Justia Public Benefits Opinion Summaries

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The Eleventh Circuit affirmed the Commissioner's denial of plaintiff's application for disability insurance benefits pursuant to 42 U.S.C. 405(g). The court held that there is no apparent conflict between one's limitation to following simple instructions and positions that require the ability to follow "detailed but uninvolved" instructions. The court concluded that the decision to deny benefits is otherwise supported by substantial evidence. View "Buckwalter v. Acting Commissioner of Social Security" on Justia Law

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The Court of Appeal reversed the superior court's decision reversing the ALJ's finding that A.V. met the statutory criteria for developmental disability: he had a qualifying condition of autism, i.e., ASD; his ASD was substantially disabling; and the condition originated before age 18. The ALJ rejected the Regional Center's argument that a qualifying condition must not only originate but must also become "substantially disabling" before age 18. Although the superior court agreed with the ALJ's decision to the extent it found a claimant's qualifying condition need not become substantially disabling before age 18, it found that the ALJ erred by weighing the parties' evidence "on an even playing field" rather than deferring to the Regional Center's opinions about A.V.'s eligibility for services under the Lanterman Developmental Disabilities Services Act.The court concluded that the superior court erred when it deferred to the Regional Center's eligibility determinations. The court explained that a fair hearing under the Act is just that – an even playing field on which the participants present their evidence to an impartial hearing officer. In this case, the superior court owed deference not to the Regional Center's evaluators but to the administrative process created to fairly resolve disputes over eligibility for services. Accordingly, the court directed the superior court to review the petition under the appropriate standard on remand. View "Tri-Counties Ass'n v. Ventura County Public Guardian" on Justia Law

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Flores-Vazquez served on active duty in the Navy, 1984-1988. In 1998, he sought service connection for depression for which he received treatment while onboard the U.S.S. Kitty Hawk. Flores-Vazquez claimed that he had witnessed several accidental deaths during service, including “a man being sucked inside the nose of an airplane.” Flores-Vazquez did not then submit service department records verifying the incidents. Flores-Vazquez did not appeal the denial of his claim. In 2005, Flores-Vazquez sought to reopen his claim. A medical examiner diagnosed bipolar disorder with depression and determined that the condition was “due to or the result of in[-]service illness.” The regional office denied service connection, reasoning that the medical opinion was “appeared to be based on the veteran’s unsupported report.”In 2008-2009, while Flores-Vazquez’s appeal to the Board of Veterans’ Appeals was pending, the VA received the 1986-1987 command histories of the Kitty Hawk. In 2010, the Board decided that, while the evidence was not compelling, service connection was warranted. The Board relied primarily on the 2005 medical report, not the command histories, and granted an effective date of January 2005. On remand from the Veterans Court, the Board found that 38 C.F.R. 3.156(c) did not apply because the Board’s 2010 award of benefits “was not based on” the new service department records. The Federal Circuit affirmed. The command histories submitted in 2008 played no role in the grant of service connection; the favorable resolution turned on a 2005 VA opinion that was based on service medical records that were always part of the claims file. View "Flores-Vazquez v. McDonough" on Justia Law

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The Equal Access to Justice Act (EAJA), 28 U.S.C. 2412, requires that if statutory requirements are met, the federal government must reimburse attorneys’ fees of a party who prevails in a lawsuit against the government. Smith, dissatisfied with the VA’s decision regarding his claims for veterans’ benefits, took an appeal to the Veterans Court. He was successful on the merits in part of his case and requested an EAJA award for his appellate counsel. The Veterans Court agreed to an award which included fees for 18 hours the attorney spent on an initial review of the 9,389-page agency record. The court imposed a reduction in that part of the award because Smith prevailed on some but not all of the issues that were litigated. The Veterans Court reasoned that this reduction was required as a matter of law by the EAJA.The Federal Circuit reversed in part. The Veterans Court undervalued the importance of the initial review of the case, a review that is necessary before appellate counsel could determine what bases existed for an appeal. That decision was contrary to the purpose and law of the EAJA. The court noted that if Smith had brought only the successful claim, the hours would have been fully compensated. View "Smith v. McDonough" on Justia Law

