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

Case No. 2018 NY Slip Op 07432 [166 AD3d 621]
Regular Panel Decision
Nov 07, 2018

Matter of Progressive Advanced Ins. Co. v. New York City Tr. Auth.

This case involves an appeal by Progressive Advanced Insurance Company (Progressive) against the New York City Transit Authority (NYCTA) concerning an arbitration award. The dispute arose under Insurance Law § 5105 regarding a loss transfer claim, where NYCTA sought reimbursement from Progressive for workers' compensation benefits paid to its employee after a collision involving Progressive's insured. The central issue was whether a 20% no-fault offset applied to the workers' compensation wages, with the arbitrator ruling it did not, as a one-third offset had already been applied. Progressive's petition to vacate the award was denied by the Supreme Court, Queens County. The Appellate Division affirmed this denial, concluding that the arbitrator's determination was supported by a reasonable hypothesis and was not arbitrary or capricious.

Arbitration AwardLoss TransferInsurance LawWorkers' Compensation BenefitsNo-Fault OffsetAppellate ReviewStatutory InterpretationEvidentiary SupportArbitrary and CapriciousReasonable Hypothesis
References
9
Case No. MISSING
Regular Panel Decision

Progressive Casualty Insurance v. New York State Insurance Fund

Zimone Brown, a sanitation worker insured by the New York State Insurance Fund (NYSIF), was injured after being struck by an automobile insured by Progressive Casualty Insurance Company (Progressive). The NYSIF sought reimbursement of workers’ compensation benefits from Progressive through arbitration, citing Insurance Law § 5105. Progressive contended that the garbage truck was not 'involved' in the accident as statutorily required. Although the arbitration panel sided with NYSIF, the Supreme Court denied Progressive's petition to vacate the award. This appellate court reversed the Supreme Court's decision, finding no evidentiary support or rational basis for the arbitrators' determination, thus granting Progressive's petition and vacating the arbitration award.

Arbitration Award VacaturInsurance LawWorkers' Compensation BenefitsLoss Transfer ProvisionsStatutory InterpretationMotor Vehicle AccidentEvidentiary SupportArbitrary and CapriciousJudicial ScrutinyCPLR Article 75
References
15
Case No. MISSING
Regular Panel Decision

Progressive Transportation Services, Inc. v. County of Essex

Progressive Transportation Services, Inc. sued Essex County, James Pierce, and Clifford Donaldson, asserting a 42 U.S.C. § 1983 civil rights claim for First Amendment retaliation and a state law claim for breach of contract. Progressive claimed the County retaliated against it by rejecting bids and withholding funds after Progressive combined transportation routes for efficiency, arguing this was a matter of public concern regarding taxpayer money and fuel usage. The Court determined that Progressive's speech, made in the context of contract negotiations to secure payment, was primarily an issue of economic self-interest and not a matter of public concern protected by the First Amendment. Consequently, the Court granted the defendants' motion for summary judgment, dismissing the federal claim with prejudice. The state law breach of contract claim was dismissed without prejudice, as the court declined to exercise supplemental jurisdiction after the dismissal of the federal claim.

42 U.S.C. Section 1983Civil RightsBreach of ContractFirst Amendment RetaliationSummary JudgmentGovernment ContractsFreedom of SpeechPublic Concern DoctrineSupplemental JurisdictionGovernmental Waste
References
16
Case No. MISSING
Regular Panel Decision

Progressive Northern Insurance Co. v. Sentry Insurance A Mutual Co.

Progressive Northern Insurance Company initiated an arbitration against Sentry Insurance A Mutual Company to recover first-party benefits paid to its insured following an automobile accident. After an initial arbitration claim (priority-of-payment) was denied, Progressive commenced a second arbitration based on a loss-transfer claim for the same reimbursement. Sentry raised the affirmative defense of res judicata, which the arbitrator upheld, denying Progressive's claim. Progressive then petitioned the Supreme Court, Nassau County, to vacate this arbitration award, but the petition was denied. The appellate court affirmed the Supreme Court's order, ruling that the arbitrator properly exercised its authority in applying res judicata, as both claims arose from the same transaction despite different legal theories.

