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

Case No. 2013-1427 K C
Regular Panel Decision
Jun 03, 2016

Harvard Med., P.C. v. Tri State Consumers Ins. Co.

This is an appeal by Harvard Medical, P.C., as assignee of Lenford Carty, against Tri State Consumers Ins. Co. The appeal is from an order of the Civil Court of the City of New York, Kings County, entered April 12, 2013, which granted the defendant's motion for summary judgment. The defendant argued that it had fully paid the plaintiff in accordance with the workers' compensation fee schedule for first-party no-fault benefits. The Appellate Term, Second Department, affirmed the Civil Court's order, citing a related case, Renelique, as Assignee of Yvon Delgado v Tri State Consumers Ins. Co.

No-fault benefitsSummary JudgmentAppellate ReviewWorkers' Compensation Fee ScheduleAssignee
References
1
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
Case No. 2011-192 K C
Regular Panel Decision
Dec 19, 2017

Jamaica Dedicated Med. Care, P.C. v. Tri State Consumer Ins. Co.

This case concerns an appeal from an order of the Civil Court of the City of New York, Kings County, which denied defendant Tri State Consumer Ins. Co.'s cross motion for summary judgment. Jamaica Dedicated Medical Care, P.C., as assignee, sought first-party no-fault benefits. Tri State Consumer Ins. Co. contended that it had either properly reimbursed services according to the workers' compensation fee schedule or timely denied others due to lack of medical necessity. The Appellate Term found a triable issue of fact regarding medical necessity and that the defendant failed to establish its workers' compensation fee schedule defense as a matter of law. Consequently, the order denying summary judgment was affirmed.

No-fault benefitsSummary judgmentMedical necessityWorkers' compensation fee scheduleAppellate reviewAssigneeInsurance claimCivil CourtAppellate TermKings County
References
2
Case No. 2017-913 K C
Regular Panel Decision
Aug 02, 2019

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

This case concerns an appeal initiated by Oriental Health Acupuncture, P.C., acting as the assignee of Carrington, Earnel, against State Farm Mutual Automobile Ins. Co. The appeal originated from an order by the Civil Court of the City of New York, Kings County, which had granted State Farm's motion for summary judgment and dismissed the plaintiff's complaint seeking first-party no-fault benefits. The Civil Court's decision was predicated on the finding that the amounts claimed by the plaintiff exceeded the limits established by the workers' compensation fee schedule. The Appellate Term, Second Department, affirmed the lower court's order. This decision was made in conjunction with a related case, BQE Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., decided concurrently.

No-fault benefitsSummary judgmentAppellate reviewWorkers' compensation fee scheduleAutomobile insuranceFirst-party benefitsMedical provider claimAssigned benefitsCivil Court appealAppellate Term decision
References
1
Case No. 2014-1535 Q C
Regular Panel Decision
Sep 22, 2017

GBI Acupuncture, P.C. v. GEICO Ins. Co.

The Appellate Term, Second Department, affirmed an order from the Civil Court of the City of New York, Queens County, in a case involving GBI Acupuncture, P.C. and GEICO Ins. Co. GBI Acupuncture, as assignee, sought to recover first-party no-fault benefits, but the Civil Court had denied its motion for summary judgment and partially granted GEICO's cross-motion. The Appellate Term concurred with the Civil Court's findings, holding that GEICO had properly mailed its denial of claim forms. Furthermore, the court found no merit in the plaintiff's arguments concerning the application of the workers' compensation fee schedule in this no-fault benefits dispute.

No-fault benefitsSummary judgmentClaims denialWorkers' compensation fee scheduleAppellate reviewProper mailingCivil courtFirst-party benefitsAssignee claimInsurance dispute
References
2
Case No. 2015-1073 K C
Regular Panel Decision
Jan 20, 2017

Acuhealth Acupuncture, P.C. v. Ameriprise Ins. Co.

This case concerns an appeal by Acuhealth Acupuncture, P.C., as assignee of Tykeisha Davis, against Ameriprise Ins. Co. The appeal challenges a Civil Court order that granted summary judgment to the defendant. The defendant successfully argued that it had properly reimbursed the plaintiff for acupuncture services rendered through September 23, 2010, based on workers' compensation fee schedules. For services provided from September 30, 2010, to October 8, 2010, the defendant timely denied reimbursement citing a lack of medical necessity, supported by an independent medical examination. The Appellate Term affirmed the lower court's decision, finding that the plaintiff failed to raise a triable issue of fact against the defendant's defenses.

