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For representation in administrative proceedings, the Social Security Act provides that if a fee agreement exists, fees are capped at the lesser of 25% of past-due benefits or a set dollar amount—currently $6,000, 42 U.S.C. 406(a)(2)(A); absent an agreement, the agency may set any “reasonable” fee, section 406(a)(1). In either case, the agency is required to withhold up to 25% of past-due benefits for direct payment of fees. For representation in court proceedings, section 406(b) caps fees at 25% of past-due benefits; the agency may withhold benefits to pay these fees. Culbertson represented Wood in Social Security disability benefit proceedings before the agency and in court. The agency ultimately awarded Wood past-due benefits, withheld 25%, and awarded Culbertson fees under section 406(a) for representation before the agency. Culbertson sought a separate award under 406(b) for the court proceedings, requesting 25% of past-due benefits. The Eleventh Circuit held that 406(b)’s 25% limit applies to the total fees awarded under both sections. The Supreme Court reversed. Section 406(b)(1)(A)’s 25% cap applies only to fees for court representation, not to the aggregate fees awarded under 406(a) and (b). The subsections address different stages of the representation and use different methods for calculating fees. Applying 406(b)’s 25% cap on court-stage fees to 406(a) agency-stage fees, or the aggregate fees, would make little sense and would subject 406(a)(1)’s reasonableness limitation to 406(b)’s 25% cap—a limitation not included in the statute. The fact that the agency presently withholds a single pool of past-due benefits for payment of fees does not support an aggregate reading. The amount of past-due benefits that the agency can withhold for payment does not delimit the amount of fees that can be approved for representation before the agency or the court. View "Culbertson v. Berryhill" on Justia Law

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Ashlee Oldham and Robert Prunckun (collectively, “Recipients”) were the only two Delaware Medicaid recipients housed at Judge Rotenberg Center (“JRC”), a facility in Massachusetts and the only facility in the United States known to use electric shock therapy as part of their comprehensive behavioral treatment plans. These services were covered by Medicaid with the knowledge and approval of Delaware’s Department of Health and Social Services (“DHSS”). in 2012, the Center for Medicare and Medicaid Services (“CMS”) advised the Massachusetts state agency responsible for Medicaid administration that continued use of electric shock therapy would place that state’s waiver program in jeopardy of losing federal funding. Following CMS’s letter to Massachusetts, Delaware took measures to avoid placing its own Home and Community Based Services (“HCBS”) waiver program at risk. DHSS finally terminated JRC as a qualified provider after JRC refused to cease using electric shock therapy. Although the procedural history was complex, the gist of Appellants’ challenge on appeal to the Delaware Supreme Court was that they were denied due process because Delaware’s administrative hearing officer bifurcated proceedings to address what she concluded was a threshold issue, namely, whether electric shock therapy was a covered Medicaid service under the Medicaid HCBS Waiver program. Instead, Recipients contended they should have been allowed to introduce evidence that electric shock therapy was medically necessary, and that by removing shock services, DHSS threatened Recipients’ ability to remain in a community-based setting (a conclusion they desired to prove through evidence and expert testimony). The Supreme Court determined the hearing officer's determination that electric shock therapy was not a covered service under federal and state law was supported by substantial evidence and free from legal error, and affirmed the district court. View "Prunckun v. Delaware Dept. of Health & Social Services" on Justia Law

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McHenry, a 49-year-old former hair stylist who suffers from several physical and mental disabilities, challenged the denial of her application for Social Security disability benefits. The ALJ had concluded that, although McHenry suffers from degenerative disc disease and fibromyalgia, she lacked sufficient medical evidence that the conditions were disabling, and that she was not credible about her limitations. The district court affirmed. The Seventh Circuit vacated. The ALJ erred by failing to have a medical expert review a consequential MRI report. The court rejected arguments that the ALJ improperly determined McHenry’s residual functional capacity by not accounting for McHenry’s anxiety-related limits on social functioning and limits in her ability to sustain concentration because of her medications’ side effects and by discounting McHenry’s credibility. View "McHenry v. Berryhill" on Justia Law

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Ross worked as a coal miner for approximately 30 years. He smoked cigarettes for almost as long but was able to quit after his first heart attack. Ross continued to work as a coal miner even though he suffered another heart attack and had difficulty breathing at work. Approximately six years after Ross stopped working in the coal mines, his breathing problems became severe. In 2012, Ross sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901. The Department of Labor’s Benefits Review Board vacated a denial. On remand, the ALJ granted Ross’s claim. The Board affirmed. The Seventh Circuit enforced the decision. Rejecting a due process argument, the court noted the employer had the opportunity to argue its case twice before the ALJ and twice before the Board, including the chance to submit supplemental medical opinion evidence. A theory that something must be amiss because the ALJ changed his mind on remand is particularly unpersuasive here because the parties submitted five additional medical opinions after the Board’s second decision. Ross proved by a preponderance of the evidence that he was totally disabled. View "Consolidation Coal Co. v. Director, Office of Workers’ Compensation Programs, United States Department of Labor" on Justia Law

