Justia Public Benefits Opinion Summaries

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The hospital, located in Philadelphia, received a reclassification into the New York City area, which would sizably increase the hospital’s Medicare reimbursements due to that area’s higher wage index, 42 U.S.C. 1395ww(d). Although a statute makes such reclassifications effective for three fiscal years, the agency updated the geographical boundaries for the New York City area before the close of that period and reassigned the hospital to an area in New Jersey with an appreciably lower wage index. The hospital successfully sued three agency officials in the Eastern District of Pennsylvania.The Third Circuit vacated and remanded for dismissal. The Medicare Act, 42 U.S.C. 1395oo(f)(1), channels reimbursement disputes through administrative adjudication as a near-absolute prerequisite to judicial review. The hospital did not pursue its claim through administrative adjudication before suing in federal court. By not following the statutory channeling requirement, the hospital has no valid basis for subject-matter jurisdiction. View "Temple University Hospital, Inc. v. Secretary United States Department of Health & Human Services" on Justia Law

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The “effective date of an award” of disability compensation to a veteran “shall not be earlier than the date” the veteran’s application for such compensation is received by the VA. 38 U.S.C. 5110(a)(1). Section 5110(b)(1) provides an exception that permits an earlier effective date if the VA receives the application within one year of the veteran’s discharge from military service: under such circumstances, the effective date of the award shall date back to “the day following the date of the veteran’s discharge or release.”Arellano filed his application more than 30 years after he was discharged from the Navy, he argued that section 5110(b)(1)’s one-year period should be equitably tolled to afford his award an earlier effective date reaching back to the day after his discharge. The Veterans Court denied Arellano an effective date earlier than the date his disability benefits application was received by the VA. The Federal Circuit previously held that 5110(b)(1) is not a statute of limitations amenable to equitable tolling but merely establishes an effective date for the payment of benefits, thereby categorically foreclosing equitable tolling. The Federal Circuit affirmed as to Arellano, declining to overrule that precedent, stating that the statutory text evinces clear intent to foreclose equitable tolling of section 5110(b)(1)’s one-year period. View "Arellano v. McDonough" on Justia Law

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The Supreme Court affirmed the ruling of the district court against Defendant and in favor of Plaintiff finding breach of contract and breach of implied covenant of good faith and fair dealing, holding that the district court erred.Defendant, a managed care organization, entered into a contract with Plaintiff, a dentist, to deliver dental services to Medicaid participants as a member of Defendant's network. Defendant later sent Plaintiff a "notice of non-renewal" of the provider contract. Plaintiff sued, and the district court ruled that the provider contract did not allow Defendant to terminate Plaintiff through non-renewal of the provider contract. At issue was whether Defendant properly ended a provider contract that automatically renewed for successive one-year terms by sending a notice of non-renewal. The Supreme Court affirmed, holding that the district court correctly determined that Defendant possessed no right to terminate by non-renewal. View "Colwell v. MCNA Insurance Co." on Justia Law

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Methodist Specialty Care Center (Specialty), a hospital-based nursing facility owned by Methodist Rehabilitation Center (Methodist), included an allocation of Methodist’s Medicaid Assessment in its nursing-facility cost report. The Division of Medicaid (DOM) disallowed the allocation for Specialty’s cost report, finding that Methodist’s assessment was not an allowable cost for Specialty. Specialty appealed the decision to the Chancery Court, which affirmed the decision of the DOM. Because Methodist’s assessment was not an allowable cost for Specialty under the plain language of the State Medical Plan (Plan) and the Medicaid statutory structure, the Mississippi Supreme Court affirmed the decisions of the DOM and the chancery court. View "Mississippi Methodist Hospital & Rehabilitation Center, Inc. v. Mississippi Division of Medicaid et al." on Justia Law

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Anania served in the Army, 1972-1975. In 2008, Anania sought an increased evaluation for the degenerative joint disease of his spine and major depressive disorder, and entitlement to a total disability rating based on individual unemployability. The VA issued a rating decision. Anania filed a Notice of Disagreement. In December 2009, the VA denied Anania’s request, describing the process for appeal. Anania had until March 3, 2010—one year after the date of mailing of the notification of the VA’s decision—to file a substantive appeal with the Waco Regional Office. In June 2012, Anania’s counsel, Carpenter, sent a letter to the Board of Veterans’ Appeals requesting confirmation that it had docketed Anania’s substantive appeal of the rating decision.The Board concluded that Anania failed to timely file his substantive appeal, which “was not received into VA custody until June 29, 2012.” Anania urged the Board to find his appeal timely filed under the common law mailbox rule, submitting a signed affidavit from Carpenter, alleging that Carpenter had personally mailed the substantive appeal on January 18, 2010. On remand, the Board again determined that Anania’s appeal was not timely filed, stating that the mailbox rule’s presumption of receipt did not attach because Carpenter’s affidavit was “no more than self-serving testimony.” The Veterans Court affirmed. The Federal Circuit reversed. A party’s affidavit may provide credible evidence to satisfy the mailbox rule, and the government did not challenge the credibility of Carpenter affidavit. View "Anania v. McDonough" on Justia Law

