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

Case No. 2017 NY Slip Op 08926 [156 AD3d 1192]
Regular Panel Decision
Dec 21, 2017

Cromer v. Rosenzweig Insurance Agency Inc.

Plaintiff, Bradley E. Cromer, as assignee, sued Rosenzweig Insurance Agency Inc. and other defendants for negligence, breach of contract, and fraud, alleging failure to procure appropriate insurance coverage for his assignors, Allen Skriloff and SOS 1031 Properties 112, LLC. The lawsuit stemmed from a workplace injury where the assignors' insurance carrier disclaimed coverage due to an employee exclusion. The Supreme Court granted summary judgment to the insurance agency, finding the assignors were presumed to know their policy's contents. The Appellate Division affirmed this decision, concluding that plaintiff failed to demonstrate a specific request for the excluded coverage or establish a 'special relationship' with the broker that would impose a higher duty of advisement beyond the written notice provided.

Insurance Broker LiabilityNegligenceBreach of ContractFraudMaterial MisrepresentationSummary JudgmentAppellate ReviewSpecial RelationshipDuty to AdviseCommercial General Liability
References
11
Case No. MISSING
Regular Panel Decision

Clear Water Psychological Services PC v. American Transit Insurance Co.

Plaintiff Clear Water Psychological Services PC sought no-fault benefits from defendant American Transit Insurance Company. The plaintiff moved for summary judgment, while the defendant cross-moved for a 90-day stay, arguing that the assignor, Oshane Crooks, was acting as an employee at the time of the November 10, 2014 automobile accident, falling under Workers’ Compensation Board jurisdiction. A key issue was the admissibility of an uncertified police accident report (MV-104AN) which suggested the assignor was driving a taxi. The court ruled the uncertified report inadmissible under CPLR 4518 (c) for authentication reasons, despite the officer's personal observations. However, acknowledging the unresolved factual question of the assignor’s employment status and the Workers’ Compensation Board's primary jurisdiction, the court granted the defendant’s motion, staying the action for 90 days for a Workers’ Compensation Law applicability determination.

No-fault benefitsSummary judgmentStay of actionWorkers' CompensationPolice accident reportAdmissibility of evidenceCPLR 4518Vehicle and Traffic LawPrimary jurisdictionEmployment status
References
12
Case No. 2013-1639 K C
Regular Panel Decision
Jun 03, 2016

LMS Acupuncture, P.C. v. New York Cent. Mut. Fire Ins. Co.

This case involves an appeal by New York Central Mutual Fire Insurance Company from an order denying its motion for summary judgment. LMS Acupuncture, P.C., as assignee of John H. Sosa, sought first-party no-fault benefits. The defendant argued that the plaintiff's assignor failed to appear for independent medical examinations (IMEs) and that certain claims lacked medical necessity or exceeded the workers' compensation fee schedule. The Appellate Term affirmed the order, finding that the defendant did not establish personal knowledge of the assignor's non-appearance for IMEs. Furthermore, the plaintiff's affidavits were deemed sufficient to raise triable issues of fact concerning medical necessity and fee schedule compliance.

No-Fault BenefitsIndependent Medical Examination (IME)Summary Judgment MotionMedical Necessity DisputeWorkers' Compensation Fee ScheduleAppellate Term ReviewAssignee ClaimPersonal Knowledge RequirementTriable Issues of FactCivil Court Appeal
References
2
Case No. 2015-455 K C
Regular Panel Decision
Dec 19, 2017

Metro Psychological Servs., P.C. v. Travelers Prop. & Cas. Ins. Co.

This case involves Metro Psychological Services, P.C., as an assignee, seeking first-party no-fault benefits from Travelers Property & Casualty Insurance Company. The defendant moved for summary judgment, arguing the assignor's injuries occurred during employment, which would make workers' compensation benefits applicable. The Civil Court denied the defendant's motion and granted the plaintiff's cross-motion for summary judgment. The Appellate Term reversed this order, concluding there was an unresolved issue as to whether the plaintiff's assignor was acting in the course of employment at the time of the accident. Consequently, the matter was remitted to the Civil Court to be held in abeyance, pending a determination by the Workers' Compensation Board regarding the parties' rights under the Workers' Compensation Law, underscoring the Board's primary jurisdiction in such matters.

