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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 00599 [224 AD3d 428]
Regular Panel Decision
Feb 06, 2024

Matter of New Millennium Pain & Spine Medicine, P.C. v. Garrison Prop. & Cas. Ins. Co.

This case involves two appeals by New Millennium Pain & Spine Medicine, P.C. against Garrison Property & Casualty Insurance Company and GEICO Casualty Company. New Millennium sought to vacate master arbitration awards that denied its claims for no-fault benefits for medical services. The Supreme Court denied these applications. The Appellate Division, First Department, affirmed the Supreme Court's decisions, stating that an arbitrator's award will not be set aside unless it is irrational. The court also addressed the argument regarding a 20% wage offset in no-fault benefits, finding it unavailing under Insurance Law § 5102 (b). Ultimately, New Millennium was not entitled to attorneys' fees as it was not the prevailing party.

No-fault benefitsarbitration awardvacaturinsurance lawwage offsetappellate reviewmedical servicesno-fault policy exhaustionattorneys' feesCPLR Article 75
References
8
Case No. MISSING
Regular Panel Decision
May 05, 2000

Pain Resource Center v. Travelers Insurance

This case addresses a dispute regarding the payment of first-party no-fault benefits to a health provider, Pain Resource Center, as the assignee of John Hiotis, who was injured in an auto accident. The defendant, Travelers Ins. Co., challenged the validity of the assignment and the necessity of the medical services provided. The court affirmed the validity of the assignment under New York's Insurance Law and related regulations. However, based on conflicting expert testimonies, the court limited the compensable medical services to six hours and awarded the plaintiff $566.10, along with statutory interest and attorney's fees.

No-Fault InsuranceFirst-Party BenefitsAssignment ValidityMedical ServicesPeer ReviewInsurance LawHealth Provider ClaimAutomobile AccidentDamagesStatutory Interpretation
References
5
Case No. MISSING
Regular Panel Decision

Universal Acupuncture Pain Services, P.C. v. Lumbermens Mutual Casualty Co.

The New York court addresses a motion for reargument by Universal Acupuncture Pain Services, P.C. against Lumbermens Mutual Casualty Company concerning no-fault insurance claims. The central legal question is whether an expert witness's peer review report, created after a timely denial of a no-fault claim, can be admitted at trial, specifically under the Cirucci precedent regarding the specificity of denial grounds. The court grants the motion for reargument but upholds its initial ruling, which granted partial summary judgment on one of five claims. It clarifies that the expert's testimony must be strictly limited to the "concurrent or excessive care" ground initially stated by the insurer, excluding any new grounds like "medical necessity" not specified in the original denial. The court emphasizes that the issue of whether different treatment modalities constitute concurrent care for the same condition requires a trial for factual determination.

No-Fault InsurancePeer ReviewExpert Witness TestimonySummary Judgment MotionInsurance Law InterpretationSpecificity of DenialConcurrent Medical CareAcupuncture TreatmentChiropractic TreatmentPhysical Therapy
References
7
Case No. MISSING
Regular Panel Decision
Sep 04, 2013

Matter of Madigan v. ARR ELS

In 1994, the claimant sustained a low back injury during employment as a machinist, leading to workers' compensation benefits. Liability for the case was transferred to the Special Fund for Reopened Cases in 2003. Due to poor surgical outcomes, the claimant has been on pain medication, including oxycontin, since at least 2007, with doses escalating. A consultant for the Special Fund questioned the necessity of the increased medication, prompting a hearing. A Workers’ Compensation Law Judge ruled that the pain medications should continue, with the Special Fund covering the costs, until new Board guidelines or physician recommendations advised otherwise. The Workers’ Compensation Board affirmed this decision, citing that their Medical Treatment Guidelines for chronic pain were still in draft form at the time. The appellate court subsequently affirmed the Board's decision, noting that the guidelines were not yet in effect at the time of the Board's ruling and that the Board's interim guidance was rational.

Workers' CompensationPain ManagementOpioid PrescriptionsMedical Treatment GuidelinesSpecial FundReopened CasesLumbar InjuryOxycontinAppellate ReviewAdministrative Law
References
4
Case No. MISSING
Regular Panel Decision

Brentwood Pain & Rehabilitation Services, P.C. v. Allstate Insurance

This opinion addresses whether Magnetic Resonance Imaging (MRI) procedures are subject to the same fee limitations as X-rays under New York's no-fault auto insurance law. Plaintiffs, a group of MRI service providers ("Providers"), argued that applying x-ray fee schedules to MRIs is improper and violates insurance contracts. Defendants, numerous insurance companies ("Insurers"), along with the New York State Workers’ Compensation Board (WCB) and Department of Insurance (DOI), contended that the fee limitations for multiple diagnostic x-ray procedures (Ground Rule 3 of the WCB Fee Schedule) should also apply to MRIs. The court, deferring to the interpretations of the WCB and DOI, found their application of Ground Rule 3 to MRIs to be reasonable. Consequently, the court granted the Insurers' motion for summary judgment, denied the Providers' cross-motion for summary judgment, and denied the Providers' motion for class certification as moot.

