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

Case No. Motions Nos. 5 and 7
Regular Panel Decision
Jul 27, 1978

Rachlin v. Lewis

This case consolidates two CPLR article 78 proceedings challenging the Insurance Department's regulations on attorneys' fees in no-fault automobile insurance disputes and the constitutionality of certain sections of the Insurance Law. The petitioners sought to rescind 11 NYCRR 65.16 and declare Insurance Law section 671 et seq. unconstitutional. The court ruled that sections 11 NYCRR 65.16 (c) (7) (ix), which prohibited attorneys from charging clients fees in excess of insurer-paid fees, and 11 NYCRR 65.16 (c) (7) (vii), concerning the regulation of disbursements, were invalid as they exceeded the scope of the enabling legislation. However, the court upheld the general fee schedule, finding a rational basis for its establishment by the Insurance Department.

Attorney's FeesNo-Fault InsuranceInsurance LawRegulatory ChallengeCPLR Article 78Administrative LawConstitutional LawDisbursementsArbitrationAutomobile Insurance
References
6
Case No. 2019 NY Slip Op 08942 [178 AD3d 512]
Regular Panel Decision
Dec 12, 2019

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

This case addresses the appropriate fee schedule for licensed acupuncturists providing services to individuals injured in motor vehicle accidents under no-fault insurance. Plaintiff insurers moved for summary judgment, contending that acupuncturists should be reimbursed according to the workers' compensation fee schedule for chiropractors, not physicians. The Supreme Court denied this motion, and the Appellate Division, First Department, affirmed. The Appellate Division ruled that plaintiffs failed to make a prima facie showing of entitlement to judgment as a matter of law, noting the lack of a specific fee schedule for acupuncturists by the superintendent and prior rulings allowing flexibility in using either chiropractor or physician schedules based on consistency. The court also found an issue of fact raised by defendants regarding the physician fee schedule's applicability and deemed the motion for summary judgment on overbilling premature prior to discovery.

No-fault insuranceacupuncturefee scheduleworkers' compensationinsurance lawsummary judgmentappellate reviewmedical reimbursement11 NYCRR 68.5[b]judicial deference
References
11
Case No. MISSING
Regular Panel Decision

Surgicare Surgical v. National Interstate Insurance

This case addresses whether an insurer complies with New York's 11 NYCRR 68.6 regulation by reimbursing for out-of-state medical services according to the host state's (New Jersey's) no-fault fee schedule. Plaintiff Surgicare Surgical, assignee of an injured party, sought full payment for surgery performed in New Jersey, but defendant National Interstate Insurance Company paid a reduced amount based on New Jersey's fee schedule. The court affirmed the defendant's method, ruling that when medical services are rendered in another jurisdiction with its own fee schedule, the 'permissible' charge under that schedule constitutes the 'prevailing fee' under New York's regulation. The decision emphasized alignment with legislative intent to contain no-fault insurance costs and reduce judicial burden, dismissing the plaintiff's complaint and denying its cross-motion.

No-Fault BenefitsInsurance LawFee Schedule DisputeOut-of-State Medical ServicesNew York RegulationsNew Jersey Fee ScheduleStatutory InterpretationAutomobile AccidentReimbursement DisputeSummary Judgment
References
17
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

Tucciarone v. Progressive Insurance

Plaintiffs, chiropractors, initiated a breach of contract action against defendants, a group of insurance companies. They sought additional compensation for specific chiropractic treatments (diathermy, ultrasound, traction) administered during office and home visits, arguing these were not explicitly covered by no-fault insurance fee schedules. Plaintiffs contended they should receive prevailing fees for these nonscheduled discrete treatments, despite being paid the scheduled fees for visits. The Supreme Court granted summary judgment in favor of the defendants, dismissing the complaint. The appellate court affirmed, emphasizing that the chiropractic fee schedule explicitly includes "any and all chiropractic treatment and modalities" within the flat fees for home and office visits, aligning with the legislative intent of Insurance Law § 5108.

No-Fault InsuranceAutomobile Liability InsuranceChiropractic ServicesMedical Fee ScheduleBreach of ContractSummary JudgmentAppellate ReviewStatutory InterpretationRegulatory InterpretationProfessional Fees
References
1
Case No. 2022 NY Slip Op 05964 [209 AD3d 596]
Regular Panel Decision
Oct 25, 2022

Pirozzo v. Laight St. Fee Owner LLC

Plaintiff Paul Pirozzo sought summary judgment on his Labor Law § 240 (1) claim against defendants Laight Street Fee Owner LLC, Laight Street Fee Owner II LLC, and Sciame Construction, LLC, which was granted by the Supreme Court. The Appellate Division, First Department, affirmed this decision. The plaintiff established a prima facie case by demonstrating that the scaffold he was working on collapsed without an apparent reason. The defendants' arguments that the plaintiff was the sole proximate cause, either by failing to lock scaffold pins or remaining on the scaffold while it was moved, were deemed unavailing. The court noted that these actions, even if proven, would amount to comparative negligence, which is not a defense to a Labor Law § 240 (1) claim, and there was no evidence of specific instructions to the plaintiff that were disobeyed.