No-Fault BenefitsWorkers' Compensation LawPrimary JurisdictionAbeyanceSummary JudgmentAppellate ReviewInsurance DisputeMedical ProviderAssigneeCourse of Employment
References
9
Case No. MISSING
Regular Panel Decision
May 14, 2014

Forest Rehabilitation Medicine PC v. Allstate Insurance

Plaintiff Forest Rehabilitation Medicine PC sued defendant Allstate to recover $3,490 for no-fault medical benefits provided to assignor Tracy Fertitta. The core issue was the medical necessity of "Calmare pain therapy" (scrambler therapy), a novel treatment. The court conducted a bench trial, hearing expert testimony from both sides. Dr. Ayman Hadhoud, for the defense, argued the treatment was not medically necessary, not cost-effective, and essentially a form of physical therapy. Dr. Jack D’Angelo, for the plaintiff, countered that the therapy, though new, had FDA approval, was used by the military, and reduced the assignor's pain levels. Applying the Frye standard, the court found the evidence regarding Calmare scrambler therapy reliable and ruled it was medically necessary for Ms. Fertitta's pain management. Consequently, judgment was awarded to the plaintiff, Forest Rehabilitation Medicine PC, for $3,490 plus attorney's fees and interest.

No-Fault InsuranceMedical NecessityCalmare Pain TherapyScrambler TherapyNovel TreatmentFrye StandardExpert TestimonyPain ManagementFDA ApprovalCervical Radiculopathy
References
14
Case No. 2016-189 K C
Regular Panel Decision
Nov 09, 2018

Active Care Med. Supply Corp. v. Hartford Ins. Co.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant's motion for summary judgment dismissing the complaint and denied plaintiff's cross motion for summary judgment. The court found that defendant had established that there was no coverage for no-fault benefits since defendant had demonstrated that the Workers' Compensation Board had awarded workers' compensation benefits to plaintiff's assignor for injuries she had sustained in the accident which gave rise to the claims at issue. Contrary to plaintiff's contention, a lack of coverage defense may be raised without regard to any issue as to the propriety or timeliness of an insurer's denial of claim form. The papers submitted by defendant in support of its motion, and by plaintiff in support of its cross motion, established that plaintiff had submitted claims for workers' compensation benefits and that the Workers' Compensation Board had awarded plaintiff's assignor workers' compensation benefits for injuries she had sustained in the accident at issue. As plaintiff failed to demonstrate the existence of a triable issue of fact, the order is affirmed.

No-fault benefitsSummary JudgmentWorkers' Compensation BoardLack of coverage defenseAssignee claimsAppellate ReviewFirst-party benefitsInsurance claimsTriable issue of factCivil Court
References
2
Case No. MISSING
Regular Panel Decision
Mar 18, 2016

Friedman v. Allstate Ins. Co.

This case involves an appeal from a Civil Court judgment that awarded the plaintiff, Paul Friedman, L.Ac., LMT, the principal sum of $2,160 for assigned first-party no-fault benefits for acupuncture services. The defendant, Allstate Insurance Company, denied the claims based on an independent medical examination (IME) by Dr. Chiu, which concluded that the assignor's injuries had resolved. However, the plaintiff's expert, Dr. Friedman, testified that further treatment was necessary. The Civil Court found the services medically necessary, and the appellate court affirmed this judgment, concluding that the plaintiff met its burden of demonstrating medical necessity.

AcupunctureMedical NecessityNo-Fault BenefitsIMEAssignorProvider ActionCivil Court AppealExpert TestimonyInsurance Denial
References
2
Case No. MISSING
Regular Panel Decision

Walt v. GEICO General Insurance

Judge Rios concurs with the majority regarding the reversal of the judgment and the denial of plaintiff's motion for summary judgment. However, Rios dissents from searching the record to grant summary judgment in favor of the defendant, advocating for a remand for a trial. The purpose of the trial would be to ascertain the specific services provided by the plaintiff to its assignor. Rios emphasizes the importance of distinguishing between chiropractic services, for which workers’ compensation fee schedules exist, and acupuncture services, which may require a separate acupuncturist license and thus different fee schedule applicability, depending on whether the billed services fall within the scope of a chiropractor’s license.

Summary JudgmentReversalChiropractic ServicesAcupuncture ServicesWorkers' Compensation Fee SchedulesScope of PracticeProfessional LicensingMedical BillingRemandTrial
References
0
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. 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
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