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Gedatus, born in 1976, sought social security disability benefits, alleging many medical conditions, including lumbar degenerative disc disease, sciatica, leg pain, knee pain, wrist difficulties, tremors, and residual effects from a head hemorrhage. She graduated from high school. By 2003, she worked at a bar. Over the years, she underwent multiple surgeries and other treatments.After a hearing, the Administrative Law Judge agreed with Gedatus about several issues, but concluded she could perform light work with some limits, so she was not disabled. No doctor opined she needed more limits than the ALJ determined. The district judge affirmed. The Seventh Circuit affirmed the denial as supported by substantial evidence, rejecting claims that errors permeated the ALJ’s symptom evaluation and that the ALJ erred by not setting forth an assessment of her limited sitting tolerance or tremors. View "Gedatus v. Saul" on Justia Law

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In this case arising from what the Social Security Administration (SAA) did to Appellants, Marie Pagan-Lisboa and Daniel Justiniano-Ramirez, after Jose Hernandez-Gonzalez and Samuel Torres-Crespo admitted to fraudulently helping people get disability-insurance benefits from the SAA, the First Circuit held that Appellants were entitled to a new redetermination proceeding.With the help of Hernandez-Gonzalez and Torres-Crespo, Pagan-Lisboa applied for and started getting disability benefits from the SAA. An ALJ determined that Pagan-Lisboa did not have sufficient evidence to support her initial benefits claim and terminated her benefits. An ALJ also canceled Justiniano-Ramirez's benefits benefits on the grounds that Hernandez-Gonzalez had provided fraudulent evidence in support of the benefits. Thereafter, Appellants sued a putative class action, arguing that the SAA could not terminate their benefits without letting them contest the existence of fraud in their cases. The court of appeals affirmed the ALJ's decision in Justiniano-Ramírez's case and remanded Pagan-Lisboa's case back to the agency. The First Circuit held (1) the judge erred in not accepting Justiniano-Ramírez's amended complaint, which showed that he had exhausted his administrative remedies; and (2) the judge did not wrongly dismiss Appellants' policy challenges to the redetermination procedure. View "Pagan-Lisboa v. Social Security Administration" on Justia Law

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Petitioners, whose applications for disability benefits were denied by the Social Security Administration (SSA) unsuccessfully challenged their adverse determinations before an SSA administrative law judge (ALJ). The SSA Appeals Council denied discretionary review in each case. Thereafter, the Supreme Court decided Lucia v. SEC, holding that the appointment of Securities and Exchange Commission ALJs by lower-level staff violated the Constitution’s Appointments Clause. The SSA ALJs were also appointed by lower-level staff. The Courts of Appeals held that the petitioners could not obtain judicial review of their Appointments Clause claims because they failed to raise those challenges in their administrative proceedings. The Supreme Court reversed. The Courts of Appeals erred in imposing an issue-exhaustion requirement on petitioners’ Appointments Clause claims. Administrative review schemes commonly require parties to give the agency an opportunity to address an issue before seeking judicial review of that question. If no statute or regulation imposes an issue-exhaustion requirement, courts decide whether to require issue exhaustion based on “an analogy to the rule that appellate courts will not consider arguments not raised before trial courts.” In the context of petitioners’ Appointments Clause challenges, two considerations tip the scales against imposing an issue-exhaustion requirement: agency adjudications are generally ill-suited to address structural constitutional challenges, which usually fall outside the adjudicators’ areas of technical expertise, and the Supreme Court has consistently recognized a futility exception to exhaustion requirements. Petitioners assert purely constitutional claims about which SSA ALJs have no special expertise and for which they can provide no relief. View "Carr v. Saul" on Justia Law

