Justia Public Benefits Opinion Summaries

The case involves Alam & Sarker, LLC, a convenience store in New Bedford, Massachusetts, which was disqualified from participating in the federal Supplemental Nutrition Assistance Program (SNAP) by the United States Department of Agriculture's Food and Nutrition Service (FNS). The FNS's decision was based on data indicating irregular SNAP transactions at the store, including a high number of back-to-back transactions and unusually large purchases, which suggested trafficking in SNAP benefits.The United States District Court for the District of Massachusetts granted summary judgment in favor of the FNS. The court found that the transaction data provided sufficient evidence of trafficking and that the store failed to rebut this inference with significantly probative evidence. The Market's opposition, which included customer statements and inventory records, was deemed insufficient to create a genuine issue of material fact.The United States Court of Appeals for the First Circuit reviewed the case de novo and affirmed the district court's decision. The appellate court held that the FNS's reliance on SNAP transaction data was appropriate and that the Market did not provide adequate evidence to counter the strong inference of trafficking. The court also rejected the Market's procedural due process claim, noting that the de novo hearing in the district court cured any potential procedural deficiencies at the administrative level. The court concluded that the Market received all the process that was due and upheld the permanent disqualification from SNAP. View "Alam & Sarker, LLC v. US" on Justia Law

Harold Grimes, a coal miner for 34 years, developed black lung disease and later died of lung cancer in 2018. His widow, Susan Grimes, is eligible for survivor’s benefits under the Black Lung Benefits Act. The dispute centers on whether Apogee Coal Company, Grimes’s last employer, or the Black Lung Disability Trust Fund should pay these benefits. The Department of Labor’s administrative law judge (ALJ) and the Benefits Review Board assigned financial responsibility to Apogee, with Arch Resources Inc., Apogee’s former parent corporation, bearing the liability. Arch contested this, arguing that the Trust Fund should pay.The district director initially identified Apogee as a potentially liable operator and notified Arch as Apogee’s “Insurance Carrier.” Despite Apogee’s bankruptcy in 2015, the district director and ALJ concluded that Arch, as Apogee’s self-insuring parent, was responsible for the benefits. The ALJ’s decision was based on the premise that Arch’s self-insurance umbrella covered Apogee’s liabilities. The Benefits Review Board affirmed this decision, referencing its prior cases, including Howard v. Apogee Coal Co., which supported the Department’s theory of liability for self-insuring parents.The United States Court of Appeals for the Seventh Circuit reviewed the case and found no statutory or regulatory basis for holding Arch liable for Apogee’s obligations. The court emphasized that neither the ALJ nor the Board identified a specific provision in the Act or its regulations that justified this liability. The court vacated the Board’s decision and remanded the case with instructions to assign Mrs. Grimes’s benefits to the Black Lung Disability Trust Fund. The court noted that future cases might provide additional arguments for such liability, but in this instance, the Trust Fund must pay. View "Apogee Coal Co. v. Office of Workers' Compensation Programs" on Justia Law

In 2013, Johnny Ray Penegar, Jr. was diagnosed with mesothelioma, and Medicare partially covered his treatment costs. He filed a workers' compensation claim against his employer, UPS, and its insurer, Liberty Mutual. After his death, his wife, Carra Jane Penegar, continued the claim and added a death benefits claim. The North Carolina Industrial Commission (NCIC) ruled in her favor, ordering Liberty Mutual to cover all medical expenses related to the mesothelioma and reimburse any third parties, including Medicare. The NCIC's decision was affirmed by the North Carolina Court of Appeals and the Supreme Court of North Carolina denied further review. In 2020, Penegar and Liberty Mutual settled, with Liberty Mutual agreeing to pay $18,500 and to handle any Medicare liens.Penegar filed a class action lawsuit in the Western District of North Carolina under the Medicare Secondary Payer Act (MSP Act), alleging that Liberty Mutual failed to reimburse Medicare, leading to a collection letter from the Centers for Medicare and Medicaid Services (CMS) demanding $18,500. Liberty Mutual moved to dismiss, arguing Penegar lacked standing and that the settlement precluded her claims. The district court agreed, finding Penegar lacked standing and dismissed the case.The United States Court of Appeals for the Fourth Circuit reviewed the case and affirmed the district court's decision. The court held that Penegar did not suffer a cognizable injury in fact at the time she filed the lawsuit. The NCIC had ordered Liberty Mutual to reimburse Medicare directly, not Penegar, distinguishing her case from Netro v. Greater Baltimore Medical Center, Inc. Additionally, the CMS letter only posed a risk of future harm, which is insufficient for standing in a damages suit. Finally, any out-of-pocket expenses Penegar incurred were already compensated by Liberty Mutual before she filed the lawsuit, negating her claim of monetary injury. View "Penegar v. Liberty Mutual Insurance Co." on Justia Law