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The Eighth Circuit reversed and remanded the district court's denial of disability insurance benefits and supplemental security income to plaintiff. The court held that the ALJ failed to provide a good reason for disregarding the treating physician's opinion when, after noting that the patient's subjective complaints formed the basis for the doctor's opinion, the ALJ stated only that she declined to accept portions of the treating physician's functional capacities assessment. View "Walker v. Commissioner, Social Security Administration" on Justia Law

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The district court affirmed the denial of social security disability benefits to claimant, holding that substantial evidence supported the ALJ's finding that claimant had the residual functional capacity to perform sedentary work. In this case, the ALJ did not err by discounting the treating physician's opinions because they conflicted with claimant's treatment records. View "Adkins v. Commissioner, Social Security Administration" on Justia Law

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After the Settlement Agreement Appeal Panel affirmed the Claim Administrator's classification of the Arcadia Facility as a "Failed Business," Graphic Packaging sought and was denied discretionary review from the district court. The Fifth Circuit affirmed the district court's denial of discretionary review, holding that the Appeals Panel did not misapply the Settlement Agreement. Even if it did, Graphic Packaging merely disputed the correctness of a discretionary administrative decision in the facts of a single claimant's case. The court rejected Graphic Packaging's remaining claim that the decision merits review because it contradicts a previous Appeals Panel decision. View "Claimant ID 100262194 v. BP Exploration & Production, Inc." on Justia Law

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The Supreme Court reversed the opinion of the district court affirming the decision of the Nebraska Department of Health and Human Services (DHHS) terminating the Medicaid benefits of Eric S., holding that the corpus of a trust was not available to Eric for purposes of determining his Medicaid eligibility. Specifically, the Court held (1) the trust at issue was properly characterized as a testamentary trust; (2) applying Pohlmann v. Nebraska Department of Health & Human Services, 710 N.W.2d 639 (Neb. 2006), the trust was a discretionary trust, and Eric did not have the ability to compel distribution of the entire corpus; and (3) therefore, it was error to find the entire trust corpus was an available resource in evaluating Eric’s eligibility for Medicaid. View "Donna G. v. Nebraska Department of Health & Human Services" on Justia Law

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Hansen served in the Army National Guard for six years, which included, at the start of his service in 1959, 182 days of active duty for training. Hansen died from amyotrophic lateral sclerosis (ALS) in 1998. In 2009, his widow applied to the VA for benefits under 38 U.S.C. 1310(a), which provides that “[w]hen any veteran dies after December 31, 1956, from a service-connected or compensable disability, the Secretary shall pay dependency and indemnity compensation to such veteran’s surviving spouse, children, and parents.” A 2008 regulation declares that “the development of [ALS] manifested at any time after discharge or release from active military, naval, or air service is sufficient to establish service connection for that disease.” 38 C.F.R. 3.318(a) (ALS Rule). The Board of Veterans’ Appeals and the Veterans Court held that Hansen’s “active duty for training” service does not qualify as active duty, and denied the benefits claim. The Federal Circuit affirmed. The 38 U.S.C.101(24) definition of “active military, naval, or air service” has been interpreted as excluding training in these circumstances. View "Hansen-Sorensen v. Wilkie" on Justia Law

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Lindh, a law enforcement officer, took blows to the head during training. He subsequently had severe headaches lasting between several hours and two days. A month later, Lindh suddenly lost most of the vision in his left eye. Two treating physicians did not believe the vision loss was related to the blows. Dr. Kaye, a neuro-ophthalmologist, the Qualified Medical Examiner (QME), agreed with the other physicians, that Lindh’s “blood circulation to his left eye was defective,” absent the injury,” Lindh likely would have retained a lot of his vision. He agreed that even had Lindh not suffered the blows, he could have lost his vision due to this underlying condition; it was “unlikely” Lindh would have suffered a vision loss if he had not had the underlying “vascular spasticity,” a rare condition. His professional opinion was that: 85% of the permanent disability was due to his old condition and 15% was due to the work injury. The ALJ rejected that analysis and found Lindh had 40 percent permanent disability without apportionment between his underlying condition and the work-related injury. The Board affirmed, concluding that the preexisting conditions were mere risk factors for an injury entirely caused by industrial factors; the QME had “confused causation of injury with causation of disability.” The court of appeal ordered an apportioned award. Dr. Kaye’s opinion was consistent with the other physicians' opinions, that it was unlikely the trauma caused the loss of vision. Whether an asymptomatic preexisting condition that contributed to the disability would, alone, have inevitably resulted in disability, is immaterial. View "City of Petaluma v. Workers' Compensation Appeals Board" on Justia Law