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The Eighth Circuit affirmed the district court's dismissal of plaintiff's action challenging the denial of his application for disability insurance benefits. The court held that plaintiff was not entitled to equitable tolling of the time limit, because no extraordinary circumstance prevented him from timely filing an action in the district court. In this case, plaintiff's failure to file his appeal despite clear, repeated instructions that he should do so, was at best a garden variety claim of excusable neglect for which equitable tolling was unavailable. Therefore, plaintiff's action was time-barred and was properly dismissed by the district court. View "Thompson v. Commissioner of Social Security Administration" on Justia Law

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The First Circuit reversed the order of the district court ruling that the automatic stay provision of the Puerto Rico Oversight, Management, and Economic Stability Act (PROMESA) did not apply to proceedings to determine the amount of federal court-ordered payments that the Commonwealth owed to several federally qualified health centers (FQHCs) per a 2010 injunction, holding that the automatic stay applied in this case. In 2003, several FQHCs sought to enjoin the Secretary of the Department of Health of Puerto Rico from failing to reimburse them for their reasonable costs of providing services to Medicaid patients. In 2018, the Commonwealth filed a motion notifying the district court that the Commonwealth had filed for bankruptcy under Title III of PROMESA and, therefore, the litigation was subject to the automatic stay. The district court ruled that the automatic stay did not apply. The First Circuit reversed, holding that certain provisions of PROMESA did not preclude the automatic stay’s application in this case. View "Migrant Health Center, Inc. v. Commonwealth of Puerto Rico" on Justia Law

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The Commissioner of Social Security imposed an assessment of $51,410 and a civil monetary penalty of $75,000 on Valent after the Social Security Administration found that Valent failed to disclose that she had engaged in paid work activity while receiving Social Security disability benefits. Valent argued that 42 U.S.C. 421(m)(1)(B) prohibits the Administration from considering her work activity in determining whether she continues to be eligible as a disability-benefits recipient and that her failure to disclose her paid work activity was, therefore, not a material omission, and that even if her failure to disclose her paid work activity was a material omission, she did not have actual or constructive knowledge that her omission was material. The Sixth Circuit affirmed, rejecting Valent’s argument that the Administration can consider “substantial gainful activity” but not “work” or “work activity.” The Administration’s interpretation is a permissible construction of the statute and Valent’s construction “would be impossible to implement.” The Administration would be unable to examine a beneficiary’s substantial gainful activity without considering the beneficiary’s work activity that generates profit or pay. Valent had constructive notice that her failure to report her work activity that generated profit or pay was a material omission that misled the Administration. View "Valent v. Commissioner of Social Security" on Justia Law

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Hernandez filed a voluntary Chapter 7 bankruptcy petition in December 2016, reporting one sizable asset: a pending workers’ compensation claim valued at $31,000. To place that claim beyond the reach of creditors, she listed it as exempt under section 21 of the Illinois Workers’ Compensation Act, 820 ILCS 305/21, applicable via 11 U.S.C. 522(b). Two days after filing for bankruptcy, Hernandez settled the claim. Hernandez owed significant sums to three healthcare providers who treated her work-related injuries. The providers objected to her claimed exemption, arguing that 2005 amendments to the Illinois Act enable unpaid healthcare providers to reach workers’ compensation awards and settlements. The bankruptcy court denied the exemption and the district judge affirmed. The Seventh Circuit certified to the Illinois Supreme Court the question: Whether the Illinois Workers’ Compensation Act, as amended, allows care-provider creditors to reach the proceeds of workers’ compensation claims. The court noted that Section 21 has been interpreted by bankruptcy courts to create an exemption for these assets; 2005 amendments imposed a new fee schedule and billing procedure for care providers seeking remuneration. The Illinois Supreme Court has not addressed the interplay between these competing components of state workers’ compensation law. View "Hernandez v. Marque Medicos Fullerton, LLC" on Justia Law

