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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. 2019 NY Slip Op 08951 [178 AD3d 525]
Regular Panel Decision
Dec 12, 2019

Matter of Global Liberty Ins. Co. of N.Y. v. North Shore Family Chiropractic, PC

The Appellate Division, First Department, affirmed the dismissal of a petition by Global Liberty Insurance Company of New York, which sought to vacate an arbitration award denying their claim. Global Liberty had argued that workers' compensation benefits were available to the assignor, Ramon Martinez, and thus their denial of the no-fault insurance claim to North Shore Family Chiropractic, PC (Martinez's assignee) was proper. The court found that Global Liberty failed to prove Martinez was injured in the course of his employment. The order was modified to remand the matter for a determination of attorneys' fees owed to North Shore Family Chiropractic, PC, including those for the appeal.

Insurance DenialNo-Fault BenefitsArbitration AwardAttorneys' FeesWorkers' Compensation CoverageEmployment StatusAppellate ReviewRemandBurden of ProofAssignor
References
4
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. 2014-1527 Q C
Regular Panel Decision
Dec 08, 2017

AVM Chiropractic, P.C. v. American Tr. Ins. Co.

This case concerns an appeal from an order of the Civil Court of the City of New York regarding assigned first-party no-fault benefits. Plaintiff, AVM Chiropractic, P.C., sought to recover benefits from American Transit Ins. Co. The Civil Court initially granted some branches of the defendant's motion for summary judgment and reduced claims based on a fee schedule defense. The Appellate Term modified the order, denying summary judgment for the defendant on specific causes of action (second, third, and sixth through eighth) and vacating findings on others (ninth and tenth). The court found that the defendant did not adequately demonstrate appropriate reductions in accordance with workers' compensation Ground Rules for several claims.

No-Fault BenefitsSummary JudgmentWorkers' Compensation Fee ScheduleAppellate ReviewInsurance ClaimsAssigneeFirst-Party BenefitsCivil ProcedureGround RulesNew York Law
References
1
Case No. 2014-1568 S C
Regular Panel Decision
Jul 20, 2016

Chirocare Chiropractic Assoc. v. State Farm Mut. Auto. Ins. Co.

This case involves a provider, Chirocare Chiropractic Associates, as assignee of Antoneta Mertiri, seeking first-party no-fault benefits from State Farm Mutual Automobile Insurance Company. The District Court initially granted State Farm's motion for summary judgment, dismissing the complaint based on a workers' compensation fee schedule defense. The Appellate Term reversed this order, finding that the District Court erred by dismissing the entire complaint on this ground, as the fee schedule defense only applied to amounts in excess of the schedule. Furthermore, the District Court failed to address State Farm's primary defense of lack of medical necessity, which could have been dispositive of the whole action. The matter was remitted to the District Court for a new determination addressing the medical necessity defense first.

No-fault insuranceAutomobile insuranceSummary judgmentAppellate reversalRemittiturMedical necessity defenseWorkers' compensation fee scheduleFirst-party benefitsAssignee claimChiropractic care
References
2
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. 2015-1649 Q C
Regular Panel Decision
Jan 20, 2017

Flatbush Chiropractic, P.C. v. American Tr. Ins. Co.

Flatbush Chiropractic, P.C., as assignee of Pierre Luxio, appealed an order that granted American Transit Ins. Co.'s motion to dismiss the complaint and denied plaintiff's cross-motion for leave to renew its prior motion for summary judgment. The Civil Court initially denied plaintiff's summary judgment motion and granted defendant's cross-motion, requiring Workers' Compensation Board resolution within 90 days due to an issue of fact regarding the accident occurring in the course of employment. After 21 months, defendant moved to dismiss for non-compliance, and plaintiff cross-moved to renew, presenting an affidavit indicating no record of a workers' compensation application. The Appellate Term affirmed the Civil Court's decision, stating that the alleged 'new facts' would not change the prior determination and plaintiff failed to show good cause against dismissal.

No-Fault BenefitsWorkers' Compensation IssueSummary Judgment MotionMotion to DismissLeave to RenewAppellate ReviewProcedural ComplianceAssignor-AssigneeCivil CourtAppellate Term
References
1
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
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