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Case Law Database

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. MISSING
Regular Panel Decision

A&S Medical, P.C. v. Allstate Insurance

This legal text presents a dissenting opinion by Justice McCooe concerning a no-fault benefits claim. The case revolves around an injured assignor who was struck by a motor vehicle, leading to a denial of further orthopedic benefits by the defendant insurer effective January 26, 1999. Subsequently, the plaintiff assignee submitted a bill for physical therapy services, resulting in a partial payment and a second partial denial of claim from the insurer dated July 28, 1999. The central legal question is whether the defendant insurer was obligated to issue a second denial within 30 days for the continuing services. Justice McCooe argues that the initial denial provided sufficient advance notice of benefit termination, rendering a subsequent denial redundant and causing no prejudice to the claimant. The dissent concludes that the order denying summary judgment should be affirmed, with a hearing on the necessity of the therapy.

No-fault benefitsClaim denialInsurance lawAssignee's rightsNotice requirementsSummary judgmentDissenting opinionStatutory interpretationPrejudicePhysical therapy claims
References
7
Case No. MISSING
Regular Panel Decision
Oct 15, 1979

In re the General Assignment for the Benefit of Creditors of Am-Lon Knit Goods Finishing Corp.

This proceeding involved an assignee for the benefit of creditors seeking judicial determination of priority among various creditor claims. The claims included those from the Federal Government, preferred wage claims, the New York State Tax Commission for income withholding taxes, the Industrial Commissioner for unemployment insurance contributions, the Director of Finance of the City of New York for various city taxes, and two insurance companies for workers' compensation insurance premiums. The court reconsidered an earlier decision and clarified that Labor Law § 574 is applicable and controlling in this context, establishing parity between New York State and City tax claims. Consequently, these tax claims were granted priority over the workers' compensation insurance premiums. The decision also distinguishes insolvency proceedings from decedent's estate cases, which are governed by SCPA 1811.

InsolvencyCreditor PriorityTax ClaimsUnemployment InsuranceWorkers' CompensationAssignee for Benefit of CreditorsState TaxesCity TaxesLabor LawSCPA
References
14
Case No. 2022 NY Slip Op 02757
Regular Panel Decision
Apr 26, 2022

Home Depot U.S.A., Inc. v. State of New York

This case involves Home Depot U.S.A., Inc., as an assignee, appealing orders that denied its motion for summary judgment in a breach of contract claim against the New York State Insurance Fund (SIF). Home Depot sought coverage under an Employer's Liability Policy issued by SIF to Bryan's Home Improvement Corporation, covering damages for employee injuries where recovery is permitted by law, specifically for

Breach of ContractEmployer's Liability PolicyCollateral EstoppelGrave InjuryWorkers' Compensation LawSummary JudgmentIndemnificationAppellate ReviewInsurance CoverageAssignee Rights
References
4
Case No. 2013-1456 K C
Regular Panel Decision
Mar 11, 2016

EMC Health Prods., Inc. v. Allstate Ins. Co.

This case involves an appeal from an order of the Civil Court of the City of New York, Kings County, which had granted the plaintiff's motion for summary judgment. The plaintiff, EMC Health Products, Inc., as an assignee, sought to recover assigned first-party no-fault benefits from Allstate Insurance Company. The Appellate Term affirmed the Civil Court's decision concerning the first and second causes of action, determining that the defendant failed to establish timely mailing of denial of claim forms. However, the court modified the original order by denying summary judgment for the third and fourth causes of action. This modification was based on the defendant successfully raising triable issues of fact regarding timely denial due to lack of medical necessity and claims exceeding the workers' compensation fee schedule.

Summary JudgmentNo-Fault BenefitsFirst-Party BenefitsMedical NecessityWorkers' Compensation Fee ScheduleTimely DenialAppellate ReviewCivil Court OrderAssignee ClaimsInsurance Law
References
3
Case No. 2014-773 Q C
Regular Panel Decision
Sep 27, 2016

Laga v. Foremost Signature Ins. Co.

In this action, provider Adelaida M. Laga, as assignee of Jenny Jimenez, sought assigned first-party no-fault benefits from Foremost Signature Insurance Company. The Civil Court initially granted the defendant's motion for summary judgment, thereby dismissing the complaint. On appeal, the plaintiff argued that the defendant failed to legally establish that the fees charged exceeded the workers' compensation fee schedule. The Appellate Term, Second Department, reversed the Civil Court's order and denied the defendant's motion for summary judgment, siding with the plaintiff's argument.