Res JudicataArbitration Award VacaturInsurance ReimbursementAutomobile Accident ClaimLoss Transfer ClaimPriority-of-Payment ClaimAppellate ReviewSupreme Court NassauCPLR Article 75Arbitration Forum
References
24
Case No. MISSING
Regular Panel Decision

Garden State Anesthesia Associates, PA v. Progressive Casualty Insurance

Garden State Anesthesia Associates (GSAA) sued Progressive Casualty Insurance Company for unpaid first-party no-fault benefits after providing services to Angela Gowan-Walker. Progressive delayed payment, citing the need for Gowan-Walker's examination under oath (EUO) and extensive medical and workers' compensation records. Although Gowan-Walker completed her EUO, Progressive continued to issue delay letters, requesting information primarily from third parties and Gowan-Walker's attorney, without directly contacting GSAA for verification. The court denied Progressive's motion for summary judgment, ruling that an insurer cannot indefinitely toll the 30-day payment period by requesting verification unrelated to the specific provider's claim or by failing to request verification directly from the provider.

No-fault benefitsSummary JudgmentInsurance LawVerification RequestDelay LetterEUOMedical RecordsInsurance ClaimsTimelinessTolling
References
9
Case No. 3212, 3697, 3004
Regular Panel Decision

Progressive Casualty Insurance v. Yodice

This case involves consolidated motions stemming from a personal injury accident on March 30, 1997, involving a 'Whip ride' operated at a private party, attached to a truck owned by Dominick Yodice d/b/a Mickey's Rides N More. Injured individuals sued Mickey's. Progressive Casualty Insurance Company, the insurer of Mickey's truck, sought a declaratory judgment that it had no duty to defend or indemnify Mickey's. The court granted Progressive's motion, finding that the accident did not arise from the 'use or operation of the truck as a truck' for transportation, despite an unenforeable exclusion. Mickey's Rides N More also sought a declaratory judgment that Scottsdale Insurance Company was obligated to insure and defend it under a commercial general liability policy. The court denied Mickey's motion and granted Scottsdale's cross-motion, ruling that a 'Certificate of Insurance' was not binding and the declarations page covered a different ride, with coverage for the Whip ride not afforded until after the accident.

Insurance Coverage DisputePolicy ExclusionCommercial Auto PolicyCommercial General Liability PolicyDeclaratory JudgmentSummary JudgmentMobile Amusement RideVehicle Use and OperationProximate CauseInsurance Broker
References
12
Case No. 2017-303 K C
Regular Panel Decision
Apr 12, 2019

GL Acupuncture, P.C. v. Progressive Ins. Co.

This case involves an appeal by GL Acupuncture, P.C. from a judgment of the Civil Court of the City of New York, Kings County. The plaintiff sought to recover assigned first-party no-fault benefits for acupuncture services. The Civil Court, after a nonjury trial, awarded the plaintiff only $54.74, finding that the defendant had properly paid the claims based on the workers' compensation chiropractic fee schedule. The Appellate Term, Second Department, affirmed the judgment, concurring that the Civil Court correctly determined that the defendant had fully paid for the services billed under CPT codes 97810 and 97811 in accordance with the fee schedule, and that the plaintiff failed to rebut this showing.

Acupuncture servicesNo-fault benefitsChiropractic fee scheduleCPT codesAssigned claimsInsurance disputePrima facie caseCredibilityAppellate reviewCivil Court judgment
References
1
Case No. ADJ800751 (VNO 0554673)
Regular
May 24, 2012

RUBEN KESHISHIAN vs. PROGRESS RAIL SERVICE/VIC'S TRUCKING, LIBERTY MUTUAL INSURANCE

The Workers' Compensation Appeals Board denied reconsideration of a decision finding Ruben Keshishian was employed as a truck driver by Progress Rail Service on August 30, 2007. This finding was supported by the WCJ's analysis under the *Borello* factors, which the Board adopted. The decision was further supported by cited cases from the California Supreme Court and appellate courts. Therefore, the Petition for Reconsideration was denied.

Workers' Compensation Appeals BoardReconsideration DeniedEmployment StatusTruck DriverS.G. Borello & SonsLiberty Mutual InsuranceProgress Rail ServiceVic's TruckingWCJ OpinionAdministrative Law Judge
References
3
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. MON 0327319
Regular
Jun 02, 2008

RAMIRO DIAZ vs. THE VONS COMPANIES, INC.

This case concerns a workers' compensation claimant, Ramiro Diaz, terminated from Vons Companies after returning to work with restrictions following an industrial shoulder injury. The Appeals Board denied Vons's reconsideration request, affirming the finding that Vons violated Labor Code section 132a by illegally discriminating against the injured employee. The Board found Vons failed to follow its own progressive discipline policy and lacked credible business necessity for immediate termination, inferring retaliation for the injury.

Labor Code section 132aPrima facie caseDiscriminatory actsImpeached testimonyBusiness reality defenseProgressive disciplineSubstantial evidenceDisparate treatmentIndustrial injuryRetaliation
References
14
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