Christina Barrera, the office manager at PowerMed, was involved in a scheme to help unqualified individuals, mainly employees of AB InBev, fraudulently obtain disability benefits from the Social Security Administration (SSA) and private insurers. Patients paid PowerMed $21,600 for a "disability package" that included unnecessary medical tests and assistance in fraudulently applying for disability benefits. Barrera explained the scheme to patients, helped them complete paperwork, and coached them on how to appear disabled. An undercover officer's investigation led to Barrera's indictment and subsequent trial, where a jury found her guilty of conspiracy to defraud the SSA but acquitted her of health care fraud and theft of government funds.The United States District Court for the Eastern District of Missouri sentenced Barrera, ordering her to pay restitution to the SSA and private insurers. The presentence investigation report (PSR) recommended $339,407.80 in restitution to the SSA, but the Government argued for additional restitution to private insurers, totaling $203,907.62. The district court adopted the Government's figures, ordering Barrera to pay a total of $543,315.42 in restitution. After Barrera's sentencing, her co-conspirator Clarissa Pogue was sentenced but was not required to pay restitution to private insurers, leading Barrera to appeal.The United States Court of Appeals for the Eighth Circuit reviewed the case. The court held that Barrera's criminal conduct included defrauding private insurers as part of the scheme to defraud the SSA, affirming the district court's decision to order restitution to private insurers. However, the court found errors in the calculation of restitution amounts for Prudential and MetLife, vacating those portions and remanding for further proceedings. The court rejected Barrera's argument regarding sentencing disparities with Pogue, emphasizing that the statutory direction to avoid unwarranted sentence disparities refers to national disparities, not differences among co-conspirators. The judgment was affirmed in part, vacated in part, and remanded. View "United States v. Barrera" on Justia Law

Nancy Vargas, a bus driver for the Santa Barbara Metropolitan Transit District, injured her foot at work in March 2018. She settled her workers' compensation claim with the district in December 2020, agreeing that the injury caused a 26 percent permanent disability. Vargas also applied for subsequent injury benefits from the Subsequent Injuries Benefits Trust Fund (Fund), listing pre-existing disabilities and disclosing that she was receiving Social Security Disability Insurance (SSDI) payments.The Workers’ Compensation Appeals Board (Board) joined the Fund as a defendant in Vargas’s case. The Fund acknowledged Vargas’s eligibility for benefits but sought a credit for a portion of her SSDI payments, arguing that these payments were for her pre-existing disabilities. The workers’ compensation judge (WCJ) found that the Fund had not proven its entitlement to the credit. The Board upheld this decision, stating that the Fund failed to show that the SSDI payments were awarded for Vargas’s pre-existing disabilities.The California Court of Appeal, Second Appellate District, reviewed the case. The court affirmed the Board’s decision, holding that the Fund bears the burden of proving its entitlement to a credit for SSDI payments under Labor Code section 4753. The court found that the Fund did not provide sufficient evidence to establish that Vargas’s SSDI payments were for her pre-existing disabilities. The court emphasized that the Fund must prove the extent to which SSDI payments are attributable to pre-existing disabilities to reduce subsequent injury benefits. The court also noted that the Fund had ample opportunity to gather evidence but failed to do so. The Board’s order denying the Fund’s petition for reconsideration was affirmed. View "Subsequent Injuries Benefits Trust Fund v. Workers' Compensation Appeals Board" on Justia Law

In 2013, Ronald Fossat, a coal miner, filed a claim for benefits under the Black Lung Benefits Act (BLBA). Fossat had worked in coal mines for 24 years, with 10 years underground and 14 years above ground. He suffered from severe respiratory issues and was on oxygen therapy. After filing his claim, he underwent medical evaluations, including those by Dr. Gagon (OWCP-sponsored) and Drs. Farney and Rosenberg (requested by his employer, Sunnyside Coal Company). The evaluations produced mixed results regarding the cause and extent of his respiratory impairment.An Administrative Law Judge (ALJ) awarded Fossat benefits in 2021, concluding that he was totally disabled based on arterial blood gas studies and medical opinions. Sunnyside appealed to the U.S. Department of Labor Benefits Review Board, which affirmed the ALJ’s decision. Sunnyside then petitioned the United States Court of Appeals for the Tenth Circuit for review, arguing that the agency’s interpretation of the BLBA was erroneous and that the ALJ’s medical merits analysis was flawed.The Tenth Circuit reviewed the case and rejected Sunnyside’s arguments. The court held that Fossat’s employment qualified him for the rebuttable presumption under the BLBA, as he had worked for more than 15 years in an underground coal mine, including above-ground work at the same mine. The court also found that the ALJ correctly applied the burden of proof and that substantial evidence supported the ALJ’s conclusion that Fossat was totally disabled. The court further determined that any error in admitting a supplemental medical report was harmless, as the ALJ’s conclusions were supportable without it. Consequently, the Tenth Circuit denied Sunnyside’s petition for review. View "Sunnyside Coal Company v. Office of Workers' Compensation Programs" on Justia Law