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MSPA, a firm that obtains Medicare Secondary Payer Act (MSP Act) claims and brings them on behalf of Medicare Advantage Organizations (MAOs), filed suit against Tenet over a delayed reimbursement of $286. The Eleventh Circuit affirmed the district court's grant of Tenet's motion to dismiss. The court held that MSPA had standing to invoke a federal court's jurisdiction because it suffered an injury in fact when it had to wait seven months for appropriate reimbursement and it validly assigned the right to vindicate that injury to La Ley Recovery Systems, who in turn validly assigned it to MSPA. On the merits, the court held that the MSP Act's private cause of action was only available in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement). In this case, MSPA did not sue a primary plan, but instead, it sued two medical services providers. Because private MSP Act plaintiffs could only sue primary plans, and MSPA had not done so, its claim was not plausible on its face. Therefore, the district court correctly dismissed MSPA's complaint for failure to state a claim. View "MSPA Claims 1, LLC v. Tenet Florida, Inc." on Justia Law

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Ruel served in the Marine Corps, 1966-1969, including two tours in Vietnam; he was exposed to Agent Orange. He died in 1984. His wife, Teresa, sought benefits. In July 1984, the VA received her Form 21-534, which the VA treats as an application for Dependency and Indemnity Compensation (DIC) a benefit paid to eligible survivors of veterans whose death resulted from a service-related injury or disease, and for a Death Pension, a benefit payable to a low-income, un-remarried surviving spouse of a deceased veteran with wartime service, 38 U.S.C. 5101(b)(1). The claim for pension benefits was denied based on her income; the denial did not mention a DIC claim. In response to Teresa's “Application for Burial Benefits,” the VA authorized payment of $150.00, stating: The evidence does not show that the veteran’s death was due to a service-connected condition. Teresa did not appeal. In 2009, ischemic heart disease was added to the presumptive list of diseases related to herbicide exposure while serving in Vietnam. Teresa submitted a new Form 21-534. Her claim was granted with an effective date of October 2009. Teresa sought an effective date of July 1984 arguing that the VA never adjudicated her 1984 DIC claim, which remained “pending.” The Federal Circuit reversed the Board and Veterans Court; proper notice of an explicit denial of a claim under 38 C.F.R. 3.103 requires an actual statement or otherwise clear indication of the claim being denied. View "Ruel v. Wilkie" on Justia Law

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Nita and her husband, Kirtish, pled guilty to defrauding Medicare (18 U.S.C. 1347), based on having forged physicians’ signatures on diagnostic reports and having conducted diagnostic testing without the required physician supervision. The government then brought this civil action for the same fraudulent schemes against Nita, Nita’s healthcare company (Heart Solution), Kirtish, and Kirtish’s healthcare company (Biosound). The district court granted the government summary judgment, relying on the convictions and plea colloquies in the criminal case, essentially concluding that Nita had admitted to all elements and issues relevant to her civil liability. Nita and Heart Solution appealed. The Third Circuit affirmed Nita’s liability under the False Claims Act, 31 U.S.C. 3729(a)(1)(A) and for common law fraud but vacated findings that Heart Solution is estopped from contesting liability and damages for all claims and Nita is estopped from contesting liability and damages for the remaining common law claims. The district court failed to dissect the issues that were determined in the criminal case from those that were not, lumping together Nita and Heart Solution, even though Heart Solution was not involved in the criminal case. It also failed to disaggregate claims Medicare paid to Nita and Heart Solution from those paid to Kirtish and Biosound. The plea colloquy did not clarify ownership interests in the companies; who, specifically, made certain misrepresentations; nor whether one company was paid the entire amount or whether the payments were divided between the companies. View "Doe v. Heart Solution PC" on Justia Law

