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

Case No. MISSING
Regular Panel Decision

Surgicare Surgical v. National Interstate Insurance

This case addresses whether an insurer complies with New York's 11 NYCRR 68.6 regulation by reimbursing for out-of-state medical services according to the host state's (New Jersey's) no-fault fee schedule. Plaintiff Surgicare Surgical, assignee of an injured party, sought full payment for surgery performed in New Jersey, but defendant National Interstate Insurance Company paid a reduced amount based on New Jersey's fee schedule. The court affirmed the defendant's method, ruling that when medical services are rendered in another jurisdiction with its own fee schedule, the 'permissible' charge under that schedule constitutes the 'prevailing fee' under New York's regulation. The decision emphasized alignment with legislative intent to contain no-fault insurance costs and reduce judicial burden, dismissing the plaintiff's complaint and denying its cross-motion.

No-Fault BenefitsInsurance LawFee Schedule DisputeOut-of-State Medical ServicesNew York RegulationsNew Jersey Fee ScheduleStatutory InterpretationAutomobile AccidentReimbursement DisputeSummary Judgment
References
17
Case No. 2025 NY Slip Op 02248 [237 AD3d 1379]
Regular Panel Decision
Apr 17, 2025

Matter of Jehle v. DOCCS Coxsackie Corr. Facility

William Jehle, a correction officer, sustained a work-related injury, prompting his employer, DOCCS Coxsackie Correctional Facility, to continue paying his full wages. The employer sought reimbursement, and Jehle's attorney filed for counsel fees. The Workers' Compensation Law Judge (WCLJ) established the claim, found a temporary total disability, awarded a credit to the employer for wage reimbursement, and granted counsel fees of $4,300 as a lien against this reimbursement. The Workers' Compensation Board affirmed the WCLJ's decision, deeming the lien proper under Workers' Compensation Law § 24 (2) (b). The Appellate Division, Third Department, further affirmed the Board's decision, holding that an award for previously unawarded benefits constitutes an 'increase' under the law, and that counsel fees are appropriately a lien against the employer's reimbursement, dismissing arguments of the employer subsidizing fees.

Counsel FeesLien on AwardEmployer ReimbursementTemporary Total DisabilityWorkers' Compensation LawAppellate ReviewCorrection OfficerWage ReimbursementStatutory InterpretationClaimant Attorney Fees
References
3
Case No. ADJ2806916 (SDO 0271727)
Regular
Oct 30, 2013

SOVEIDA MAGANA vs. CENTER FOR EMPLOYMENT TRAINING, CALIFORNIA INSURANCE GUARANTEE ASSOCIATION for RELIANCE INSURANCE COMPANY

This case consolidates numerous claims involving unresolved lien claims for ambulatory surgical center facility fees. The Workers' Compensation Appeals Board affirmed the Administrative Law Judge's decision establishing reasonable facility fees by averaging the January 1, 2004, Official Medical Fee Schedule for ASCs with the average amount paid to San Diego hospitals under an older inpatient fee schedule. The Board found this methodology appropriately considered extensive evidence and relevant factors for determining reasonable fees. Defendants' arguments that only the January 1, 2004, OMFS should apply or that SB 863's independent bill review process was mandatory were rejected.

Workers' Compensation Appeals BoardSoveida MaganaCenter for Employment TrainingCalifornia Insurance Guarantee AssociationReliance Insurance CompanyLien ClaimantsPoint Loma Surgical CenterElite Surgical CentersAmbulatory Surgical CenterFacility Fees
References
0
Case No. MISSING
Regular Panel Decision
Aug 24, 1999

Town of Hempstead v. Inc. Village of Atlantic Beach

This case involves two related actions arising from inter-municipal agreements for waste disposal services. The defendants appealed from initial court orders concerning their obligations to pay minimum waste commitment tonnage fees and their entitlement to various credits, including those for private carters, recyclable materials, and yard waste. The plaintiffs cross-appealed regarding the methodology for calculating yard waste credits and the fees for using the Town's transfer facility. The Supreme Court, Nassau County, issued an initial order and a subsequent amended order upon reargument, clarifying several points. The Appellate Division affirmed the amended order, holding that the agreements unambiguously required villages to pay minimum tonnage fees regardless of actual waste delivered. The court also determined that the villages were only obligated to pay transfer facility fees based on actual waste delivered and that any ambiguities regarding yard waste credits should be interpreted against the Town as the drafter of the agreements.

Inter-municipal agreementsWaste disposalSummary judgmentContract interpretationMinimum commitment feesYard waste creditTransfer facility feesUnambiguous agreementsExtrinsic evidenceAmbiguity construction
References
10
Case No. 2019 NY Slip Op 09078 [178 AD3d 1268]
Regular Panel Decision
Dec 19, 2019

Matter of Donovan v. DOCCS Coxsackie Corr. Facility

Danl D. Donovan, a correction sergeant, sustained a work-related hip injury. His employer, DOCCS Coxsackie Correctional Facility, advanced his wages and sought reimbursement. Following an award for a schedule loss of use, a dispute arose regarding the deduction of attorney fees from the claimant's payment, which the Workers' Compensation Board upheld. While Donovan's appeal was pending before the Appellate Division, the Board issued an amended decision based on a new legal rationale. Consequently, the Appellate Division, Third Department, dismissed the initial appeal as moot.

