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

Case No. 2016-334 S C
Regular Panel Decision
Apr 27, 2017

2 & 9 Acupuncture, P.C. v. 21st Century Advantage Ins. Co.

This case concerns an appeal by 2 & 9 Acupuncture, P.C. from an amended order that granted summary judgment to 21st Century Advantage Insurance Company, dismissing a complaint to recover assigned first-party no-fault benefits. The defendant argued it had paid the plaintiff in accordance with the workers' compensation fee schedule. The Appellate Term, Second Department, reversed the lower court's decision, finding that the defendant failed to prima facie demonstrate proper denial of payment for services billed under CPT codes 97026 and 97016. Consequently, the defendant's motion for summary judgment regarding these specific CPT codes was denied.

No-Fault BenefitsSummary JudgmentCPT CodesWorkers' CompensationAppellate ReviewInsurance LawMedical BillingAcupunctureSuffolk CountyPayment Dispute
References
3
Case No. MISSING
Regular Panel Decision
Jul 10, 2013

Christopher C. v. Bonnie C.

This divorce action between Christopher C. and Bonnie C. addresses equitable distribution, spousal maintenance, and counsel fees. The defendant, Bonnie C., who has a court-appointed guardian due to mental and emotional difficulties, had separated from the plaintiff in 2003 and informally divided marital assets. The court ratified this prior asset division, noting the defendant had dissipated her share. Finding the defendant unable to work and self-support, and the plaintiff capable of employment despite his claims of disability, the court awarded the defendant non-durational permanent maintenance of $2,500 per month and substantial attorney's fees. The plaintiff's motion to suspend or refund temporary maintenance was denied.

DivorceSpousal MaintenanceEquitable DistributionGuardianshipMental Health IssuesAsset DissipationAttorney's FeesFinancial CapacityPermanent MaintenanceMarital Property
References
12
Case No. ADJ8897698
Regular
Feb 19, 2015

MICHAEL GIBSON vs. ORANGE COUNTY TRANSIT AUTHORITY

In this workers' compensation case, the Appeals Board granted reconsideration and reversed the initial denial of the applicant's appeal concerning tinnitus masking treatment. The Board found that the Administrative Director's (AD) Independent Medical Review (IMR) determination was invalid because the reviewer failed to follow the statutorily mandated hierarchy of standards for assessing medical necessity. Specifically, the IMR reviewer improperly relied on Medicare guidelines without first considering peer-reviewed scientific and medical evidence, as required by Labor Code section 4610.5(c)(2). Consequently, the case was remanded to the AD for a new IMR by a different reviewer.

Independent Medical ReviewLabor Code section 4610.6(h)Tinnitus masking treatmentMedical necessityPlainly erroneous finding of factOrdinary knowledgeExpert opinionAdministrative DirectorUtilization ReviewSection 4610.5(c)(2) hierarchy
References
0
Case No. 2014-1942 K C
Regular Panel Decision
Sep 22, 2017

AL Acupuncture, P.C. v. Geico Ins. Co.

This case, AL Acupuncture, P.C. v Geico Ins. Co., concerns an appeal from a Civil Court order regarding assigned first-party no-fault benefits. The plaintiff, AL Acupuncture, P.C., sought summary judgment for services rendered, while defendant Geico Insurance Company cross-moved for dismissal. The Appellate Term modified the lower court's order. It denied the plaintiff's motion for summary judgment on claims from September 8 to September 25, 2008, citing the plaintiff's failure to prove the claim was not timely denied and issues with IME scheduling evidence. Conversely, the court granted the defendant's cross-motion, dismissing claims for services from July 8 to September 5, 2008, as Geico demonstrated timely denial and payment under the workers' compensation fee schedule. The order was affirmed as modified.

No-fault benefitsSummary judgmentIndependent medical examinationsTimely denialWorkers' compensation fee scheduleAcupuncture servicesAppellate TermProvider actionAssigned claimsCivil Court order
References
5
Case No. MISSING
Regular Panel Decision

Giordano v. Forest City Ratner Companies

Brian Giordano, a carpenter, was injured at a construction site when a sheet of plywood struck him. He sued F.C. Foley Square Associates, LLC, and FCR Construction Services, LLC, alleging violations of Labor Law § 241 (6) based on Industrial Code sections 12 NYCRR 23-2.2 (a) and 23-2.4. The Supreme Court initially granted the defendants' motion for summary judgment, dismissing claims based on both sections. On appeal, the court affirmed the dismissal regarding 12 NYCRR 23-2.4, finding it inapplicable to poured concrete construction. However, the court reversed the dismissal concerning 12 NYCRR 23-2.2 (a), stating that the defendants failed to establish prima facie entitlement to summary judgment because the Court of Appeals had previously reversed a similar precedent regarding the applicability of this section to incomplete forms.

