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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. 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. 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. 2015 NY Slip Op 01996 [126 AD3d 498]
Regular Panel Decision
Mar 12, 2015

Aramburu v. Midtown West B, LLC

Plaintiff Mark A. Aramburu was injured while moving a heavy reel of wire down a ramp, slipping on ice, and subsequently being struck by the reel. The court granted plaintiffs' motion for partial summary judgment on Labor Law § 240 (1) liability, concluding that the lack of adequate safety devices was a proximate cause of the accident, despite the presence of ice. Defendants' motion to dismiss common-law negligence and Labor Law § 200 claims was denied due to unresolved factual issues regarding notice of the hazardous icy condition. The order was modified to conditionally grant defendants' motion for contractual indemnification against Five Star Electric Corp., but defendants' claims for breach of contract and common-law indemnification/contribution against Five Star were dismissed because plaintiff did not suffer a 'grave injury' under Workers' Compensation Law § 11.

Construction AccidentLabor LawSection 240(1) LiabilityCommon-Law NegligenceContractual IndemnificationSummary JudgmentSlip and FallHazardous ConditionWorkers' Compensation Law Section 11Grave Injury
References
9
Case No. 2015 NY Slip Op 09604
Regular Panel Decision
Dec 29, 2015

Maggio v. 24 West 57 PFF, LLC

Plaintiff Joseph Maggio, a drywall installer, was injured after falling from a scaffold staircase at a premises owned by 24 West 57 APF, LLC and leased by Ana Tzarev New York, LLC (ATNY). The scaffold, constructed by Atlantic Hoist & Scaffolding, LLC, had a modified staircase with plywood covering some steps, lacking anti-slip protection and having an irregular rise. Plaintiff attributed his fall to these conditions and the presence of construction debris. The Supreme Court initially denied summary judgment motions from defendants 24 West and ATNY, citing outstanding discovery, and later denied renewed motions. On appeal, the Appellate Division found 24 West and ATNY justified in bringing the second motion but denied their request for summary judgment on negligence and Labor Law § 200 claims due to factual questions regarding notice of the dangerous condition. The court also denied plaintiff's untimely cross-motion for partial summary judgment on his Labor Law § 240 (1) claim. The Appellate Division modified the lower court's order, granting ATNY conditional contractual indemnification against R&R, and otherwise affirmed the decision.

Summary JudgmentLabor Law § 200Labor Law § 240 (1)Common-Law NegligenceContractual IndemnificationCommon-Law IndemnificationScaffold AccidentConstruction Site InjuryPremises LiabilityAppellate Procedure
References
12
Case No. 2020 NY Slip Op 08000 [189 AD3d 681]
Regular Panel Decision
Dec 29, 2020

Matias v. West 16th Realty LLC

Jose Matias, an employee of a linen company, sustained injuries on premises owned by West 16th Realty LLC and leased to Grey Dog Chelsea Inc. He was struck on the head by a cellar door while climbing stairs from the restaurant's cellar. The Appellate Division, First Department, reversed the Supreme Court's order, granting summary judgment to defendant West 16th Realty LLC. The court determined that as an out-of-possession landlord, West 16th Realty LLC was not liable, as the lease did not mandate cellar door maintenance or repair, and no significant structural or design defect violating a specific statutory safety provision was present. The court also held that West 16th owed no duty under the Administrative Code of the City of New York regarding the sidewalk.

Out-of-possession landlordPremises liabilitySummary judgmentCellar door accidentStructural defectStatutory safety provisionLease obligationsAdministrative Code liabilityAppellate DivisionFirst Department
References
9
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. MISSING
Regular Panel Decision
Jul 14, 2005

Smith v. 21 West LLC Limited Liability Co.

The Supreme Court, New York County, denied defendant Bravo’s motion for summary judgment seeking to dismiss defendant 21 West’s cross claims for contribution and indemnification. Bravo failed to establish that the plaintiff was its employee or that it operated as a joint venture, thereby not barring 21 West’s cross claims under Workers’ Compensation Law § 11. Furthermore, Bravo could not demonstrate insufficient control over the work to negate negligence liability, nor prove supervision over 21 West. The appellate court found that the parties’ conduct, including Bravo commencing work and obtaining an insurance certificate, manifested an intent to be bound by an unsigned contract. Consequently, the appellate order unanimously affirmed the denial of Bravo's summary judgment motion, upholding 21 West's cross claims.

Summary JudgmentContributionIndemnificationWorkers' Compensation LawCross ClaimsContractual IndemnificationCommon-Law IndemnificationEmployee StatusJoint VentureNegligence Liability
References
4
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