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Case Law Database

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

Case No. ADJ4513629 (SAL 0120784)
Regular
Feb 18, 2010

RICHARD GALINDO vs. MV TRANSPORTATION, INC.; BROADSPIRE, a CRAWFORD COMPANY

This case concerns a bus driver who sustained a back injury after an altercation with a passenger. The employer denied the claim, asserting the employee was the initial physical aggressor, which would bar compensation. The Board reviewed videotape evidence and affirmed the WCJ's finding that the passenger's spitting and verbal threats constituted the initial physical aggression. Therefore, the employer failed to establish the exclusion under Labor Code section 3600(a)(7), and the injury is compensable.

WORKERS' COMPENSATION APPEALS BOARDRECONSIDERATIONINDUSTRIAL INJURYBUS DRIVERCOMPENSABILITYINITIAL PHYSICAL AGGRESSORLABOR CODE SECTION 3600(a)(7)ALTERCATIONVIDEOTAPE EVIDENCETHREAT OF BODILY HARM
References
2
Case No. ADJ15544152
Regular
May 02, 2025

TALIBAH COFFEE vs. COUNTY OF LOS ANGELES, SEDGWICK

Applicant, Talibah Coffee, sought reconsideration of a finding that her claimed industrial injury was non-compensable due to her being the initial physical aggressor in an altercation. The Workers' Compensation Appeals Board reviewed the applicant's petition, the defendant's answer, and the WCJ's report. The Board concurred with the WCJ's analysis, which found that the applicant's act of physically touching and moving a cameraman's equipment constituted the initial physical aggression, thereby barring compensation under Labor Code section 3600(a)(7). Consequently, the Petition for Reconsideration was denied.

Initial physical aggressorLabor Code section 3600(a)(7)Deputy Probation Officer IIaltercationphysical conductreal and present threat of bodily harmPetition for ReconsiderationWCJReport and Recommendationinjury AOE/COE
References
3
Case No. 2016 NY Slip Op 08955 [145 AD3d 640]
Regular Panel Decision
Dec 29, 2016

Matter of Genesis R. (Marcelino C.)

The Appellate Division, First Department, affirmed a Family Court order finding respondent father Marcelino C. neglected his children, Genesis R. and another child. The court found that Marcelino C. posed an imminent danger to the children's emotional well-being through aggressive behavior towards agency personnel, disruptive conduct at a hospital, and physical abuse of the children's mother. Specific incidents included a verbal and physical altercation with the mother in front of the older child and caseworker, and allowing the mother unsupervised access to the older child despite court restrictions. These actions demonstrated impaired parental judgment, leading to a derivative finding of neglect for the younger child as well.

NeglectChild welfareFamily Court ActAppellate DivisionEmotional well-beingParental judgmentAbuseAggressive behaviorDerivative neglectAffirmed decision
References
5
Case No. 2015-2337 Q C
Regular Panel Decision
May 18, 2018

Sama Physical Therapy, P.C. v. Hereford Ins. Co.

This case concerns an action by Sama Physical Therapy, P.C., as assignee, to recover first-party no-fault benefits from Hereford Insurance Co. The defendant argued that the plaintiff's assignor had been injured during the course of employment. The Civil Court conditionally granted defendant's cross-motion for summary judgment, ordering the plaintiff to file an application with the Workers' Compensation Board within 90 days. Plaintiff failed to comply with this order, and upon renewal, the Civil Court adhered to its prior determination. The Appellate Term, Second Department, affirmed the Civil Court's order, finding that the plaintiff did not demonstrate compliance with the order to make a proper application under the Workers' Compensation Law.

No-Fault BenefitsSummary JudgmentWorkers' Compensation BoardAppellate ReviewConditional GrantFailure to ComplyRenewal MotionInsurance LawAssigneeMedical Provider
References
1
Case No. 2015-608 Q C
Regular Panel Decision
Dec 19, 2017

Adelaida Physical Therapy, P.C. v. 21st Century Ins. Co.

In this case, Adelaida Physical Therapy, P.C., acting as an assignee, appealed an order from the Civil Court of the City of New York, Queens County. The original order had granted 21st Century Insurance Company's motion for summary judgment, dismissing parts of a complaint seeking first-party no-fault benefits for services billed under specific CPT codes (97010, 97110, and 97124). The Appellate Term, Second Department, reversed the lower court's decision. The appellate court found that 21st Century Insurance Company failed to demonstrate that it had used the correct conversion factor to calculate the reimbursement rate, thus not establishing its defense that the charged fees exceeded the workers' compensation fee schedule. As a result, the branches of the defendant's motion for summary judgment related to those CPT codes were denied.

No-Fault BenefitsCPT CodesSummary JudgmentWorkers' Compensation Fee ScheduleReimbursement RateAppellate ReviewInsurance DisputeCivil ProcedureConversion FactorMedical Billing
References
2
Case No. 2016-198 Q C
Regular Panel Decision
Jun 01, 2018

Comprehensive Care Physical Therapy, P.C. v. Allstate Ins. Co.

