Justia Public Benefits Opinion Summaries

An individual, born in 1937, assumed the identity of his younger brother, who died in infancy, to fraudulently obtain a second Social Security number and collect retirement benefits under both his own and his brother’s identities. Over the course of nearly two decades, he received Social Security payments in both names and also procured and used U.S. passports issued under his deceased brother’s identity. His scheme unraveled after a state motor vehicle official noticed similarities between two identification cards with different names but similar photos and addresses. Subsequent investigation revealed the use of both identities for benefits and travel, as well as submission of multiple passport applications with false information.A grand jury in the United States District Court for the District of Maine indicted the defendant on six counts, including identity theft, passport fraud, Social Security fraud, and mail fraud. At trial, the defendant contested the propriety of venue in Maine for two passport fraud counts and challenged the calculation of restitution. The district court submitted the venue question to the jury, which found venue proper for both passport counts and convicted him on all charges. He was sentenced to probation and ordered to pay $175,757 in restitution.Upon appeal, the United States Court of Appeals for the First Circuit reviewed the jury’s venue determinations and the restitution order. The court held that sufficient circumstantial evidence supported venue in Maine for both the false statement in the passport application and the use of a fraudulently obtained passport, applying the appropriate legal standards for each count. The court also found no abuse of discretion in the district court’s method for calculating restitution, concluding that the government met its burden of proof regarding the loss amount. The First Circuit affirmed both the convictions and the restitution order. View "US v. Gonzalez" on Justia Law

After her 18th birthday, a young woman with severe disabilities, requiring 24-hour care and living in a subacute facility since infancy, was placed under extended foster care as a nonminor dependent. She had no family contact and lacked the mental capacity to make independent decisions. Her county child welfare agency regularly submitted reports and transitional independent living plans, documenting her progress and confirming her continued eligibility for extended foster care. The agency recommended continued jurisdiction, especially while her application for supplemental security income was pending, and later reported plans for her care to be managed by a regional center as she approached adulthood.The Superior Court of San Bernardino County repeatedly found that she was making satisfactory progress toward her care goals and met the requirements to remain a nonminor dependent. The court ordered continued jurisdiction until, in a subsequent review, the agency recommended dismissal, citing the transition of her care to the regional center. Following a contested hearing, despite arguments from her counsel and guardian ad litem for continued court oversight, the juvenile court terminated jurisdiction. The court reasoned that ongoing jurisdiction was not in her best interest, finding no further benefit to her from county oversight given her new care arrangements.The California Court of Appeal, Fourth Appellate District, Division Two, reviewed the appeal. The court held that the juvenile court applied the wrong legal standard by terminating jurisdiction based on a subjective best interest determination instead of the statutory criteria. Under section 391, jurisdiction over a nonminor dependent may only be terminated if the nonminor does not wish to remain under jurisdiction, is not participating in a reasonable transitional plan, or cannot be located. None of these circumstances applied. The appellate court therefore reversed the termination order and directed reinstatement of jurisdiction. View "In re Violet S." on Justia Law

Several employee associations and a retired county employee challenged a resolution adopted by the Ventura County Employees’ Retirement Association (VCERA). The resolution limited the amount of cashed out leave that could be included in the calculation of “compensation earnable”—a key figure used to determine retirement benefits for so-called legacy members (employees hired before 2013) under the County Employees Retirement Law of 1937. The dispute centered on the California Public Employees’ Pension Reform Act of 2013 (PEPRA), which amended the law to exclude from pension calculations any leave cashout payments exceeding what may be “earned and payable in each 12-month period during the final average salary period,” regardless of when the payment is made. The controversy arose when a retired employee sought to have all 240 hours of his cashed out leave included in his final compensation period, even though county rules allowed only 200 hours to be cashed out per calendar year.The Santa Barbara County Superior Court granted summary adjudication in favor of VCERA, concluding that PEPRA’s section 31461(b)(2) was ambiguous but, as explained in the California Supreme Court’s earlier decision in Alameda County Deputy Sheriff’s Assn. v. Alameda County Employees’ Retirement Assn., the Legislature intended to curb “pension spiking” by imposing annual limits. The Second Appellate District, Division Six, affirmed this decision, interpreting the statute to mean that only leave cashouts within the annual limitation set by employment terms could be counted.The Supreme Court of California affirmed the Court of Appeal’s judgment. It held that section 31461(b)(2) of PEPRA excludes from pension calculations any cashed out leave that exceeds the applicable annual limit during the final compensation period, even if the period straddles two calendar years. This construction aligns with the statute’s purpose to prevent pension spiking and maintain the integrity and predictability of public pension systems. View "Ventura Cty Emp Ret Assn v. Crim J Atty Ret Assn Ventura Cty" on Justia Law