Acupuncture servicesNo-fault benefitsWorkers' compensation fee schedulesMedical necessitySummary judgmentAppellate TermCivil CourtIndependent medical examinationReimbursementAssignee
References
1
Case No. 2014-781 Q C
Regular Panel Decision
Sep 27, 2016

Gl Acupuncture, P.C. v. Praetorian Ins. Co.

This case involves an appeal by GL Acupuncture, P.C., as assignee of Kenya M. Jones, against Praetorian Ins. Co. The appeal concerned an order from the Civil Court of the City of New York, Queens County, which had granted the defendant's cross motion for summary judgment to dismiss several causes of action for assigned first-party no-fault benefits. The Appellate Term found that while the defendant's proof was sufficient regarding the mailing of denial forms and payments for certain CPT codes, it failed to provide enough evidence to dismiss the plaintiff's claim for an initial acupuncture visit on July 8, 2010. Consequently, the order was modified to deny the dismissal of this specific claim, and affirmed as so modified.

No-fault benefitsSummary judgmentAppellate reviewAcupuncture servicesInsurance claimsWorkers' compensation fee scheduleDenial of claimMedical billingCivil court appealFirst-party benefits
References
2
Case No. 2016-1600 K C
Regular Panel Decision
Jul 06, 2018

Acupuncture Now, P.C v. GEICO Ins. Co.

Acupuncture Now, P.C., as assignee, sued GEICO Ins. Co. for assigned first-party no-fault benefits. Both parties moved for summary judgment, with GEICO asserting lack of coverage due to policy cancellation for nonpayment. The Civil Court initially granted GEICO's cross-motion, but the Appellate Term modified this decision. The Appellate Term found that GEICO failed to demonstrate proper mailing of the cancellation notice under Virginia law. Consequently, the appellate court denied the branch of GEICO's cross-motion regarding lack of coverage and remitted the matter to the Civil Court to address the remaining issues. The plaintiff's motion for summary judgment was implicitly denied due to insufficient proof regarding timely claim denials or meritless denials.

no-fault benefitsinsurance coveragepolicy cancellationsummary judgmentappellate reviewprocedural lawvehicle insuranceproof of mailingmedical claimsassignee
References
4
Case No. 2015-976 K C
Regular Panel Decision
Dec 22, 2017

Acuhealth Acupuncture, P.C. v. Hereford Ins. Co.

This case concerns an appeal from an order of the Civil Court regarding a dispute between Acuhealth Acupuncture, P.C. (applicant) and Hereford Ins. Co. (defendant) over first-party no-fault benefits. The applicant sought recovery for services billed under CPT code 97039, which has a 'By Report' designation in the workers' compensation fee schedule requiring additional documentation. The Civil Court initially granted the defendant's motion for summary judgment and denied the applicant's cross-motion. On appeal, the Appellate Term modified the order, denying the branch of the defendant's motion seeking summary judgment on the CPT code 97039 claims, as the defendant failed to demonstrate it requested the required additional verification. However, the applicant's cross-motion for summary judgment was still denied as it failed to establish its prima facie entitlement to judgment.

No-fault insuranceSummary judgment motionCPT codeWorkers' compensation fee scheduleVerification of claimAppellate reviewMedical billing disputeInsurance benefitsAssignee claimCivil procedure
References
5
Case No. 2017-1180 K C
Regular Panel Decision
Aug 02, 2019

Merrick Med., P.C. v. A Cent. Ins. Co.

The case of Merrick Med., P.C. v A Central Ins. Co. concerned a provider's action to recover assigned first-party no-fault benefits from an insurer. The defendant insurer, A Central Insurance Company, moved for summary judgment to dismiss the complaint, asserting that a portion of the claim exceeded the workers' compensation fee schedule and other claims lacked medical necessity. Initially, the Civil Court denied the defendant's motion in part, making CPLR 3212 (g) findings. However, the Appellate Term, Second Department, modified the Civil Court's order. The appellate court concluded that the defendant's motion for summary judgment dismissing the complaint should have been entirely granted, as the specific claim was properly paid under the fee schedule, and the remaining claims were successfully challenged on medical necessity grounds by the defendant, which the plaintiff failed to rebut.

No-fault benefitsSummary judgment motionWorkers' compensation fee scheduleMedical necessity defenseAppellate Term decisionInsurance litigationAssignee claimCivil procedurePeer review reportIndependent medical examination
References
3
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