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

Case No. MISSING
Regular Panel Decision

Claim of Cummins v. North Medical Family Physicians

A claimant sustained a work-related back injury and sought continued medical treatment, which was initially authorized. Disputes over authorization led the claimant to retain an attorney. A Workers’ Compensation Law Judge authorized continued medical treatment but denied counsel fees, stating no "money passing" occurred. The Workers' Compensation Board upheld this decision. The claimant appealed, arguing the Board unconstitutionally applied Workers’ Compensation Law § 24, misinterpreted the statute regarding fee payment from medical benefits, and abused its discretion. The appellate court affirmed the Board's decision, ruling that counsel fees must be paid from "compensation," defined as a money allowance, and medical benefits are not considered "compensation" for this purpose, thus finding no abuse of discretion.

Workers' CompensationCounsel FeesAttorney FeesMedical TreatmentStatutory InterpretationConstitutional LawLienCompensation DefinitionAppellate ReviewBoard Decision
References
3
Case No. MISSING
Regular Panel Decision
Oct 14, 2008

Westchester Medical Center v. Lincoln General Insurance

The plaintiff appealed an order from the Supreme Court, Nassau County, which denied its motion for summary judgment to recover no-fault medical benefits. The appellate court reversed the order, granting the plaintiff's motion. The plaintiff successfully demonstrated a prima facie case by showing that statutory billing forms were mailed and received, and the defendant failed to either pay or deny the claim within the 30-day period. The court rejected the defendant's arguments that letters advising of an investigation tolled the statutory period and that the period was tolled pending a no-fault application. Additionally, defenses related to Workers' Compensation benefits or the assignor's failure to appear at an examination under oath were found insufficient to defeat the medical provider's right to benefits.

no-fault insurancemedical benefitssummary judgmentinsurance contractstatutory periodtimely denialworkers' compensationpolicy conditionpreclusion remedyappellate review
References
19
Case No. MISSING
Regular Panel Decision

Schonholz v. Long Island Jewish Medical Center

Plaintiff Gleniss Schonholz sued her former employer, Long Island Jewish Medical Center (LIJ), and several individual defendants under ERISA, seeking severance benefits. Schonholz alleged that LIJ wrongfully denied her severance benefits after requesting her resignation and promising benefits under a May 1991 plan, which she claims was revoked after her employment termination or not in writing. She also brought a promissory estoppel claim and claims against individual defendants for breach of fiduciary duty, seeking punitive damages. The court denied defendants' motion to dismiss the ERISA claim, finding plaintiff adequately alleged non-payment of benefits under a plan in effect at her termination or an invalid unwritten revocation. However, the court granted the motion to dismiss the promissory estoppel claim with leave to amend, as plaintiff failed to allege actual reliance. Claims against individual defendants for breach of fiduciary duty and for punitive damages were dismissed with prejudice, as fiduciary duties run to the plan, not individuals, and punitive damages are generally unavailable under ERISA. Cross-motions for Rule 11 sanctions were also denied.

ERISAEmployee BenefitsSeverance PayMotion to DismissPromissory EstoppelFiduciary DutyPunitive DamagesRule 11 SanctionsEmployment LawWelfare Plan
References
39
Case No. MISSING
Regular Panel Decision

In Re New York Trap Rock Corp.

The Chapter 11 debtors moved to reject and/or terminate their Executive Medical Plan (EMP), arguing that 11 U.S.C. § 1114 did not apply because the EMP was not a "plan" under the statute and the respondents were not "retired employees." Two former executives, Jerome Bennett and Robert W. Hutton, objected, asserting their rights under §§ 1114 and 1129(a)(13) to continue benefits. The court found that the EMP constituted a "plan, fund, or program" as defined by ERISA, and that the respondents were "retired employees" under § 1114, irrespective of their former executive roles or control. There was no evidence to disqualify them based on the gross income exception under § 1114(l). Consequently, the court denied the debtors' motion, requiring them to comply with 11 U.S.C. § 1114 for any termination or modification of benefits.

BankruptcyRetiree BenefitsExecutive Medical PlanERISAEmployee Welfare Benefit PlanChapter 11Debtor in PossessionContract RejectionEmployee Benefits11 U.S.C. § 1114
References
10
Case No. MISSING
Regular Panel Decision

Meehan v. County of Tompkins

The case concerns a CPLR article 78 proceeding initiated by a Tompkins County correction officer whose General Municipal Law § 207-c benefits were terminated without a prior hearing. The petitioner was injured in July 1993, and her benefits were discontinued in April 1994, effective March 1994. A subsequent hearing in August 1994 affirmed the termination based on medical testimony suggesting her disability was no longer work-related. The court upheld the finding of sufficient medical evidence for termination but ruled that the pre-hearing termination of benefits was unlawful. Consequently, the court modified the determination, ordering Tompkins County to pay benefits to the petitioner for the period between the initial termination date and the date of the hearing.