A hospice provider participated in the Medicare program and sought reimbursement for hospice services provided to several patients. Medicare, through its contractor, conducted a review and determined that a substantial number of the provider's claims did not meet the required coverage criteria, resulting in a demand for repayment of nearly $1 million. The contractor’s decision was partially reversed at the next level of administrative review for some claims, but a significant number were still denied. The provider pursued further administrative appeals, including a hearing before an administrative law judge (ALJ), where testimony and medical records were considered. The ALJ ultimately found that some additional claims were covered but upheld the denial of coverage for others, concluding that the provider was financially responsible for those denied claims and could not benefit from the statutory safe harbor.After the Medicare Appeals Council failed to resolve the provider’s appeal within the prescribed time, the provider sought judicial review in the United States District Court for the Northern District of Ohio. The district court affirmed the ALJ’s decision, agreeing with the denial of coverage for the disputed claims and with the determination that the provider was not entitled to the safe harbor protection.On appeal, the United States Court of Appeals for the Sixth Circuit reviewed two issues: whether substantial evidence supported the ALJ’s denial of Medicare coverage for the claims, and whether the ALJ properly applied the Medicare statute’s safe harbor provision. The appellate court held that substantial evidence did support the denial of coverage. However, it determined that the ALJ had applied the wrong legal standard to the safe harbor inquiry. The Sixth Circuit clarified that the correct standard requires assessment of whether the provider reasonably interpreted the relevant Medicare guidance as covering the disputed claims. The court vacated the district court’s judgment as to the safe harbor issue and remanded with instructions to return the case to the ALJ for application of the correct safe harbor standard to each disputed claim. View "In Home Health, LLC v. Kennedy" on Justia Law

The plaintiff, who has a history of bipolar disorder, chronic pain due to orthopedic injuries, and an ear injury, applied for disability benefits in July 2020, alleging an inability to work since December 2019. Several consultative medical examiners assessed the plaintiff’s physical and mental impairments. While most concluded that the plaintiff was capable of routine, unskilled work, one psychologist, Dr. Pushkash, found that the plaintiff’s ability to concentrate and persist on tasks was markedly impaired due to chronic pain and psychological symptoms, though his cognitive abilities were otherwise unremarkable.After his claim was denied by Wisconsin’s disability agency, both initially and on reconsideration, the plaintiff requested a hearing before an Administrative Law Judge (ALJ). The ALJ found the plaintiff was not disabled, deeming Dr. Pushkash’s opinion “generally unpersuasive” for reasons including the one-time nature of the evaluation and the psychologist’s comments on physical pain. The Appeals Council denied review, making the ALJ’s decision final. The plaintiff then sought review in the United States District Court for the Western District of Wisconsin, which affirmed the ALJ’s decision, focusing on the ALJ’s treatment of Dr. Pushkash’s opinion.On appeal, the United States Court of Appeals for the Seventh Circuit held that while the ALJ’s analysis of Dr. Pushkash’s opinion contained several legal errors—such as failing to properly address required regulatory factors and inconsistently assessing medical opinions—these errors were harmless. The court concluded that, even if Dr. Pushkash’s opinion were fully credited, the plaintiff would not meet the regulatory criteria for disability, as he did not have the requisite number of “marked” or “extreme” limitations in areas of mental functioning. Therefore, the Seventh Circuit affirmed the judgment of the district court. View "Liapis v Bisignano" on Justia Law

