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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. 2017 NY Slip Op 04009 [150 AD3d 1507]
Regular Panel Decision
May 18, 2017

Matter of Jie Cao v. Five Star Travel of NY Inc.

Claimant, a bus driver, was involved in a 2007 accident and successfully applied for workers' compensation benefits, naming "Five Stars Travel Bus Inc." as his employer. Five Star Travel of NY Inc. (Five Star) did not appear after being served, leading to a WCLJ finding it liable for awards and assessments. After subsequent awards and medical treatment authorizations, a settlement was approved in 2013. In May 2015, Five Star sought to reopen the claim and challenge the prior decisions and settlement, but the Workers' Compensation Board denied the application due to untimely submission of new material evidence and the non-reviewable nature of an approved waiver agreement. The Appellate Division affirmed the Board's decision.

Workers' CompensationBus AccidentUninsured EmployerClaim ReopeningSettlement AgreementBoard ReviewAppellate DivisionTimelinessContinuing JurisdictionDue Process
References
6
Case No. ADJ2 239027 (AHM 0075690) ADJ1 391800 (AHM 0075691)
Regular
Mar 17, 2016

GUADALUPE MEDRANO vs. ARAMARK, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE, in liquidation

Defendant CIGA, as insurer for Aramark, sought reconsideration of lien payment orders, arguing the lienholder, Montebello Billing, was a suspended and canceled corporation, lacking legal standing. The Appeals Board granted reconsideration, rescinding the payment orders for OMG of Long Beach, Pharma Billing, and B12 Solutions. The matter is returned to the trial level for further proceedings to develop the record regarding CIGA's claims. Reconsideration for the Star and Sky Physical Therapy lien was denied as the prior order was final.

California Workers CompensationWorkers' Compensation Appeals BoardReliance Insuranceliquidationsuspended corporationcanceled corporationlegal rightjurisdictionvoid orderspetition for reconsideration
References
0
Case No. MISSING
Regular Panel Decision

Hoa Lam v. Sky Realty, Inc.

Hoa Lam, a day laborer, and his wife sued Triple 8 Construction, Sky Realty, and 652 Lin’s Garden for personal injuries sustained while installing a ventilation system. The plaintiff alleged violations of Labor Law § 200 and common-law negligence after a saw blade came loose. The Supreme Court, Queens County, denied the defendants' motions for summary judgment to dismiss the claims, as well as Sky Realty's motion for contractual indemnification against 652 Lin’s Garden. On appeal, the Appellate Division affirmed the Supreme Court's order, finding that the defendants failed to establish prima facie entitlement to judgment as a matter of law. Triable issues of fact remained regarding the plaintiff's employer, the scope of employment, each defendant's role in the renovation, and Sky Realty's freedom from negligence.

Personal InjurySummary Judgment MotionLabor Law § 200 ViolationCommon-Law NegligenceContractual IndemnificationSafe Place to Work DoctrineAppellate AffirmationTriable Issues of FactConstruction Site AccidentThird-Party Liability
References
14
Case No. MISSING
Regular Panel Decision

Scarfi v. Bright Star Industries, Inc.

The trustees of the District No. 15 Machinists’ Pension Fund, acting as plaintiffs, initiated this action against Bright Star Industries, Inc. seeking to compel overdue contributions to the fund under ERISA and LMRA. Bright Star moved to dismiss, contending that jurisdiction over the matter was exclusively with the National Labor Relations Board due to previous unfair labor practice proceedings. The court, presided over by District Judge Glasser, denied the defendant's motion to dismiss, asserting its concurrent jurisdiction with the NLRB in cases involving both NLRA violations and breaches of collective bargaining agreements, particularly where a valid contract is still in effect. The court also denied Bright Star's request for costs and attorney's fees.

ERISALMRANLRAPension FundCollective Bargaining AgreementUnfair Labor PracticesJurisdictionMotion to DismissPreemptionConcurrent Jurisdiction
References
5
Case No. ADJ8992954
Regular
Sep 29, 2016

JOSE CASILLAS DE DIOS vs. BROWN SHOE COMPANY, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board (WCAB) granted reconsideration for lien claimant West Star Physical Therapy, rescinding the WCJ's prior order that reduced West Star's lien to $1400.00. The WCAB found West Star's petition timely, ruling that the WCJ's purported personal service of the order was invalid due to insufficient proof. Furthermore, the WCAB noted the WCJ's order lacked the required evidentiary basis and justification, as it was based on party representations that West Star's representative lacked authority to make. The case is returned to the trial level for further proceedings.

Petition for ReconsiderationLien ClaimantOrder Reducing LienWCJTimelinessPersonal ServiceProof of ServiceStipulationNotice of RepresentationWCAB Rule 10500
References
8
Case No. ADJ563768 (SBR 0331684), ADJ2410618 (SBR 0338943)
Regular
Mar 22, 2010

JORGE GONZALEZ vs. TOYO TIRE USA, TOKO MARINE PASADENA

Lien claimant Access Health Medical Group seeks full reimbursement for services, arguing the WCJ erred by disallowing most of its lien based on anti-referral laws (Labor Code §§ 139.3, 139.31). Access contends these laws do not apply to in-house referrals for chiropractic, acupuncture, or "work conditioning" services, as these are not "physical therapy." The Appeals Board granted reconsideration, finding the WCJ applied an overly broad definition of physical therapy. The case is returned for further proceedings to determine if the billed services were distinct from physical therapy, or if "work conditioning" constitutes physical therapy under the statute.

Labor Code §§ 139.3Labor Code § 139.31anti-referral lawsin-office referralsphysical therapychiropracticacupuncturework conditioninglien claimantFindings and Order
References
6
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