Workers' CompensationSchedule Loss of UseAttorney Fee DeductionReimbursement DisputeMoot AppealAppellate DivisionWork-related InjuryWage ReimbursementIndependent Medical ExaminerAdministrative Review
References
2
Case No. ADJ4409749
Regular
Feb 07, 2011

Jill Johnson vs. Ventura Unified School District, York Oxnard

Lien claimant Access Mediquip sought reimbursement for over $68,000 for durable medical equipment, specifically neurostimulators. The WCJ denied this, finding the defendant school district had already paid for the equipment through the surgical facility's charges. The Appeals Board affirmed this denial, concluding the evidence showed the neurostimulator costs were bundled into the surgery center's facility fees, aligning with Medicare bundling rules for ambulatory surgery centers. The Board distinguished this case from a prior one where the defendant contested the inclusion of costs in the facility bill, emphasizing the defendant here demonstrated payment via the bundled facility charge.

Workers Compensation Appeals BoardLien ClaimantDurable Medical EquipmentNeurostimulatorSurgical ProceduresFacility ChargeBill ReviewCPT CodeMedicare RulesAmbulatory Surgery Center
References
1
Case No. 531543
Regular Panel Decision
Jan 07, 2021

Matter of Gilliam v. Doccs Wende Corr. Facility

Claimant Wanda Gilliam, a correction officer, sustained work-related injuries to her right hip and left shoulder in May 2017. Following various medical evaluations, including conflicting opinions from orthopedist Michael Grant and independent examiner Louis Nunez regarding schedule loss of use (SLU), a Workers' Compensation Law Judge initially awarded a 60% SLU of her left arm and 57.5% SLU of her right leg. Upon administrative review, the Workers' Compensation Board modified this decision, crediting Nunez's evaluation, and awarded a 30% SLU for her left arm while making no SLU award for her right leg, and also reduced the attorney's fee. The Appellate Division, Third Department, affirmed the Board's decision, determining that it was supported by substantial evidence, particularly in resolving conflicting medical opinions and exercising discretion regarding counsel fees. The court found no abuse of discretion in the reduction of attorney's fees, noting the limited period of representation.

Workers' CompensationSchedule Loss of Use (SLU)Left Arm InjuryRight Leg InjuryOrthopedic ExaminationMedical Opinion ConflictAppellate ReviewAttorney FeesDiscretionary AwardSubstantial Evidence
References
17
Case No. 2022 NY Slip Op 05964 [209 AD3d 596]
Regular Panel Decision
Oct 25, 2022

Pirozzo v. Laight St. Fee Owner LLC

Plaintiff Paul Pirozzo sought summary judgment on his Labor Law § 240 (1) claim against defendants Laight Street Fee Owner LLC, Laight Street Fee Owner II LLC, and Sciame Construction, LLC, which was granted by the Supreme Court. The Appellate Division, First Department, affirmed this decision. The plaintiff established a prima facie case by demonstrating that the scaffold he was working on collapsed without an apparent reason. The defendants' arguments that the plaintiff was the sole proximate cause, either by failing to lock scaffold pins or remaining on the scaffold while it was moved, were deemed unavailing. The court noted that these actions, even if proven, would amount to comparative negligence, which is not a defense to a Labor Law § 240 (1) claim, and there was no evidence of specific instructions to the plaintiff that were disobeyed.

Summary judgmentLabor Law § 240 (1)Scaffold collapseSole proximate causeComparative negligenceWorkers' compensation Form C-2Hearsay objectionPersonal knowledgeRecalcitranceAppellate Division
References
9
Case No. 25 NY3d 907
Regular Panel Decision
2015-XX-XX

Government Employees Insurance v. Avanguard Medical Group, PLLC

This case addresses whether no-fault insurance carriers are obligated to pay facility fees to New York State-accredited office-based surgery (OBS) centers for the use of their premises and support services. The court concluded that neither existing statutes nor regulations mandate such payments. Plaintiffs, a group of GEICO insurers, successfully sought a declaratory judgment that they are not legally required to reimburse Avanguard Medical Group, PLLC, for OBS facility fees, totaling over $1.3 million. The decision affirmed the Appellate Division's ruling, emphasizing that OBS facility fees are not explicitly covered by statute or fee schedules, nor do they fall under reimbursable "professional health services" as per 11 NYCRR 68.5. The court highlighted the distinct regulatory frameworks for OBS centers compared to hospitals and ambulatory surgery centers, declining to mandate policy changes best left to the legislature.

No-Fault InsuranceOffice-Based Surgery (OBS)Facility FeesInsurance LawBasic Economic LossFee SchedulesWorkers' Compensation BoardDepartment of Financial ServicesStatutory InterpretationRegulatory Framework
References
16
Case No. ADJ7911474
Regular
Jan 22, 2019

KIA SPREWELL vs. STATE OF CALIFORNIA, RICHARD J. DONOVAN CORRECTIONAL FACILITY

This case involved Kia Sprewell's workers' compensation claim against the Richard J. Donovan Correctional Facility for injuries sustained as an office assistant. The defendant sought reconsideration of the initial award, primarily contesting the commutation method for attorney fees and the substantiality of the neurologist's medical opinions. The Workers' Compensation Appeals Board granted reconsideration in part, affirming the award of permanent disability but amending the attorney fees to be commuted from the side of the life pension award. The Board found the neurologist's opinions on apportionment and rating of various injuries, including headaches and spinal issues, to be substantial medical evidence.

Workers Compensation Appeals BoardKia SprewellRichard J. Donovan Correctional FacilityState Compensation Insurance FundPetition for ReconsiderationFindings and AwardPermanent DisabilityApportionmentLife PensionAttorney Fees
References
0
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