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

Case No. CA 13-01105
Regular Panel Decision
Feb 14, 2014

KALEIDA HEALTH v. UNIVERA HEALTHCARE

This case concerns an appeal by Utica Mutual Insurance Company from a judgment that denied its motion for summary judgment and granted summary judgment to Kaleida Health and Univera Healthcare. The judgment declared Utica obligated to pay an outstanding hospital bill to Kaleida Health. Utica argued that collateral estoppel applied due to a Workers' Compensation Board determination, but the court found Kaleida Health and Univera Healthcare were not parties to that proceeding. Utica also contended the action was barred by arbitration, which was rejected as not compulsory. The Appellate Division affirmed the Supreme Court's decision, concluding Utica was responsible for the hospital bill as the patient's admission was a continuation of treatment for a work-related injury.

Workers' CompensationHospital BillCollateral EstoppelSummary JudgmentArbitrationPublic Health LawAppellate PracticeInsurance ObligationWork-Related InjuryHealth Care Provider
References
3
Case No. 2019 NY Slip Op 02599 [171 AD3d 1277]
Regular Panel Decision
Apr 04, 2019

New York State Workers' Compensation Bd. v. A&T Healthcare, Inc.

The New York State Workers' Compensation Board assumed administration of the insolvent Healthcare Providers Self-Insurance Trust, which had a deficit of $132.5 million. The Board initiated an action to recover the deficit from former employer-members, including Motherly Love Home Care Services Inc., who were jointly and severally liable. Motherly Love Home Care Services Inc. executed two settlement agreements but subsequently moved to vacate them, claiming a unilateral mistake by believing they had only signed duplicate copies of one agreement. The Supreme Court denied this motion. The Appellate Division, Third Department, affirmed the Supreme Court's decision, finding no basis for vacating the agreements given their distinct terms and the clear clarifications provided by the Board's counsel.

Workers' Compensation TrustInsolvencySettlement AgreementVacate AgreementUnilateral MistakeJoint and Several LiabilityAppellate ReviewContract PrinciplesHome Health CareEmployer Liability
References
5
Case No. 2018 NY Slip Op 07224 [165 AD3d 1558]
Regular Panel Decision
Oct 25, 2018

Healthcare Professionals Ins. Co. v. Parentis

This case involves an appeal regarding a declaratory judgment action initiated by Healthcare Professionals Insurance Company (HPI) against Michael A. Parentis and others. The dispute arises from a prior medical malpractice verdict against Parentis totaling $8.6 million, which exceeded his combined $2.3 million primary and excess insurance policies from Medical Liability Mutual Insurance Company (MLMIC) and HPI. Parentis alleged bad faith against both insurers for failing to settle the underlying action within policy limits. The Supreme Court initially granted summary judgment to HPI and MLMIC, dismissing Parentis' bad faith claim. The Appellate Division, Third Department, reversed this decision, finding that genuine issues of material fact exist concerning whether both HPI and MLMIC acted in bad faith during settlement negotiations, especially during jury deliberations.

Insurance LawBad Faith Insurance ClaimMedical MalpracticeSummary JudgmentAppellate ReviewSettlement NegotiationsExcess InsurancePrimary InsuranceJury DeliberationsDuty to Settle
References
16
Case No. 2013-1418 K C
Regular Panel Decision
Mar 11, 2016

Acupuncture Healthcare Plaza I, P.C. v. Truck Ins. Exch.

This case involves an appeal from an order of the Civil Court of the City of New York, Kings County. The Civil Court had granted the defendant's motion for summary judgment, dismissing the complaint. The plaintiff, a healthcare provider, sought to recover assigned first-party no-fault benefits. The defendant argued that it had properly reimbursed the plaintiff for acupuncture services using the workers' compensation fee schedule applicable to chiropractors. The Appellate Term affirmed the Civil Court's order, concluding that the defendant had timely mailed the denial of claim form and had fully paid the plaintiff in accordance with the workers' compensation fee schedule for acupuncture services.

No-fault benefitsAcupuncture servicesWorkers' compensation fee scheduleSummary judgmentAppellate reviewTimely mailingDenial of claimFirst-party benefitsInsuranceHealthcare provider
References
2
Case No. 2015-1243 K C
Regular Panel Decision
Feb 08, 2017

Acupuncture Healthcare Plaza I, P.C. v. Metlife Auto & Home

The case involves Acupuncture Healthcare Plaza I, P.C., as assignee of Boris Goldbaum, suing Metlife Auto & Home for first-party no-fault benefits. The defendant had paid a reduced sum, arguing the remaining amount exceeded the workers' compensation fee schedule and that one claim was subject to a policy deductible. During a nonjury trial, the parties stipulated to the plaintiff's prima facie case and timely denials. The defendant sought judicial notice of the workers' compensation fee schedule but failed to provide a witness to testify on its proper utilization or evidence for the deductible reduction. The Civil Court granted judgment to the plaintiff, which was subsequently affirmed by the Appellate Term, Second Department. The Appellate Term noted that while judicial notice of the fee schedule is permissible, the party seeking it must provide sufficient information and notice to the adverse party, and the fee schedule alone doesn't prove proper utilization of codes or reduction due to a deductible without supporting evidence.

