Justia Public Benefits Opinion Summaries

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The First Circuit held that the five-day grace period outlined in 20 C.F.R. 422.210(c) does not apply to final decisions on remand where the individual does not file any written exceptions to the administrative law judge's decision and the Appeals Council does not assume jurisdiction of the case. Plaintiff applied for Title II disability benefits with the Social Security Administration. On remand, an ALJ issued a partially favorable decision on Plaintiff’s claim. Plaintiff did not file any written exceptions to the ALJ’s decision, and the Appeals Council did not review the ALJ’s decision. Therefore, the ALJ’s decision became the final decision of the Commissioner of Social Security. Plaintiff then filed a civil action challenging the ALJ’s decision on remand. The Commissioner moved to dismiss Plaintiff’s claim as untimely. The district court ruled against Plaintiff and dismissed her complaint for being untimely filed. Plaintiff appealed, asking the First Circuit to hold that the five-day grace period outlined in section 422.210(c) applies to final decisions on remand. The First Circuit declined Plaintiff’s request, holding that Plaintiff cannot apply the five-day grace period under section 422.210(c) to save her civil claim from being untimely. View "Walker-Butler v. Berryhill" on Justia Law

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The Supreme Court held that “medical assistance” provided to Medicaid recipients includes costs for room and board and other “nonmedical” expenses at nursing facilities, and therefore, those costs can be recovered from the recipient’s estate. In this case, the Nebraska Department of Health and Human Services (DHHS) filed a petition for allowance of a claim for services provided to the decedent while he resided at two different nursing homes. The county court sustained DHHS’ motion for summary judgment, concluding that the services defined as room and board fell within the parameters of services provided under the Medical Assistance Act. The Supreme Court affirmed, holding that DHHS was statutorily authorized to recover the sums it paid for room and board costs and other expenses from the decedent’s estate. View "In re Estate of Vollmann" on Justia Law

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Substantial evidence supported finding that hospital’s contracts with physicians violated Anti-Kickback statute. Novak and Nagelvoort participated in a scheme under which Sacred Heart Hospital paid illegal kickbacks to physicians in exchange for patient referrals. Novak was the Hospital’s owner, President, and Chief Executive Officer. Nagelvoort was an outside consultant, and, at various times. served as the Hospital’s Vice President of Administration and Chief Operating Officer. Federal agents secured the cooperation of physicians and other Hospital employees, some of whom recorded conversations. Agents executed warrants and searched the Hospital and its administrative and storage facilities. The prosecution focused on direct personal services contracts, teaching contracts, lease agreements for the use of office space, and agreements to provide physicians with the services of other medical professionals. The Seventh Circuit affirmed their convictions under 42 U.S.C. 1320a-7b(b)(2)(A) and 18 U.S.C. 371, rejecting arguments that there was insufficient evidence to prove that they acted with the requisite knowledge and willfulness under the statute; that the government failed to prove that certain agreements fell outside the statute’s safe harbor provisions; and that Nagelvoort withdrew from the conspiracy when he resigned his position, so that any subsequent coconspirator statements were not admissible against him. View "United States v. Naglevoort" on Justia Law

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The Ninth Circuit affirmed the denial of plaintiff's application for attorney fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(1)(A), holding that the Commissioner's litigation position was substantially justified. Plaintiff had successfully challenged the Commissioner's denial of her application for disability benefits and obtained a remand of her claim to the agency for further consideration. In this case, the district court did not abuse its discretion in determining that the Commissioner's position was substantially justified because the Commissioner's opposition to remand the claim on the merits was reasonable, even though it turned out to be unsuccessful. Finally, plaintiff's new evidence, though sufficient in the end to persuade the district court to remand the case, did not make that the only reasonable result. View "Decker v. Berryhill" on Justia Law

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The Ninth Circuit affirmed the denial of plaintiff's application for attorney's fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(1)(A). Plaintiff presented new evidence to the Appeals Council after she lost her claim for social security disability benefits before the ALJ. The district court remanded for further consideration and the Commissioner did not appeal. The district court denied plaintiff's request for attorney's fees, concluding that the Commissioner was substantially justified in arguing that the new evidence did not undermine the ALJ's denial of benefits. The issue that was before the district court on the original merits appeal of the ALJ's denial of benefits was not whether there was other evidence that could support a denial of benefits to plaintiff, or whether the Commissioner's denial of benefits might ultimately be sustained. The Ninth Circuit explained that it was whether the actual decision that was made by the ALJ could be affirmed at that time by the district court in light of the new evidence in the record. In this case, it should have been plain that it could not have been affirmed, because the ALJ's decision failed to provide a reason that was still viable for giving the opinion of the treating doctor little weight. The doctor's final report, if credited, would have undermined the ALJ's original finding that plaintiff was not disabled. Even if the Commissioner might have had a legitimate basis for opposing plaintiff's claim, she did not have a basis to oppose remand and to argue that the district court should affirm the existing ALJ opinion. View "Gardner v. Berryhill" on Justia Law

