this arbitration award, but the petition was denied. The appellate court affirmed the Supreme Court's order, ruling that the arbitrator properly exercised its authority in applying res judicata, as both claims arose from the same transaction despite different legal theories.

Res JudicataArbitration Award VacaturInsurance ReimbursementAutomobile Accident ClaimLoss Transfer ClaimPriority-of-Payment ClaimAppellate ReviewSupreme Court NassauCPLR Article 75Arbitration Forum
References
24
Case No. MISSING
Regular Panel Decision

Garden State Anesthesia Associates, PA v. Progressive Casualty Insurance

Garden State Anesthesia Associates (GSAA) sued Progressive Casualty Insurance Company for unpaid first-party no-fault benefits after providing services to Angela Gowan-Walker. Progressive delayed payment, citing the need for Gowan-Walker's examination under oath (EUO) and extensive medical and workers' compensation records. Although Gowan-Walker completed her EUO, Progressive continued to issue delay letters, requesting information primarily from third parties and Gowan-Walker's attorney, without directly contacting GSAA for verification. The court denied Progressive's motion for summary judgment, ruling that an insurer cannot indefinitely toll the 30-day payment period by requesting verification unrelated to the specific provider's claim or by failing to request verification directly from the provider.

No-fault benefitsSummary JudgmentInsurance LawVerification RequestDelay LetterEUOMedical RecordsInsurance ClaimsTimelinessTolling
References
9
Case No. 531582
Regular Panel Decision
May 13, 2021

Matter of Matteliano v. Trinity Health Corp.

Caitlyn Matteliano, a nurse assistant, suffered work-related back, knee, and leg injuries in 2015 and 2018. Her treating orthopedic surgeon, Franco Vigna, requested authorization for multi-level lumbar fusion surgery and an external bone growth stimulator due to persistent pain and degenerative disc disease, despite conservative treatments. The employer denied this request based on an independent medical examination by Anthony Leone, who deemed the surgery aggressive and inappropriate given the lack of instability. A Workers' Compensation Law Judge initially denied the request, but the Workers' Compensation Board approved it. The employer appealed, and the Appellate Division, Third Department, affirmed the Board's decision, finding substantial evidence in Vigna's testimony to support the surgery's authorization under medical treatment guidelines for degenerative disc disease where non-surgical management has failed.

Workers' CompensationLumbar Fusion SurgeryMedical Treatment GuidelinesDegenerative Disc DiseaseDiscogenic Back PainIndependent Medical ExaminationPrior AuthorizationAppellate ReviewNurse AssistantWork Injury
References
9
Case No. MISSING
Regular Panel Decision

DE MATTIES v. Astrue

Plaintiff Michael DeMatties initiated this action under 42 U.S.C. § 405(g) to appeal the Commissioner of Social Security's denial of his disability benefits claim. DeMatties alleged disability since 2001 due to severe left arm and hand impairments stemming from cervical degenerative disc disease and polyradiculopathy. After an Administrative Law Judge (ALJ) denied benefits, the case progressed to the District Court. Judge David G. Larimer found that the ALJ erred by not affording controlling weight to the treating neurosurgeon's opinion and by incorrectly determining the plaintiff's residual functional capacity. The court concluded the Commissioner's decision lacked substantial evidence, reversed the finding, and remanded the case for the calculation and payment of benefits.

Social Security DisabilityMedical ImpairmentResidual Functional CapacityTreating Physician RuleSubstantial Evidence ReviewCervical Degenerative Disc DiseasePolyradiculopathyVocational ExpertRemand for BenefitsSummary Judgment
References
18
Case No. MISSING
Regular Panel Decision

Singletary v. Apfel

Plaintiff Sylvester M. Singletary appealed the Commissioner of Social Security's denial of disability insurance benefits, leading to this action under 42 U.S.C. § 405(g). The Court reviewed the final determination, including an Administrative Law Judge's decision, which the Appeals Council upheld. The central issue revolved around the ALJ's rejection of Singletary's treating physician's opinion of total disability, which the ALJ deemed unsupported by objective evidence, specifically the absence of disc herniation. The Court found that the ALJ arbitrarily substituted his lay opinion for competent medical evidence and ignored other objective findings like degenerative disc disease and disc bulging. Consequently, the Commissioner’s decision was not supported by substantial evidence, and the case was remanded solely for the calculation of benefits, with the plaintiff's motion for judgment on the pleadings granted.

Disability BenefitsSocial Security ActTreating Physician RuleSubstantial Evidence ReviewDegenerative Disc DiseaseChronic PainSpinal ImpairmentALJ ErrorRemandFederal Court Review
References
13
Case No. 3212, 3697, 3004
Regular Panel Decision

Progressive Casualty Insurance v. Yodice

This case involves consolidated motions stemming from a personal injury accident on March 30, 1997, involving a 'Whip ride' operated at a private party, attached to a truck owned by Dominick Yodice d/b/a Mickey's Rides N More. Injured individuals sued Mickey's. Progressive Casualty Insurance Company, the insurer of Mickey's truck, sought a declaratory judgment that it had no duty to defend or indemnify Mickey's. The court granted Progressive's motion, finding that the accident did not arise from the 'use or operation of the truck as a truck' for transportation, despite an unenforeable exclusion. Mickey's Rides N More also sought a declaratory judgment that Scottsdale Insurance Company was obligated to insure and defend it under a commercial general liability policy. The court denied Mickey's motion and granted Scottsdale's cross-motion, ruling that a 'Certificate of Insurance' was not binding and the declarations page covered a different ride, with coverage for the Whip ride not afforded until after the accident.

Insurance Coverage DisputePolicy ExclusionCommercial Auto PolicyCommercial General Liability PolicyDeclaratory JudgmentSummary JudgmentMobile Amusement RideVehicle Use and OperationProximate CauseInsurance Broker
References
12
Case No. MISSING
Regular Panel Decision

Rice v. Commissioner of Social Security

Plaintiff Tammy Rice sought judicial review of the Commissioner of Social Security's final decision denying her application for disability benefits. The District Court considered the Commissioner's motion for judgment on the pleadings. The Administrative Law Judge (ALJ) found that Plaintiff had severe impairments of mild degenerative disc disease of the lumbar spine and mild degenerative joint disease of the knees but did not meet or equal a listed impairment. The ALJ determined Plaintiff could perform light work with restrictions, concluding she was not disabled. The Court found the Commissioner's decision supported by substantial evidence and in accordance with applicable legal standards. Consequently, the Commissioner's motion for judgment on the pleadings was granted, and Plaintiff's complaint was dismissed with prejudice.

Social SecurityDisability BenefitsALJ DecisionSubstantial EvidenceMedical EvidenceResidual Functional CapacityTreating Physician RuleFederal Rules of Civil ProcedureRule 12(c)Lumbar Spine
References
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