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Langdon served on active duty in the Navy, 1980-1996. After leaving service, Langdon sought disability compensation for a “spine condition especially [the] thorac[ic] [and] lumbar regions.” The VA determined Langdon had a service-connected thoracic spine injury, a non-service-connected lumbar spine injury, and only 55 degrees of forward flexion for his thoracolumbar spine. It also determined that Langdon’s service-connected thoracic spine injury caused no functional impairment; the non-service-connected lumbar spine injury caused his reduced flexion. Because his service-connected injury caused no functional impairment, the VA assigned Langdon a zero percent disability rating under 38 C.F.R. 4.71a. The Board of Veterans’ Appeals rejected his claim of entitlement to a 20 percent rating based on his limited thoracolumbar flexion but increased Langdon’s rating to 10 percent based on upper back pain under a different regulation, 38 C.F.R. 4.45(f), 4.59. The Veterans Court affirmed.The Federal Circuit reversed. The VA’s regulation requires it to rate the thoracolumbar spine as a unit when applying the General Rating Formula. Under this interpretation, the VA does not dispute that Langdon has a service-connected thoracic injury with reduced thoracolumbar flexion that entitles him to a 20 percent disability rating under the General Rating Formula. View "Langdon v. McDonough" on Justia Law

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Snyder served in the Army for fewer than 50 days in 1974, during the Vietnam “period of war,” 38 C.F.R. 3.2(f). He received an honorable discharge when a knee injury rendered him unfit. Four decades later, he was diagnosed with Amyotrophic Lateral Sclerosis (ALS). He sought disability benefits under 38 U.S.C. 1110. The Veterans Court denied his claim, rejecting Snyder’s argument under a VA regulation, made final in 2009, that provides a presumption of service connection for veterans with ALS if specified preconditions are satisfied, 38 C.F.R. 3.318(a), (b).The Federal Circuit affirmed the denial. Snyder does not satisfy one of the preconditions—that the veteran “have active, continuous service of 90 days or more.” That precondition is not contrary to the statutory scheme nor arbitrary and capricious; 38 U.S.C. 501(a) supplies the required statutory authority for the regulation and section 3.318, as an exercise of that authority, is not contrary to other statutory provisions cited by Snyder. The Secretary found no reliable evidence of a correlation between ALS and service periods as short as 90 days; it was reasonable to choose a familiar short period to avoid too demanding an evidentiary standard (no presumption) or too lenient a standard (no minimum service period) for applying the statutory requirement of service connection to ALS. View "Snyder v. McDonough" on Justia Law

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Cameron filed a Notice of Disagreement (NOD) on behalf of an Army veteran in August 2005. The VA denied Cameron attorney’s fees under 38 C.F.R. 14.636(c), which permits an attorney to charge fees for services provided before a final Board decision only where a NOD was filed on or after June 20, 2007. Before the law was amended, attorneys representing veterans in veterans’ benefits cases before the VA were prohibited from charging fees for services provided before a final Board decision.The Veterans Court and the Federal Circuit affirmed the denial, holding that section 14.636(c) is consistent with its authorizing statute, 38 U.S.C. 5904. Congress considered eliminating all fee restrictions under section 5904(c)(1) by repealing subsection (c)(1) entirely but made a legislative choice between the competing purposes of liberalizing the availability of attorney’s fees and avoiding disruption to the veterans’ benefits system, and “adopted a delayed and staggered effective date . . . [to] allow a deliberate and gradual implementation of these policies in order to minimize any disruption to the VA system.” In denying Cameron attorney’s fees, the VA has done no more than give effect to that legislative choice. View "Cameron v. McDonough" on Justia Law

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The Eleventh Circuit reversed and remanded the denial of social security disability benefits to plaintiff, who stated that he was no longer able to work due to various psychiatric conditions, which included chronic depression, anxiety, and bipolar disorder. The court held that the SSA's denial of plaintiff's application for disability benefits was not supported by substantial evidence where the ALJ did not articulate adequate reasons for discounting evidence of plaintiff's mental illness, which provided support for a finding of disability. In this case, the ALJ gave little or no weight to three pieces of evidence in the record indicating that plaintiff's mental illness prevents him from maintaining a job: (1) the opinions of plaintiff's treating psychiatrist, (2) the opinions of a consulting psychologist who examined plaintiff at the request of the SSA, and (3) plaintiff's own testimony as to the severity of his symptoms. View "Simon v. Commissioner, Social Security Administration" on Justia Law

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The plaintiffs retired from the Louisville Metropolitan police department and received free health insurance, administered by Kentucky Retirement Systems. Kentucky initially paid all of their healthcare costs. After the officers turned 65, Medicare became the primary payer, leaving Kentucky to cover secondary expenses. Each officer came out of retirement, joining county agencies different from the ones they served before retiring. They became eligible for healthcare benefits in their new positions. Kentucky notified them that federal law “mandate[d]” that it “cannot offer coverage secondary to Medicare” for retirees “eligible to be on [their] employer’s group health plan” as “active employees.” Some of the officers then paid for insurance through their new employers; others kept their retirement insurance by quitting or going part-time. The officers sued.The district court granted summary judgment to the officers, ordered Kentucky to reinstate their retirement health insurance, and awarded the officers some of the monetary damages requested. The Sixth Circuit affirmed. The officers have a cognizable breach-of-contract claim. Under Kentucky law, the Kentucky Retirement Systems formed an “inviolable contract” with the officers to provide free retirement health insurance and to refrain from reducing their benefits, then breached that contract. The Medicare Secondary Payer Act of 1980 did not bar Kentucky from providing Medicare-eligible police officers with state retirement insurance after they reentered the workforce and became eligible again for employer-based insurance coverage, 42 U.S.C. 1395y. View "River City Fraternal Order of Police v. Kentucky Retirement Systems" on Justia Law