Summary judgmentLabor Law § 240 (1)Scaffold collapseSole proximate causeComparative negligenceWorkers' compensation Form C-2Hearsay objectionPersonal knowledgeRecalcitranceAppellate Division
References
9
Case No. MISSING
Regular Panel Decision

Great Wall Acupuncture, P.C. v. GEICO Insurance

This case involves an action brought by a medical provider against an insurer to recover assigned first-party no-fault benefits. The insurer partially paid the claim but denied the remaining portion, arguing that charges for acupuncture treatments exceeded the maximum fees allowed under the applicable fee schedule. Following a nonjury trial, the Civil Court ruled in favor of the defendant, dismissing the complaint. The court held that an insurer may utilize the workers’ compensation fee schedule for acupuncture services rendered by chiropractors, even when the services are performed by a licensed acupuncturist. The appellate court affirmed this judgment, concluding that since the defendant reimbursed the plaintiff according to the workers’ compensation fee schedule for chiropractor-provided acupuncture services, no additional reimbursement was due.

Acupuncture ServicesChiropracticNo-Fault InsuranceFee ScheduleWorkers' Compensation Fee ScheduleLicensure RequirementsFirst-Party BenefitsAppellate ReviewInsurance ReimbursementCivil Court Decision
References
4
Case No. MISSING
Regular Panel Decision

Claim of Conn v. Kotasek Corp.

A New York claimant injured their back and moved to Florida for treatment, including fusion surgery. The workers’ compensation carrier objected to the Florida physician’s bills, arguing they should conform to the New York fee schedule and that Workers’ Compensation Law § 13 (b) only applies to injuries outside New York. The Workers’ Compensation Board affirmed a decision allowing out-of-state provider fees to be limited by the Florida workers’ compensation system, not New York's fee schedule. The employer and carrier appealed this decision to the Appellate Division. The Appellate Division affirmed, citing Workers’ Compensation Law § 13 (a), which requires employers to provide necessary medical treatment, and reasoning that imposing New York’s fee schedule would effectively deny care in other states; it found the Board’s decision to apply Florida’s system rational.

Workers' Compensation LawOut-of-State Medical TreatmentFee ScheduleAppellate ReviewMedical BillsReimbursementFlorida Workers' Compensation SystemJurisdictionClaimant RightsEmployer Liability
References
4
Case No. ADJ10348591 ADJ10349019
Regular
Jan 07, 2019

MIGUEL VELAZQUEZ, SERVANDO VELAZQUEZ vs. ARTEMIO ARCE, SOLOMON MARTINEZ

The Workers' Compensation Appeals Board denied a defendant's petition for reconsideration, upholding a prior finding that liens for interpreting services were not barred by AD rule 9792.5.5. This rule, requiring a second review request for fee schedule disputes, did not apply because the interpreter services were not subject to an applicable fee schedule at the time of service. Therefore, the lien claimant's failure to request a second review did not preclude the WCAB from adjudicating the lien dispute. The Board reasoned that AD rule 9792.5.5 and associated statutes only mandate the second review process for disputes concerning amounts under an "applicable fee schedule."

Workers' Compensation Appeals BoardAD Rule 9792.5.5Official Medical Fee ScheduleIndependent Bill ReviewExplanation of ReviewLabor Code section 4603.2Senate Bill 863Threshold IssueFee Schedule DisputeInterpreter Services
References
0
Case No. ADJ5829433
Regular
Nov 08, 2017

JESSICA SENQUIZ vs. CITY OF FREMONT, YORK INSURANCE

In this workers' compensation case, the Workers' Compensation Appeals Board (WCAB) reconsidered a prior decision regarding payment for medical services. The defendant reduced payments for epidural steroid injections based on National Correct Coding Initiative (NCCI) edits, arguing this was a fee schedule dispute subject to Independent Bill Review (IBR). The WCAB ultimately rescinded the prior decision, finding that disputes over procedure coding, even if not explicitly adopted in the fee schedule, are considered disputes over the amount payable under the Official Medical Fee Schedule. Therefore, the WCAB concluded that such billing disputes are subject to IBR and not within the WCAB's jurisdiction.

WCABJessica SenquizCity of FremontYork InsuranceADJ5829433Opinion and Decision After Reconsiderationtransforaminal epidural steroid injectionsFremont Surgery CenterIndependent Bill Review (IBR)National Correct Coding Initiative (NCCI)
References
0
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