MRIX-rayNo-Fault InsuranceFee ScheduleWorkers' Compensation BoardDepartment of InsuranceRegulatory InterpretationSummary JudgmentClass ActionDiagnostic Imaging
References
35
Case No. MISSING
Regular Panel Decision

Davis v. Larhette

The plaintiffs appealed an order from the Supreme Court, Dutchess County, which denied their motion to add Watson & Chalin Manufacturing, Inc. as an additional defendant in a personal injury case. The plaintiff, Steven L. Davis, was involved in a collision with the defendant, Allen R. Larhette, who was on a business trip for Watson & Chalin. The plaintiffs sought to apply the 'relation-back doctrine' to overcome the statute of limitations, arguing that Larhette and Watson & Chalin were 'united in interest' due to vicarious liability. The Supreme Court initially denied the motion, finding no evidence Larhette was acting within the scope of employment. The appellate court reversed, ruling that the defendant's activities while on a business trip, including stopping for dinner and returning to his motel, were incidental to the employer's business, thus establishing vicarious liability and unity of interest. Consequently, the motion to add Watson & Chalin as a defendant was granted.

Relation-back doctrineVicarious liabilityScope of employmentStatute of limitationsPersonal injuryAppellate reviewMotion to amend complaintUnity of interestEmployer liabilityRespondeat superior
References
16
Case No. 06 Civ. 3994(DC)
Regular Panel Decision
Sep 14, 2007

BRENTWOOD PAIN & REHABILITATION SERV. v. Allstate Ins. Co.

The case examines whether Magnetic Resonance Imaging (MRI) charges fall under the same discounted fee schedule rules as x-rays for multiple body parts under New York's no-fault auto insurance law. Plaintiffs, MRI service providers, contested the application of Workers' Compensation Board (WCB) Radiology Ground Rule 3 to MRIs, arguing the rule specifically mentions only x-rays. Defendant insurance companies, supported by interpretations from the Department of Insurance (DOI) and WCB, asserted the rule's applicability to MRIs. The U.S. District Court for the Southern District of New York granted summary judgment to the insurers, deferring to the agencies' "rational" and "reasonable" interpretation. The court concluded that applying the discount rule to MRIs aligns with the No-Fault Law's objectives to control costs and prevent fraud, thus denying the providers' motions.

No-Fault InsuranceMRIX-rayFee ScheduleRadiologyWorkers' Compensation BoardDepartment of InsuranceAgency DeferenceStatutory InterpretationSummary Judgment
References
25
Case No. MISSING
Regular Panel Decision
Apr 12, 1996

Van Guilder v. Sands Hecht Construction Corp.

This case involves an appeal from a judgment in an action under Labor Law § 240 (1). The judgment, entered April 12, 1996, awarded damages for past pain and suffering and past lost earnings, but zero for future damages. The court unanimously affirmed the judgment. The central issue was whether the trial court correctly instructed the jury on mitigation of damages, specifically regarding the plaintiff's refusal to undergo a myelogram, a test repeatedly recommended by his treating orthopedist for diagnosis and potential surgery. The appellate court found ample evidence to justify the mitigation charge, citing the physician's recommendation and the plaintiff's failure to attend physical therapy or seek employment. The court also affirmed the damage award, finding it reasonable given conflicting medical testimony about a herniated disc and inconsistencies in the plaintiff's testimony about his post-accident lifestyle and efforts to find work.

Labor Law § 240 (1)DamagesMitigation of DamagesMyelogramMedical DiagnosisRefusal of TreatmentPain and SufferingLost EarningsHerniated DiscWorkers' Compensation Board
References
1
Case No. ADJ10725180 ADJ11229196
Regular
Aug 08, 2018

JOAQUIN ROSALES vs. SWANSON FAHRNEY FORD, ZURICH NORTH AMERICA, GALLAGHER BASSETT SERVICES, INC.

The Workers' Compensation Appeals Board denied the defendant's petition for reconsideration, upholding the administrative law judge's award of 8% permanent disability for the applicant's left elbow injury. The award was based on a panel QME's opinion that, while no scheduled impairment existed under the AMA Guides, other factors like constant pain, loss of strength, grasping difficulty, and tendon tears justified a rating under Table 13-22 and *Guzman*. The Board found Dr. Tabaddor's rationale sufficiently supported the impairment rating, distinguishing it from the "add-on" pain provisions addressed in *Blackledge*.

ADJ10725180ADJ11229196lateral epicondylitisAMA Guidespermanent disability ratingpanel qualified medical evaluatorKhosrow TabaddorMilpitas Unified School District v. Workers' Comp. Appeals Bd. (Guzman)scheduled impairmentwhole person impairment
References
4
Case No. ADJ7850522
Regular
Mar 13, 2017

JERRY FALSETTO vs. ARCADIA UNIFIED SCHOOL DISTRICT, YORK RISK SERVICES GROUP

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration. The applicant sought to overturn a prior decision that found injury to specific body parts and awarded $42\%$ permanent disability after apportionment, while also allowing credit for temporary disability overpayments. Applicant's arguments included issues with the apportionment process, credit for overpayments, average weekly wage calculation, improper evidence service, and the inclusion of pain and IBS in the award. The Board adopted the Judge's report recommending denial, finding substantial justice did not require further record development. A dissenting commissioner believed the matter should be remanded for further evaluation of a $3\%$ pain add-on.

Workers' Compensation Appeals BoardFindings of Fact and AwardPetition for ReconsiderationArising out of and within the course of employmentAOE/COEApportionmentTemporary disability overpaymentsAverage weekly wagePermanent disabilityPain add-on
References
0
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