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Jones served in the Marine Corps, 1968-1970. A VA psychiatrist treated him and diagnosed him with PTSD in 2000. Jones formally applied for disability benefits for PTSD in 2011. In 2012, the VA Regional Office awarded him a 100% disability rating, effective April 2011, the date it received his formal application. Jones filed a notice of disagreement arguing that he should receive an earlier effective date that reflects VA medical treatment beginning in 2000. Jones asserted that he “did not file until 11 years later because the doctors did not explain to [him] what PTSD really was.” In 2015, the Board denied the claim, acknowledging the existence of “VA medical records showing treatment for mental health symptoms” in 2000, but finding that the records before it “[did] not indicate an intent to file a claim for benefits and are not considered an ‘informal claim’'.” The Veterans Court affirmed, finding no informal claim under 38 C.F.R. 3.155(a). Jones died in 2016; his wife substituted into the case, arguing that the Veterans Court applied a heightened standard to determine whether the VA was required to assist Jones in obtaining his treatment records, which might contain an earlier, informal claim. The Federal Circuit vacated the denial. The Veterans Court erred in ruling that the duty to assist only “includes obtaining records of treatment at VA facilities that are relevant to the claim.” View "Jones v. Wilkie" on Justia Law

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In this case, a Supplemental Nutrition Assistance Program (“SNAP”) recipient, Cindy Gonzalez, was found to have defrauded the federal government of $6,159 worth of SNAP benefits by representing that she lived alone and did not receive any income, when in fact she was not living alone and was receiving income. After discovering this wrongdoing, the Delaware Department of Health and Social Services (“DHSS”) brought an administrative proceeding against Gonzalez to disqualify her from continued participation in SNAP and claw back the benefits she received through her misrepresentations. The hearing officer found that DHSS had established intentional program violations and disqualified Gonzalez from continued participation in SNAP for one year, and DHSS’s audit and recovery arm assessed an overpayment of $6,159, which the federal government has started to collect by offsetting the other federal benefits she receives against her SNAP obligations. About five months after the DHSS final decision, the State of Delaware brought a civil action against Gonzalez under Delaware common law and the Delaware False Claims and Reporting Act based on the same circumstances underlying the DHSS administrative proceeding. This time, however, the State sought between approximately $200,000 and $375,000 in restitution, damages, and penalties; attorneys’ fees and costs; and an order enjoining Gonzalez from participating in SNAP until she pays the judgment. Gonzalez in turn filed an answer asserting an affirmative defense that federal law preempted the State’s Delaware law claims, and the State moved for judgment on the pleadings. The Superior Court granted the State’s motion, holding that federal law did not preempt the State’s claims. Gonzalez brought an interlocutory appeal of that determination. After review, the Delaware Supreme Court reversed, finding federal law prohibited the State from bringing consecutive administrative and civil actions against a SNAP recipient based on the same fraud. View "Gonzalez v. Delaware" on Justia Law

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James served on active duty during the Vietnam War. He sought service-connected disability compensation for “a lumbar spine disability and cervical spine disability, as well as an increased rating claim for pseudofolliculitis barbae.” On January 28, 2016, the Board of Veterans’ Appeals denied his claims.. On Friday, May 27, James placed his notice of appeal (NOA) in a stamped envelope addressed to the Veterans Court in the mailbox at his residence and put the flag up for collection. James left town and did not return until late on Monday, May 30. James discovered the NOA still in his mailbox and deposited it that night at the post office. The next day, the Veterans Court received and docketed James’s NOA, which bore a postmark of May 31, more than 120 days after the Board mailed its decision. The court ordered James to “show cause why his appeal should not be dismissed.” James argued that the 120-day appeal window should be equitably tolled because an errantly lowered mailbox flag constituted an extraordinary circumstance beyond his control. The Veterans Court dismissed James’s appeal as untimely. The Federal Circuit vacated. The Veterans Court erred in creating a categorical ban by holding that equitable tolling can never apply to an entire category of cases involving a fallen mailbox flag. The extraordinary circumstance element necessarily requires a case-by-case analysis and not a categorical determination. View "James v. Wilkie" on Justia Law