General Municipal Law § 207-cCPLR Article 78Benefit TerminationCorrection Officer InjuryDisability BenefitsWorkers' Compensation BoardPrior Hearing RequirementMedical Evidence SufficiencyDue ProcessTompkins County
References
2
Case No. ADJ2270634 (VNO 0521616)
Regular
Aug 03, 2018

SHEVON THOMAS vs. POMONA VALLEY HOSPITAL MEDICAL CENTER, Administered by ADMINSURE, INC., SUBSEQUENT INJURIES BENEFITS TRUST FUND

This case concerns an applicant seeking benefits from the Subsequent Injuries Benefits Trust Fund (SIBTF) following a 2005 industrial injury that resulted in a 69% permanent disability and a substantial settlement. The applicant's claim for SIBTF benefits was denied because she failed to establish a prior "labor disabling" permanent disability that existed before the 2005 injury. The Appeals Board upheld the denial, finding that the applicant's evidence of prior symptoms, including a doctor's speculative impairment ratings, lacked substantial medical evidence and did not meet the strict requirements for establishing a pre-existing, labor-disabling condition. The Board emphasized that post-injury medical opinions, especially those based on hypotheticals and inadequate history, cannot retroactively establish a prior disability for SIBTF eligibility.

Subsequent Injuries Benefits Trust FundSIBTFlabor disablingpermanent partial disabilityLabor Code section 4751SB 899apportionmentpreexisting disabilityAMA Guides impairment ratingsretrospective prophylactic work restrictions
References
8
Case No. MISSING
Regular Panel Decision

Claim of Rodriguez v. Burn-Brite Metals Co.

A claimant sustained a shoulder injury while working as a welder and initially received workers' compensation benefits. Payments were later suspended after the claimant admitted to being self-employed, leading to a finding of false representation in violation of Workers’ Compensation Law § 114-a. The Workers’ Compensation Law Judge (WCLJ) and subsequently the Workers’ Compensation Board terminated indemnity benefits but authorized continued coverage for causally related medical treatment. The employer and carrier appealed, contending that § 114-a should grant the Board discretionary power to terminate medical benefits as well. The appellate court affirmed the Board's decision, ruling that § 114-a is limited to wage replacement benefits (referencing Workers’ Compensation Law § 15) and does not extend to medical benefits (addressed in Workers’ Compensation Law § 13), citing the specific statutory language.

Workers' Compensation LawStatutory InterpretationMedical Benefits TerminationFraudulent RepresentationIndemnity BenefitsAppellate ReviewWorkers' Compensation BoardWage Replacement
References
2
Case No. MISSING
Regular Panel Decision

Pension Benefit Guaranty Corp. v. Broadway Maintenance Corp.

This case involves the Pension Benefit Guaranty Corporation (PBGC) and the bankrupt Broadway Maintenance Corporation (Broadway) disputing the termination date of Broadway's non-union employee pension plan. PBGC initiated the lawsuit to become the statutory trustee and sought to establish March 26, 1981, as the termination date. Broadway argued for an earlier, retroactive date. The court, guided by ERISA and the interests of the plan participants, rejected both parties' proposed dates. The judge formulated a test for involuntary terminations and ultimately established December 5, 1980, as the official termination date, citing the date PBGC first formalized its intent to terminate the plan.

ERISAPension Plan TerminationEmployee Retirement Income Security ActInvoluntary TerminationTermination Date DisputeBankruptcyPlan Participants' InterestsStatutory TrusteeFiduciary DutyPension Benefit Guaranty Corporation
References
2
Case No. 19 Misc 3d 1104(A), 2008 NY Slip Op 50546(U)
Regular Panel Decision

Westchester Medical Center v. American Transit Insurance

This case involves an appeal in an action to recover no-fault medical payments. The plaintiff, Westchester Medical Center (WMC), as assignee of Daphne McPherson, sought summary judgment against American Transit Insurance Company, arguing that the defendant failed to timely pay or deny benefits. The Supreme Court initially granted WMC summary judgment. However, the appellate court reversed this judgment, finding that the defendant had presented a prima facie case for a timely request for additional verification, which effectively tolled the period for denying the claim. The defendant's denial was based on the premise that McPherson might be entitled to workers' compensation benefits. While reversing the summary judgment for WMC, the appellate court declined the defendant's request for summary judgment or referral to the Workers' Compensation Board due to insufficient evidence from the defendant regarding workers' compensation eligibility.

No-fault medical paymentsInsurance disputeSummary judgment reversalTimely denialAdditional verificationWorkers' compensation eligibilityAppellate DivisionAssignee claimMotor vehicle accidentCivil Practice Law and Rules
References
6
Case No. MISSING
Regular Panel Decision

Queens Blvd. Medical, P.C. v. Travelers Indemnity Co.

The plaintiff, Queens Blvd. Medical, P.C., sought $950 in first-party no-fault benefits for biofeedback medical services provided to its assignor for lower back and chronic pain syndrome. The central issue at trial was the medical necessity of these services under Insurance Law § 5102 (a) (1). The plaintiff established a prima facie case with expert testimony from a board-certified neurologist affirming the medical appropriateness of biofeedback. The defendant insurance company failed to present admissible evidence to disprove medical necessity, as its expert was deemed incompetent to testify on biofeedback for back pain. Consequently, the court granted the plaintiff's motion for a directed verdict, awarding judgment for $950 along with statutory costs, interest, and attorney's fees.

No-fault benefitsMedical necessityBiofeedback treatmentExpert testimonyDirected verdictInsurance lawChronic pain syndromeBack injuryCPT codesBurden of proof
References
9
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