The case concerns an attorney who represented a veteran in seeking disability benefits from the Department of Veterans Affairs (VA). The veteran originally filed a claim in 2007 for a bilateral hip disability and received a rating in 2008, which was later increased. In 2018, the Board issued a final denial for a higher rating for the left hip, which was not appealed and thus became final. In 2021, after the veteran underwent left hip replacement surgery, the attorney assisted with a new claim, resulting in a significantly increased rating and an award of past-due benefits. The attorney sought fees from this award, arguing that her work fell within the statutory scheme permitting attorney’s fees for representation after notice of the agency’s initial decision.The Board of Veterans’ Appeals denied the attorney’s request for fees, reasoning that the December 2021 rating decision was the initial decision for the increased rating claim, and since the attorney had not performed compensable work after that decision, she was not entitled to fees under 38 U.S.C. § 5904(c)(1). The United States Court of Appeals for Veterans Claims affirmed, concluding that the September 2021 claim for increased compensation was a new claim, not part of the same “case” as the original 2007 claim, and thus the attorney’s work prior to the December 2021 decision was not compensable.The United States Court of Appeals for the Federal Circuit reviewed the matter de novo and affirmed the Veterans Court’s decision. The court held that, for purposes of attorney’s fees under § 5904(c)(1), a new claim for increased disability based on new evidence and circumstances is not part of the same “case” as the original claim. The attorney was not entitled to fees for work performed prior to the December 2021 rating decision. The judgment was affirmed. View "JACKSON v. COLLINS " on Justia Law

The plaintiff, born in 1959, alleged disability beginning in 2016 due to chronic lower back and neck pain, degenerative disc disease, several mental health conditions, and a seizure disorder. His medical history included diagnoses of bipolar disorder, anxiety disorder, personality disorder, and non-epileptic seizures, all of which interfered with his ability to work and perform daily activities. He had not worked since 2010. His treating physician and two examining psychologists provided opinions that, if credited, would have required a disability finding.After an initial denial by an Administrative Law Judge (ALJ) and a remand by the Social Security Administration’s Appeals Council due to inconsistencies, the ALJ again denied benefits in 2020. The United States District Court for the Western District of Washington reversed and remanded, finding the ALJ’s rejection of the treating physician’s opinion was not supported by substantial evidence. On remand, a new ALJ issued another denial, again discounting the opinions of the treating and examining physicians and psychologists, and finding the plaintiff not disabled based mainly on nonexamining sources and selected evidence of normal functioning. The Magistrate Judge affirmed this decision, relying on the ALJ’s findings of inconsistencies and the law of the case doctrine regarding earlier credibility challenges.The United States Court of Appeals for the Ninth Circuit reviewed the case and held that the ALJ erred by not providing specific and legitimate reasons, supported by substantial evidence, for discounting the plaintiff’s treating physician’s and examining psychologists’ opinions, as well as the plaintiff’s subjective testimony regarding seizures and mental health symptoms. The court reversed the district court’s judgment and remanded with instructions to award benefits, concluding that the record was fully developed and did not leave serious doubt as to disability. View "ORTIZ V. BISIGNANO" on Justia Law

A state agency responsible for Medicaid administration alleged that a pharmacy and its owner, operating as a Medicaid provider, received excess Medicaid payments between 2011 and 2016 by submitting claims for more medications than records supported. After an audit, an administrative law judge upheld the agency’s determination of overpayment. The agency issued a final order demanding repayment, which survived several unsuccessful challenges by the pharmacy. In 2022, the agency, represented by the Attorney General, filed a civil action in Ingham County seeking to enforce its order and alleging common-law and statutory conversion, breach of contract, and unjust enrichment related to the overpayments.The defendants moved to change venue, arguing that the action should be heard in Wayne County, where the pharmacy owner resided and where the acts giving rise to the claims allegedly occurred, based on Michigan’s tort venue statutes. The Ingham Circuit Court transferred the case to Oakland County, identifying it as the site of the original injury. The Michigan Court of Appeals affirmed, holding that the tort venue statutes took precedence over the Attorney General venue provisions and that venue was proper in Oakland County, where the pharmacy’s registered office was located and where the funds were allegedly wrongfully withheld.The Supreme Court of Michigan reviewed the case and agreed with the Court of Appeals that the tort venue statutes, specifically MCL 600.1629 as mandated by MCL 600.1641(2), governed the venue determination because the complaint contained multiple claims, including a tort. However, the Supreme Court held that the “original injury” occurred in Ingham County, where the state agency was deprived of the funds and conducts its business. Therefore, venue was proper in Ingham County, not Oakland County. The Court affirmed in part, reversed in part, and remanded for transfer of the case to the Ingham Circuit Court. View "Department Of Health And Human Services v. Nrk Rx Inc." on Justia Law