No-fault insuranceMedical billing disputeAppellate reviewJudicial noticeBurden of proofFee schedule applicationPolicy deductibleAssigned claimsCivil procedureEvidence admissibility
References
5
Case No. MISSING
Regular Panel Decision

US Healthcare, Inc.(New York) v. O'BRIEN

This action concerns the interpretation of a right of recovery clause in a health benefits plan issued by U.S. Healthcare, Inc. of New York (USH), an ERISA-governed plan. USH sought a declaratory judgment to recover over $1 million in benefits paid for Michael O’Brien's care from a medical malpractice settlement. USH moved for summary judgment against the O’Briens and other defendants, arguing its right to recover from the settlement regardless of allocation. The defendants, including Michael O'Brien's parents and their law firm, contended that the settlement with Dr. Robbins was for pain and suffering, not medical services, and thus USH had no right of recovery under its plan's specific terms or unjust enrichment. The court denied USH's motion for summary judgment and granted the defendants' motions in part, finding that USH failed to prove the settlement included payment for medical services provided by USH, and dismissed claims for future declaratory relief as premature.

ERISAHealth Benefits PlanRight of Recovery ClauseSubrogationMedical Malpractice SettlementSummary JudgmentUnjust EnrichmentCollateral Source RuleDeclaratory JudgmentContract Interpretation
References
18
Case No. ADJ8094646
Regular
Jan 17, 2014

ALEJANDRINA BARRETO vs. OUT OF THE SHELL, SOUTHERN INSURANCE COMPANY, REPUBLIC INDEMNITY COMPANY, PHARMAFINANCE, LLC, HEALTHCARE FINANCE MANAGEMENT, LLC

This case involves lien claimants PharmaFinance and Healthcare Finance Management, and their representatives Landmark Medical Management and Brian Hall, who sought reconsideration of a decision disallowing their liens for medical treatment. The Appeals Board granted reconsideration solely to notice its intention to impose sanctions of up to $2,500 against the lien claimants and their representatives. This action is due to a pattern of allegedly filing petitions containing false statements about not receiving notices, which violates the Board's Rules of Practice and Procedure and Labor Code Section 5813. The Board found these claims not persuasive and indicative of a tactic to avoid responsibility.

Workers' Compensation Appeals BoardPetition for ReconsiderationSanctionsLien ClaimantsHearing RepresentativesIndustrial InjuryFindings and OrderCompromise and ReleaseNotice of IntentionLabor Code section 5813
References
0
Case No. 2017 NY Slip Op 01454
Regular Panel Decision
Feb 23, 2017

Sokolovic v. Throgs Neck Operating Co., Inc.

This case involves an appeal concerning hold harmless and indemnity agreements. The Supreme Court, Bronx County, initially granted Vision Healthcare Services' motion to enforce a hold harmless agreement and Throgs Neck Operating Company, Inc.'s motion for summary judgment on its contractual indemnity claim against Vision. The Appellate Division, First Department, affirmed these orders. The court held that the plaintiff was obligated to hold Vision harmless from Throgs Neck's indemnification claim due to a hold harmless agreement executed during settlement. It further clarified that a nurse provided by Vision to Throgs Neck remained Vision's general employee, thereby triggering Vision's contractual indemnity obligation, despite being considered a special employee of Throgs Neck for the purpose of Throgs Neck's liability to the plaintiff.

hold harmless agreementcontractual indemnityspecial employeegeneral employeestaffing agreementsettlement agreementsummary judgmentnegligenceagency liabilityappellate review
References
3
Case No. MISSING
Regular Panel Decision

Health v. Univera Healthcare

Defendant Utica Mutual Insurance Company appealed a judgment denying its motion for summary judgment and granting motions by the plaintiff and defendant Univera Healthcare, which declared Utica obligated to pay an outstanding hospital bill. The appellate court affirmed the judgment, rejecting Utica's arguments that collateral estoppel barred the claims and that the dispute required arbitration. The court found that neither the plaintiff nor Univera Healthcare were parties to the Workers' Compensation Board determination, thus collateral estoppel did not apply. Furthermore, arbitration was not compulsory as the value of medical services was not in dispute. The court concluded that Utica was responsible for the hospital bill because the patient's admission was a continuation of treatment for a work-related injury, pursuant to Public Health Law § 2807-c (1) (b-2).

Collateral EstoppelSummary JudgmentWorkers' CompensationHospital BillInsurance ObligationArbitrationPublic Health LawAppellate ReviewErie CountyMedical Services
References
3
Case No. MISSING
Regular Panel Decision

DelRossi v. V

This case addresses an application by Bernadette DelRossi, as administratrix of her deceased husband John E. DelRossi's estate, for court approval of a wrongful death settlement and a declaration regarding a lien asserted by Aetna/U.S. Healthcare. John E. DelRossi died due to alleged medical malpractice, leading to a wrongful death action that settled for $825,000. Aetna/U.S. Healthcare (Aetna/Rawlings), an ERISA plan administrator, sought reimbursement for medical benefits paid to the decedent from these proceeds. The court ruled that Aetna/Rawlings' lien was invalid against the wrongful death settlement, as such proceeds do not form part of the decedent's estate and the administratrix, in this capacity, is not considered a plan member. The court granted all aspects of the plaintiff's application, including approving the settlement, counsel fees, the proposed distribution plan to the six distributees, and dispensing with the requirement for the administratrix to post a bond.

Wrongful DeathMedical MalpracticeERISA PreemptionSettlement DistributionLien InvalidityEstate AdministrationPecuniary LossInfant DistributeesJudicial DiscretionStatutory Interpretation
References
31
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