This case concerns a provider, Comprehensive Care Physical Therapy, P.C., seeking no-fault benefits from Allstate Insurance Company. The Civil Court initially denied the plaintiff's summary judgment motion and granted the defendant's cross-motion, dismissing the complaint based on the assignor's failure to appear for independent medical examinations (IMEs) and claims exceeding the fee schedule. On appeal, the Appellate Term modified this order, finding that Allstate failed to provide sufficient proof of timely denial form mailing, thereby precluding its defenses regarding IMEs and the fee schedule. Consequently, Allstate's cross-motion for summary judgment was denied, reversing that part of the lower court's decision. However, the Appellate Term affirmed the denial of the plaintiff's summary judgment motion, as the plaintiff also failed to establish their claims.

no-fault insurancesummary judgmentindependent medical examinationstimely denialinsurance defenseappellate reviewmedical billingassignee rightsprocedural requirementsfee schedule
References
5
Case No. 46885/05, 47943/05, 47945/05
Regular Panel Decision

Robert Physical Therapy, P.C. v. State Farm Mutual Automobile Insurance

This case involves three consolidated claims for first-party no-fault benefits related to physical therapy services. The plaintiff's assignors received physical therapy, and the defendant, an insurer, denied some claims due to disputes over billing codes. The central legal issues concerned whether a physical therapist could utilize billing codes from the medicine fee schedule when such services were not explicitly in the physical medicine schedule, and if range of motion and muscle testing could be billed separately from evaluation and management on the same day. The court determined that physical therapists are not confined to the physical medicine section and can use codes from any section of the medical fee schedule. Furthermore, the defendant failed to provide sufficient evidence to justify its denials regarding separate billing for range of motion and muscle testing. Consequently, the court ruled in favor of the plaintiff, awarding judgment for all disputed amounts.

Physical Therapy BillingNo-Fault BenefitsMedical Fee ScheduleCPT CodesWorkers' Compensation RegulationsEvaluation and Management ServicesRange of Motion TestingMuscle TestingProvider SpecialtyBilling Disputes
References
4
Case No. ADJ9781533
Regular
Aug 02, 2017

Rodolfo Boate vs. Truegreen Landcare, Zurich American Insurance Company

This case involves Rodolfo Boate's workers' compensation claim against Truegreen Landcare and Zurich American Insurance Company for injuries sustained during an altercation with a coworker. The defendant argued the claim was barred because Boate was the initial aggressor, citing his physical advance towards the coworker. However, the Workers' Compensation Appeals Board (WCAB) denied reconsideration of the Administrative Law Judge's (WCJ) finding that Boate's actions were in reasonable fear of bodily harm due to the coworker's prior severe threats and aggressive behavior. The WCAB adopted the WCJ's credibility determinations, finding no substantial evidence to reject them. Therefore, Boate's injury was deemed industrial.

Workers' Compensation Appeals BoardRODOLFO BOATETRUGREEN LANDCAREZURICH AMERICAN INSURANCE COMPANYADJ9781533Petition for ReconsiderationDeniedWCJCredibility determinationsGarza v. Workmen's Comp. Appeals Bd.
References
1
Case No. ADJ563768 (SBR 0331684), ADJ2410618 (SBR 0338943)
Regular
Mar 22, 2010

JORGE GONZALEZ vs. TOYO TIRE USA, TOKO MARINE PASADENA

Lien claimant Access Health Medical Group seeks full reimbursement for services, arguing the WCJ erred by disallowing most of its lien based on anti-referral laws (Labor Code §§ 139.3, 139.31). Access contends these laws do not apply to in-house referrals for chiropractic, acupuncture, or "work conditioning" services, as these are not "physical therapy." The Appeals Board granted reconsideration, finding the WCJ applied an overly broad definition of physical therapy. The case is returned for further proceedings to determine if the billed services were distinct from physical therapy, or if "work conditioning" constitutes physical therapy under the statute.

Labor Code §§ 139.3Labor Code § 139.31anti-referral lawsin-office referralsphysical therapychiropracticacupuncturework conditioninglien claimantFindings and Order
References
6
Case No. MISSING
Regular Panel Decision

In re Shane T.

This case concerns a 14-year-old child, Shane T., declared abused by his natural parents. The court found that the father subjected Shane to incessant verbal abuse, calling him derogatory names related to his sexual identity, causing him stomach pain and emotional distress. The court interpreted "physical injury" under the Family Court Act to include harm inflicted by verbal means, leading to protracted impairment of emotional health, expanding beyond physical force. The mother was also found to have allowed the abuse by failing to protect her son, despite knowing of the father's actions. Consequently, Shane was declared an abused child, remanded to the Commissioner of Social Services, and psychiatric and psychological evaluations were ordered.

Child AbuseVerbal AbuseEmotional InjuryFamily Court ActPhysical Injury InterpretationParental Rights vs. Child's RightsFailure to ProtectSexual Identity DiscriminationRemandPsychiatric Evaluation
References
11
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