No-fault benefitsSummary judgmentWorkers' compensation fee scheduleAppellate reviewInsurance claimMedical providerAssigneeCivil CourtAppellate TermDenial of benefits
References
1
Case No. 2016-1458 K C
Regular Panel Decision
Nov 09, 2018

Pavlova v. Allstate Ins. Co.

This case concerns an appeal regarding first-party no-fault benefits sought by Ksenia Pavlova, D.O., as assignee of Cosby Reavis, against Allstate Insurance Company. The Civil Court had denied the plaintiff's motion for summary judgment and partially granted the defendant's cross-motion, dismissing claims for services billed under CPT code 20999, arguing plaintiff was not entitled to payment under the workers' compensation fee schedule. The Appellate Term modified the Civil Court's order, finding that Allstate's denial of claims for CPT code 20999 was without merit because the insurer failed to request additional documentation as required by 11 NYCRR 65-3.5(b) for "By Report" codes. However, the Appellate Term affirmed the denial of the plaintiff's summary judgment motion, noting the plaintiff failed to demonstrate that claims were not timely denied or that denials were conclusory. The matter was remitted to the Civil Court for a determination on the medical necessity of the CPT code 20999 services, a ground not previously addressed.

No-Fault BenefitsSummary JudgmentAppellate TermCPT Code 20999Workers' Compensation Fee ScheduleMedical NecessityClaim DenialVerification Request11 NYCRR 65-3.5(b)Insurance Law
References
0
Case No. 2019 NY Slip Op 03749
Regular Panel Decision
May 15, 2019

Allstate Ins. Co. v. Buffalo Neurosurgery Group

The plaintiff, Allstate Insurance Company, appealed an order from the Supreme Court, Nassau County, which denied its motion for summary judgment on a complaint seeking a de novo determination of no-fault insurance benefits and, upon searching the record, awarded summary judgment to the defendant, Buffalo Neurosurgery Group. The case originated from a motor vehicle accident where Christopher Krull underwent spinal fusion surgery. The defendant, as Krull's assignee, submitted a claim for no-fault benefits, which Allstate denied. The matter proceeded through arbitration, with the master arbitrator affirming an award to the defendant. The Appellate Division modified the Supreme Court's order. It granted Allstate's motion for summary judgment on the grounds that the amount of benefits sought by the defendant was not in accordance with the workers' compensation fee schedule, and it deleted the provision awarding summary judgment to the defendant. The court affirmed the denial of Allstate's motion concerning the medical necessity of the surgery, stating Allstate failed to meet its prima facie burden on that issue. The order was affirmed as modified, with costs payable to the plaintiff.

no-fault insurance benefitsworkers' compensation fee schedulesummary judgmentmedical necessityde novo determinationarbitration awardappellate reviewspinal fusion surgeryinsurance law § 5106assignee claim
References
10
Case No. 2017-2139 K C
Regular Panel Decision
Nov 29, 2019

Quality Health Prod., Inc. v. American Tr. Ins. Co.

This case concerns an appeal by Quality Health Product, Inc., as an assignee, against American Transit Insurance Company regarding a no-fault benefits claim. The defendant successfully moved for a stay of the action, pending a determination by the Workers' Compensation Board concerning the applicability of workers' compensation benefits. The Civil Court granted this motion based on the potential that the plaintiff's assignor was injured during the course of employment. The Appellate Term affirmed this decision, reiterating that the Workers' Compensation Board holds primary jurisdiction over such determinations. The court found sufficient evidence to warrant the Board's initial review of whether workers' compensation benefits were available.

No-fault benefitsWorkers' Compensation BoardPrimary JurisdictionStay of ActionAppellate ReviewInsurance DisputeCivil Court OrderAssignee RightsEmployment Injury
References
9
Case No. 2014-1081 K C
Regular Panel Decision
Oct 05, 2016

High Quality Med. Supplies, Inc. v. Mercury Ins. Group

This case involves an appeal concerning assigned first-party no-fault benefits sought by High Quality Medical Supplies, Inc., as assignee of Charles Botwee. The defendant, Mercury Ins. Group, appealed an order from the Civil Court that denied its motion for summary judgment to dismiss the complaint. Mercury Ins. Group contended that billing for durable medical equipment not listed in a fee schedule is not compensable. However, the Appellate Term affirmed the lower court's decision, citing 11 NYCRR 68.5, which specifically permits reimbursement for healthcare services not explicitly covered by fee schedules, thereby rejecting the defendant's argument.

No-Fault BenefitsFirst-Party BenefitsDurable Medical EquipmentFee ScheduleSummary JudgmentAppellate TermAssigned BenefitsInsurance LawReimbursementCivil Court
References
3
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