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

Case No. 2024 NY Slip Op 03519
Regular Panel Decision
Jun 27, 2024

Matter of Reyes Bonilla v. XL Specialty Ins.

Claimants Jose Reyes Bonilla and Marvin Reyes Bonilla, carpenters, were involved in a motor vehicle accident while commuting to a job site in Greenpoint, Brooklyn, in an employer-provided van. They filed workers' compensation claims, which were established against XL Specialty Insurance by a Workers' Compensation Law Judge (WCLJ). XL Specialty appealed, arguing its policy did not cover commuting injuries and that it was not the proper carrier. The Workers' Compensation Board affirmed the WCLJ's decisions, finding XL Specialty failed to preserve its challenge to being the carrier and that the employer's responsibility for transportation made the injuries compensable. The Appellate Division, Third Department, affirmed, agreeing that the issue was unpreserved and that the injuries arose out of and in the course of employment due to the employer's control over the conveyance.

Workers' CompensationMotor Vehicle AccidentEmployment InjuriesCommuting AccidentEmployer Provided TransportationWrap-up PolicyInsurance Coverage DisputeCarrier LiabilityIssue PreservationAppellate Review
References
16
Case No. MISSING
Regular Panel Decision

Claim of Smith v. Specialty Services, Inc.

Claimant, a construction foreman for Specialty Services, Inc., was injured while performing work for a church in Pennsylvania. Although Specialty filed a work-related accident report and its carrier began paying benefits, the carrier filed a notice of controversy over seven months after the Workers' Compensation Board indexed the case, exceeding the 25-day limit. The carrier argued that the late filing was due to surprise, mistake, and newly discovered evidence regarding the church's involvement, which claimant and Specialty allegedly failed to disclose. The Workers' Compensation Board refused to excuse the late filing, finding the carrier failed to demonstrate good cause. The appellate court affirmed the Board's decision, noting that the carrier had ample time to investigate and that belatedly obtained evidence is not a sufficient ground to excuse a late filing.

Workers' CompensationLate Notice of ControversyTimely FilingEmployer-Employee RelationshipInsurance CarrierGood CausePleading BarAppellate ReviewBoard DecisionStatutory Interpretation
References
2
Case No. ADJ11446545
Regular
Dec 03, 2019

ROSA LOPEZ RODRIGUEZ vs. UNIVERSAL BUILDING SERVICES SUPPLY COMPANY, INSURANCE COMPANY OF THE WEST

This case concerns a dispute over the appropriate medical specialty for a Qualified Medical Evaluator (QME) panel. The applicant, Rosa Lopez Rodriguez, initially requested a chiropractic QME panel, which was issued first. The defendant objected, arguing that chiropractic was inappropriate due to the applicant's prior surgery and lack of full recovery. The Medical Unit then invalidated the chiropractic panel and issued an orthopedic surgery panel. The Workers' Compensation Appeals Board granted reconsideration, overturning the WCJ's decision. The Board held that the party who first requests a QME panel has the right to designate the specialty and that the defendant failed to provide sufficient grounds to invalidate the chiropractic panel. Therefore, the Board amended the findings to sustain the applicant's objection and affirm chiropractic as the appropriate panel specialty.

AD Rule 31.5(a)(10)AD Rule 31.5(a)(9)AD Rule 31.1(b)Labor Code section 4062Labor Code section 4062.2Qualified Medical Evaluator (QME)QME panel specialtyPetition for RemovalPetition for ReconsiderationMedical Unit determination
References
1
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. MISSING
Regular Panel Decision

GuideOne Specialty Insurance v. Admiral Insurance

This case involves an insurance coverage dispute where Weingarten Custom Homes (WCH) contracted with Torah Academy for construction, designating Torah Academy as an additional insured under WCH's liability policy with Admiral Insurance Company. The Admiral policy had lower coverage limits ($1,000,000) than required by the contract ($2,000,000/$5,000,000), with GuideOne Specialty Insurance Company providing secondary and excess coverage to Torah Academy. After a construction worker's injury led to a $1,225,000 settlement, Admiral paid $1,000,000, and GuideOne paid $225,000. GuideOne then sued Admiral to recover its payment, arguing that a letter signed by Admiral's claims superintendent effectively modified Admiral's policy to higher limits. The appellate court reversed the Supreme Court's decision, ruling that the letter did not constitute a valid policy endorsement and that the policy's unambiguous terms could not be altered by extrinsic evidence, thereby granting Admiral's motion to dismiss GuideOne's complaint.

Insurance Policy DisputeContract InterpretationLiability InsuranceAdditional InsuredPolicy LimitsMotion to DismissAppellate ReversalDocumentary EvidenceExtrinsic Evidence RulePolicy Amendment
References
12
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. 2025 NYSlipOp 06801
Regular Panel Decision
Dec 09, 2025

AmTrust N. Am., Inc. v. Insurance Specialty Group LLC

The plaintiff, AmTrust North America, Inc., appealed an order dismissing parts of its breach of contract claim against Insurance Specialty Group LLC. The dispute stems from a 2010 Managing Producer Agreement where the defendant was to administer an asset protection program for the plaintiff, with fiduciary duties. Plaintiff alleged multiple breaches, including improper underwriting and concealment of issues, which came to light in 2022. The Supreme Court dismissed claims before May 19, 2017, but the Appellate Division modified this by applying equitable estoppel. The appellate court ruled that estoppel could allow most breach of contract claims, except those solely based on the fiduciary duty to disclose, which are not subject to estoppel for time-barred breaches.

Breach of ContractEquitable EstoppelFiduciary DutyStatute of LimitationsAsset Protection ProgramUnderwriting GuidelinesInsurance AdministrationConcealmentContinuing Wrong DoctrineAppellate Division
References
8
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. 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. 2019 NY Slip Op 00061 [168 AD3d 431]
Regular Panel Decision
Jan 08, 2019

U.S. Specialty Ins. Co. v. SMI Constr. Mgt., Inc.

The U.S. Specialty Insurance Company sought summary judgment to avoid defending or indemnifying SMI Construction Management, Inc. in a personal injury lawsuit and to recoup defense costs. The Supreme Court, New York County, denied this motion, and the Appellate Division, First Department, unanimously affirmed the decision. The appellate court found that material issues of fact existed regarding whether SMI Construction Management, Inc. performed as a construction manager for a fee, which could trigger an exclusion in the insurance policy. The determination hinges on the actual duties performed by SMI, rather than merely its label, with evidence suggesting roles consistent with both a construction manager and a general contractor, including providing workers, materials, and supervision. Furthermore, the court noted that the compensation structure, which included profit and overhead, raised further questions, distinguishing the case from precedents involving flat fees. The plaintiff's claim of prejudice due to delayed notice was also deemed insufficient, and any determination regarding the primacy of coverage was considered premature.

Insurance PolicyConstruction ManagementSummary JudgmentIndemnificationDefense CostsPolicy ExclusionGeneral ContractorDuty to DefendNotice of AccidentContract Interpretation
References
5
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