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Social security survivors' benefits are a thing of value of the United States that can support a conviction under 18 U.S.C. 641. Viewed in the light most favorable to the government, the Fourth Circuit concluded that substantial evidence supported defendant's conviction for theft of government property beyond a reasonable doubt. In this case, the jury could reasonably infer from two denied benefits applications that defendant had a motive to file under a different benefits program to again attempt to obtain benefits to which he was not entitled. Finally, the district court's trial management was reasonable and far from an abuse of discretion. Accordingly, the court affirmed the judgment. View "United States v. Kiza" on Justia Law

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Qui tam relator failed to satisfy the False Claims Act’s materiality requirement in alleging that the manufacturer of a widely-prescribed cancer drug, Avastin, suppressed data that caused doctors to certify incorrectly that Avastin was “reasonable and necessary” for certain at-risk Medicare patients. Avastin is FDA-approved and has accounted for $1.13 billion a year in Medicare reimbursements. The relator, formerly the head of healthcare data analytics for the manufacturer, claimed the company ignored and suppressed data that would have shown that Avastin’s side effects for certain patients were more common and severe than reported and that such analyses would have required the company to file adverse event reports with the FDA, and could have resulted in changes to Avastin’s FDA label. He claimed the company caused physicians to submit Medicare claims that were not “reasonable and necessary.” The Third Circuit affirmed dismissal of the claim, stating the allegations may be true but a False Claims Act suit is not the appropriate way to address them. The manufacturer followed all pertinent statutes and regulations. If those laws and regulations are inadequate to protect patients, it falls to the other branches of government to reform them. View "Petratos v. Genentech Inc" on Justia Law

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The court affirmed the denial of plaintiff's application for supplemental security income, concluding that substantial evidence supported the ALJ's decision. Substantial evidence supported the ALJ's conclusion that claimant did not meet or equal Listing 12.05C because he did not demonstrate the adaptive function limitations necessary to qualify; the ALJ adequately accounted for plaintiff's limitations in concentration persistence, or pace in the residual functional capacity; and the vocational expert's testimony constituted substantial evidence supporting the ALJ's finding at step five. View "Scott v. Berryhill" on Justia Law

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Monk served in the Marine Corps during the Vietnam War. In 2012, Monk sought VA disability benefits, alleging service-connected PTSD, diabetes, hypertension, and strokes. The VA denied the claim, finding that his discharge was “other than honorable.” Monk filed a Notice of Disagreement (NOD) and separately applied to the Board of Correction of Naval Records (BCNR) to upgrade his discharge status. In 2015, the VA informed Monk that it could not process his appeal until it received BCNR records. Monk sought a writ of mandamus with Veterans Court and requested that the court certify a class of all veterans who had applied for VA benefits, had timely filed an NOD, had not received a decision within 12 months, and had demonstrated medical or financial hardship (38 U.S.C. 7107(a)(2)(B)–(C)). The Veterans Court denied the request for class certification, denied another veteran’s request to join the action, and ordered the VA to respond to Monk’s petition regarding the denial of disability benefits. BCNR then granted Monk an upgraded discharge status. The Federal Circuit reversed the denial of class certification, finding that the Veterans Court has authority to certify a class for a class action and to maintain similar aggregate resolution procedures with respect to benefit denials. View "Monk v. Shulkin" on Justia Law

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Plaintiff appealed the partial denial of his applications for disability insurance benefits (DIB) and supplemental security income (SSI). Plaintiff suffers from asthma, chronic obstructive pulmonary disease, high blood pressure, depression, hepatitis C, diabetes, liver damage, hepatomegaly, uveitis of the left eye, coronary artery disease, and degenerative disc disease. In this case, the Commissioner concluded that plaintiff was able to perform light work, with limitations, for a period of time before he became disabled under the Guidelines, after the Commissioner reviewed the entire record and considered the objective test results, plaintiff's subjective reports and complaints of pain, as well as the opinions of treating and consulting physician. The court found that the Commissioner's determination was within a reasonable "zone of choice." Because the Commissioner's decision to deny benefits prior to August 24, 2012, was supported by substantial evidence on the record as a whole, the court affirmed the judgment. View "Fentress v. Colvin" on Justia Law