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MAO-MSO acquired rights to collect conditional payments that Medicare Advantage Organizations (MAOs) made if a primary insurer (such as automobile insurance carriers) has not promptly paid medical expenses. MAO-MSO sued those primary payers. The district court proof of required actual injury. Specifically, MAO-MSO needed to identify an “illustrative beneficiary”— a concrete example of a conditional payment that State Farm, the relevant primary payer, failed to reimburse to the pertinent MAO. MAO-MSO alleged that “O.D.” suffered injuries in a car accident and that State Farm “failed to adequately pay or reimburse” the appropriate MAO. The district court determined that these allegations sufficed for pleading purposes to establish standing.As limited discovery progressed, MAO-MSO struggled to identify evidence supporting the complaint. One dispute centered on whether O.D.’s MAO made payments related to medical care stemming from a car accident before State Farm reached its limit under O.D.’s auto policy so that State Farm should have reimbursed the MAO. The payment in question was to a physical therapist. State Farm argued that the physical therapy services had no connection to O.D.’s car accident and related only to her prior knee surgery.The district court determined no reasonable jury could find that the payment related to O.D.’s car accident, meaning that MAO-MSO lacked standing. The Seventh Circuit affirmed the dismissal. The Medicare Act may authorize the lawsuit but MAO-MSO fail to establish subject matter jurisdiction by establishing an injury in fact. View "MAO-MSO Recovery II, LLC v. State Farm Mutual Automobile Ins. Co." on Justia Law

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Alma Vidauri was convicted of one count of theft and three counts of forgery in connection with filings she made with the Garfield County, Colorado Department of Human Services (“Department”) between 2009 and 2016 for medical assistance benefits. A division of the court of appeals concluded that the evidence was insufficient because the prosecution had not shown the difference in value between the total amount of certain public benefits Vidauri received and the amount for which she might have been eligible had she accurately reported her household income. Therefore, the division reversed the trial court and entered judgment for the lowest level of theft, a class 1 petty offense. The Colorado Supreme Court reversed the division, finding the applicable theft statute placed no burden on the prosecution to establish that Vidauri would have been ineligible for any of the benefits she received. "Because an applicant is not entitled to, and so has no legally cognizable interest in, any benefits until she has submitted accurate information demonstrating as much, we conclude that all the benefits Vidauri received by submitting false information were obtained by deception. Therefore, the original judgment of conviction for a class 4 felony must be reinstated." View "Colorado v. Vidauri" on Justia Law

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Morse served in the Navy, 1970-1972; including six months in Da Nang, Vietnam. In 1999, Morse filed a claim for compensation, listing several disabilities, including PTSD. A VA regional office granted him a nonservice-connected pension in 2001, based on joint disease. He later obtained Social Security disability benefits. In 2002, the regional office denied Morse’s claim of service connection for PTSD, finding "no credible evidence of verification of the claimed stressors.” In 2004, Morse sought to reopen his PTSD claim. The regional office received service department records in 2005, showing that in 1972 a psychiatrist reported that Morse appeared “moderately depressed” about personal problems. An examiner concluded that Morse was unable to provide convincingly relate symptoms to his reported military exposure. The Board of Veterans’ Appeals affirmed.In 2009, Morse sought to reopen his claim. A VA examiner diagnosed Morse as suffering from PTSD. The Joint Services Records Research Center (JSRRC) coordinator's memo noted that the events “reported by the veteran" are "consistent" with the conditions of service "even though we were unable to locate official records of the specific occurrence.” Morse was granted service connection for PTSD, effective in 2009. The Board in 2016 affirmed; because no additional service records had been obtained since the Board’s 2008 decision, the VA was not required to conduct another reconsideration. In 2018, the Board found that the 2010 JSRRC memorandum did not constitute an “official service department record”; Morse was “essentially attacking the merits of" the 2008 Board decision, "which is final.”The Veterans Court and Federal Circuit affirmed; the “VA’s obligation to reconsider the PTSD claim upon receipt of new service department records was exhausted in 2008.” The 2010 JSRRC memorandum did not constitute a service department record that triggered a renewed obligation to reconsider Morse’s claim. View "Morse v. McDonough" on Justia Law