Personal InjuryConstruction AccidentLabor LawSummary JudgmentIndustrial CodePlywood InjuryConcrete WorkFlooring RequirementsAppellate DecisionPrima Facie Entitlement
References
6
Case No. MISSING
Regular Panel Decision

Coyne Electrical Contractors, Inc. v. United States (In Re Coyne Electrical Contractors, Inc.)

This case addresses whether a New York Lien Law "trust fund" beneficiary’s claim to priority payment under Lien Law Section 71(2)(d) is preempted by ERISA. The applicant, The Joint Industry Board of the Electrical Industry and its Participating Funds (JIB), sought priority payment from funds held by the debtor, asserting a claim for unpaid benefits. The defendant, A-J Contracting, Inc. (A-J), challenged this, arguing ERISA preemption, specifically that the Lien Law provided an "alternative enforcement mechanism" forbidden by ERISA. The court reviewed federal preemption doctrine and ERISA's objectives, ultimately concluding that Section 71(2)(d) does not create such a mechanism as it confirms existing employer liability rather than shifting it. Therefore, the court found that ERISA does not preempt JIB's assertion of priority rights under Lien Law Section 71(2)(d).

ERISA preemptionLien Law trust fundpriority disputeunpaid employee benefitsbankruptcy estatedebtor liabilityconstruction subcontractsfederal supremacystatutory interpretationcollective bargaining agreement
References
29
Case No. 2016-910 K C
Regular Panel Decision
Jan 12, 2018

Precious Acupuncture Care, P.C. v. Hereford Ins. Co.

This case concerns an action by Precious Acupuncture Care, P.C., as assignee of James Hough, against Hereford Insurance Company to recover assigned first-party no-fault benefits. Plaintiff sought the unpaid balance of five claims for services rendered between December 2013 and April 2014. Defendant cross-moved for summary judgment, asserting that the amounts claimed exceeded the workers' compensation fee schedule. The Civil Court initially granted plaintiff's motion, ruling that defendant was precluded from the defense due to untimely denial. However, the Appellate Term reversed this decision, clarifying that under 11 NYCRR 65-3.8 (g) (1) (ii); (2), for services rendered after April 1, 2013, payment is not due for fees exceeding permissible charges, irrespective of timely denial. Consequently, the Appellate Term vacated the prior order, denied plaintiff's motion, and granted defendant's cross-motion for summary judgment dismissing the complaint.

No-Fault BenefitsSummary JudgmentFee Schedule DefenseAppellate ReviewTimely DenialWorkers' Compensation Fee ScheduleMedical BillingInsurance LawCivil CourtAppellate Term
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. 2014-2225 K C
Regular Panel Decision
Oct 27, 2017

Acupuncture Approach, P.C. v. NY Cent. Mut. Fire Ins. Co.

This case concerns an appeal from an order of the Civil Court of the City of New York, Kings County, relating to assigned first-party no-fault benefits. Acupuncture Approach, P.C., as assignee, sought to recover sums from NY Central Mutual Fire Ins. Co. The defendant moved for summary judgment, arguing timely payment according to the workers' compensation fee schedule for some claims, and lack of medical necessity for others. The plaintiff cross-moved for summary judgment. The Appellate Term modified the Civil Court's order, denying the defendant's motion for summary judgment on claims totaling $3,495, $2,695, and $1,965, due to the defendant's failure to demonstrate timely denial. The Appellate Term affirmed the reduction of the amount in controversy for other claims and the denial of the plaintiff's cross-motion.

No-Fault BenefitsSummary JudgmentAppellate ReviewInsurance ClaimsWorkers' Compensation Fee ScheduleMedical NecessityTimely DenialCivil Court OrderAssignee ClaimsPreclusion
References
4
Case No. 2013-2706 Q C
Regular Panel Decision
Sep 19, 2016

NYS Acupuncture, P.C. v. State Farm Mut. Auto. Ins. Co.

This case, NYS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., concerned an appeal from an order of the Civil Court of the City of New York, Queens County. The plaintiff, NYS Acupuncture, P.C., sought assigned first-party no-fault benefits from State Farm, which had moved for summary judgment arguing full payment according to the workers' compensation fee schedule. The Civil Court initially granted State Farm's motion. On appeal, NYS Acupuncture, P.C. contended that the fee schedule reductions were improper. The Appellate Term, Second Department, affirmed the prior ruling, finding that State Farm adequately demonstrated it had fully compensated the plaintiff for acupuncture services based on the applicable workers' compensation fee schedule for services performed by chiropractors, referencing Great Wall Acupuncture, P.C. v Geico Ins. Co.

Workers' Compensation Fee ScheduleNo-Fault BenefitsAcupuncture ServicesChiropractorsSummary JudgmentAppellate ReviewInsurance DisputeFee Schedule ReductionAssigned BenefitsMedical Billing
References
1
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