Joseph Fortin applied for disability insurance benefits, but his claim was denied by an Administrative Law Judge (ALJ) from the Social Security Administration (SSA). Fortin argued that the ALJ who denied his claim was improperly appointed because the then-Acting Commissioner of the SSA, Nancy Berryhill, lacked the authority to ratify the ALJ's appointment. Fortin did not challenge the merits of the ALJ's decision but focused on the validity of the ALJ's appointment.The United States District Court for the Eastern District of Michigan granted summary judgment in favor of the Commissioner of Social Security, rejecting Fortin's arguments. The court held that Berryhill's ratification of the ALJ's appointment was valid and that the ALJ did not err in denying Fortin's application for benefits.The United States Court of Appeals for the Sixth Circuit reviewed the case and affirmed the district court's decision. The court held that Berryhill, as Acting Commissioner, had the authority to ratify the appointments of SSA ALJs in response to the Supreme Court's decision in Lucia v. Securities and Exchange Commission, which required ALJs to be appointed in accordance with the Appointments Clause. The court also concluded that Berryhill's actions were valid under the Federal Vacancies Reform Act and that she did not need to be reappointed by the sitting President to serve as Acting Commissioner. The court found that Berryhill's ratification of the ALJ's appointment was both constitutionally and statutorily valid, and therefore, Fortin was not entitled to a new hearing before a different ALJ. View "Fortin v. Commissioner of Social Security" on Justia Law

The case involves a class action lawsuit brought by several minor children, through their legal guardians, against the Commissioner of the Georgia Department of Community Health. The plaintiffs challenged the Department's practices regarding the provision of skilled nursing services under the Medicaid Act. Specifically, they contested the Department's use of a scoresheet to determine the number of skilled nursing hours and the practice of reducing those hours as caregivers learn to perform skilled tasks.The United States District Court for the Northern District of Georgia granted summary judgment in favor of the plaintiffs. The court ruled that the Department's review process did not give appropriate weight to the recommendations of treating physicians and that the practice of reducing skilled nursing hours as caregivers learn skilled tasks violated the Medicaid Act. The district court issued permanent injunctions requiring the Department to approve the skilled nursing hours prescribed by the patients' treating physicians.The United States Court of Appeals for the Eleventh Circuit reviewed the case and reversed the district court's decision. The appellate court held that the Department's review process, which includes the use of a scoresheet to determine a presumptive range of skilled nursing hours, complies with the Medicaid Act. The court also found that the practice of reducing skilled nursing hours as caregivers learn skilled tasks is reasonable and does not violate the Act. The court vacated the permanent injunctions and remanded the case for further proceedings. The appellate court did not address the plaintiffs' challenge regarding the consideration of caregiver capacity, as the district court had ruled that issue moot. The appeal of the preliminary injunctions was deemed moot following the vacatur of the permanent injunctions. View "M.H. v. Commissioner, Georgia Dept. of Community Health" on Justia Law

John Doe, a recipient of vocational rehabilitation services from the California Department of Rehabilitation, sought to have his rent covered while attending a law school outside commuting distance from his home. The Department agreed to cover his tuition and other expenses but refused to pay his rent, classifying it as a non-covered "long-term everyday living expense." Doe argued that rent should be considered "maintenance" under the Rehabilitation Act of 1973 and related California law, which the Department disputed.An administrative law judge (ALJ) upheld the Department's decision, interpreting the law to allow rent as "maintenance" only for short-term shelter, not for the three-year duration Doe required. The Superior Court of Orange County denied Doe's petition for a writ of mandate, agreeing with the ALJ that three years of rent did not qualify as "short-term shelter."The California Court of Appeal, Fourth Appellate District, Division Three, reviewed the case. The court found that the term "maintenance" under the Rehabilitation Act and California law includes costs incurred in excess of normal expenses while receiving vocational rehabilitation services, without distinguishing between short-term and long-term costs. The court held that the Department's categorical refusal to cover long-term rent as "maintenance" was incorrect. The court reversed the lower court's decision and remanded the case, directing the Department to reconsider Doe's request for rental assistance based on his individual circumstances, rather than a blanket policy against long-term expenses. View "Doe v. Dept. of Rehabilitation" on Justia Law

Donna Ard applied for disability benefits, claiming she was disabled due to various health issues, including anemia, chronic pain, depression, PTSD, and OCD. She was 49 years old at the time of her application, six months and seventeen days shy of her 50th birthday. Ard's application was denied by the Social Security Administration, and she subsequently requested a hearing before an administrative law judge (ALJ). The ALJ also denied her application, finding that she was not disabled under the Social Security Act.Ard appealed the ALJ's decision to the Social Security Appeals Council, which denied her request for review. She then filed a complaint in the United States District Court for the District of South Carolina. The magistrate judge affirmed the ALJ's decision, holding that the ALJ was not required to consider whether Ard should be treated as a person closely approaching advanced age under the borderline age rule, as she was more than six months away from her 50th birthday.The United States Court of Appeals for the Fourth Circuit reviewed the case and affirmed the magistrate judge's decision. The court held that the borderline age rule, which allows for consideration of a higher age category if an applicant is within a few days to a few months of reaching that category, did not apply to Ard because she was more than six months away from turning 50. The court found that the ALJ had correctly applied the legal standards and that the factual findings were supported by substantial evidence. Therefore, the court concluded that the ALJ was not required to consider treating Ard as a person closely approaching advanced age. The decision of the district court was affirmed. View "Ard v. O'Malley" on Justia Law