Four individuals who were Medicaid beneficiaries in Illinois were admitted to long-term care facilities between 2018 and 2023. The facilities submitted required electronic admission packets to the Illinois Department of Healthcare and Family Services so that the cost of care could be reimbursed by Medicaid. In each case, the Department either rejected or mishandled these admission packets, resulting in the facilities not being reimbursed for all or part of the care provided. Despite regulations prohibiting providers from billing Medicaid beneficiaries for unreimbursed care, the facilities sent bills to the plaintiffs. The plaintiffs, however, did not pay these bills, nor did they suffer any loss of benefits or interruption in care.The plaintiffs filed a proposed class action in the United States District Court for the Northern District of Illinois against state officials responsible for Medicaid administration. They alleged violations of due process and the Medicaid Act, and requested only injunctive relief to require systemic changes in the admission packet review process. The defendants moved to dismiss, arguing both lack of standing and failure to state a claim. The district court found that the plaintiffs had standing because they received bills, but it dismissed the case for failure to state a claim, reasoning that the plaintiffs were not denied benefits or services and no statutory or constitutional rights were violated.On appeal, the United States Court of Appeals for the Seventh Circuit reviewed only standing. The appellate court held that the plaintiffs lacked standing for injunctive relief because they did not allege a real and immediate threat of repeated injury. The prior receipt of bills did not amount to legal harm, as the plaintiffs had no obligation to pay. The court modified the district court’s judgment to reflect a jurisdictional dismissal for lack of standing and affirmed the judgment as modified. View "Arcidiacono v Whitehorn" on Justia Law

A part-time airport guide was terminated at the onset of the COVID-19 pandemic by her employer, a tour operations company serving Japanese-speaking tourists. The employer cited three incidents as reasons for termination: the employee’s failure to sign an acknowledgment of a revised handbook (containing an at-will employment clause), an incident involving attempted unauthorized use of a TSA priority lane at the airport, and a complaint from an airline about the employee’s conduct with staff. The employee, who was not proficient in English, did not sign the acknowledgment form due to lack of understanding and requested an explanation, as directed by the handbook.Following her termination, the employee applied for unemployment benefits. The Department of Labor and Industrial Relations’ Employment Security Appeals Referees’ Office initially granted benefits, but after a hearing (which the employee missed), an appeals officer reversed that decision, finding misconduct based on the three incidents. After a second hearing with interpretation services, the appeals officer reaffirmed the misconduct finding. The Circuit Court of the First Circuit affirmed the agency’s decision, finding no abuse of discretion or error, and adequate support in the record. The Intermediate Court of Appeals also affirmed, concluding the appeals officer did not clearly err and the employee had a fair opportunity to present her case.The Supreme Court of the State of Hawai‘i reviewed the case on certiorari. It held that none of the three incidents constituted misconduct under Hawai‘i unemployment law, which requires a wilful or wanton disregard of the employer’s interests. The Court reasoned that the failure to sign the acknowledgment did not meet this standard, especially since the employer’s own deadline was flexible and progressive discipline was not properly followed. The customer service incidents did not display the necessary degree of disregard. The Supreme Court vacated the decisions of the DLIR, circuit court, and ICA, and remanded for proceedings to determine the employee’s unemployment benefit amount. View "Choi v. Tachibana Enterprises, LLC" on Justia Law