Justia Public Benefits Opinion Summaries

Articles Posted in California Courts of Appeal
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Four consolidated appeals presented a question of whether medical providers who provided services under California’s Medi-Cal program were entitled to reimbursement for the costs of providing in-house medical services for their own employees through “nonqualifying” self-insurance programs. Even for nonqualifying self-insurance programs, however, the Provider Reimbursement Manual allowed providers to claim reimbursement for reasonable costs on a “claim-paid” basis. Oak Valley Hospital District (Oak Valley) and Ridgecrest Regional Hospital (Ridgecrest) had self-insurance programs providing health benefits to their employees. Claims for in-house medical services to their employees were included in cost reports submitted to the State Department of Health Care Services (DHS). DHS allowed the costs when Oak Valley and Ridgecrest employees received medical services from outside providers but denied costs when the medical services were provided in-house. DHS determined claims paid to Oak Valley and Ridgecrest out of their self-insurance plan for in-house medical services rendered to their employees were not allowable costs. The trial court granted Oak Valley and Ridgecrest's the writ petitions on grounds that costs of in-house medical services were reimbursable so long as they were “ ‘reasonable’ ” as defined by the Provider Reimbursement Manual. DHS appealed in each case. After review, the Court of Appeal concluded Oak Valley’s and Ridgecrest’s self-insurance programs did not meet the requirements of a qualified plan under CMS guidelines and Provider Reimbursement Manual. The Court of Appeal rejected DHS’s contention that Oak Valley and Ridgecrest costs relating to in-house medical services for their employees were inherently unreasonable. To the extent DHS argued the cost reports were not per se unreasonable, but unreasonable under the circumstances of the actual treatments of Oak Valley and Ridgecrest employees, the Court determined the evidence in the record supports the trial court’s findings that expert testimony established Oak Valley and Ridgecrest incurred actual expenses in providing in-house medical services for their employees that were not otherwise reimbursed. Accordingly, the Court affirmed the trial court’s granting of the petitions for writs of administrative mandate. View "Oak Valley Hospital Dist. v. Cal. Dept. of Health Care Services" on Justia Law

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The California State Teachers’ Retirement System (CalSTRS) determined that Ernest Moreno’s retirement benefits had been incorrectly calculated and initiated proceedings to adjust Moreno’s retirement benefits and collect the overpayment. The trial court denied Moreno’s petition for writ of administrative mandamus challenging the CalSTRS actions. Moreno appealed, contending: (1) CalSTRS’s adjustment of his retirement benefits and collection of the overpayment were barred by the statute of limitations found in Education Code section 22008 (c) because CalSTRS was on inquiry notice of the problem as early as 2008; and (2) CalSTRS should have been equitably estopped from adjusting his retirement benefits and collecting the overpayments. After review, the Court of Appeal concluded: (1) CalSTRS was not on inquiry notice of the reporting error that led to overpayment until December 2014 when it began an audit of Moreno’s retirement benefits, and, therefore, CalSTRS’s adjustments to Moreno’s retirement benefits and collection of overpayments were not barred by the statute of limitations; and (2) CalSTRS was not equitably estopped because CalSTRS was not apprised of (or on notice about) the overpayments until December 2014. View "Moreno v. Cal. State Teachers' Retirement System" on Justia Law

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The Orange County Department of Child Support Services (Department) has withdrawn money from Daniel Lak’s (Father) Social Security Disability Insurance benefits (SSDI) to pay for child/spousal support arrears since 2015. Father disputed the Department's authority to withdraw money, and at a hearing, sought reimbursement for overpayments and maintained the Department violated Family Code section 5246 (d)(3) by collecting more than five percent from his SSDI. The court denied Father’s requests and determined the Department could continue withdrawing money from SSDI for support arrears. On appeal, Father maintaned the court misinterpreted the law and failed to properly consider his motion for sanctions. Finding his contentions lack merit, the Court of Appeal affirmed the court’s order the Department did not overdraw money for arrears, Father failed to demonstrate he qualified for section 5246(d)(3)’s five percent rule, and sanctions were not warranted. View "Lak v. Lak" on Justia Law

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Justice, employed as a workers’ compensation claims adjuster since 1991, fell at work in 2011 and injured her left knee. She later developed problems in her right knee, which was found to be a compensable consequence of the first injury. In 2012-2013 Justice had total bilateral knee replacement. Dr. Anderson, an orthopedic surgeon, testified that there was significant preinjury degeneration in both knees, that knee replacement was not required because of the meniscus tear, and that the fall “hasten[ed]” the need for knee replacement by “lighting up the underlying pathology.” Anderson apportioned 50 percent of the bilateral knee disability to the nonindustrial, preexisting degeneration. The workers’ compensation judge determined that Justice had sustained permanent partial disability of 48 percent, worth $59,110.00, stating that “the need for these surgeries was at least partially non-industrial. … the surgeries appear to have significantly increased [Justice’s] ability to walk and engage in weight-bearing activities. The judge stated that before the 2017 Hikida decision, he would have awarded permanent disability with 50% apportionment but that Hikida precluded apportionment. The Appeals Board affirmed.The court of appeal annulled the decision. Justice's permanent disability should have been apportioned between industrial and nonindustrial causes. Hikida, in which a medical treatment resulted in a new compensable consequential injury, is distinguishable. Here, there was unrebutted substantial medical evidence that Justice’s permanent disability was caused, in part, by preexisting pathology. Apportionment was required. Whether or not the workplace injury “directly caused” the need for surgery, the apportionment statutes demand that the disability be sorted among direct and indirect causal factors. View "County of Santa Clara v. Workers' Compensation Appeals Board" on Justia Law

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Defendant Leola Allen plead guilty to committing felony welfare fraud in 1993, 1997, and 2000 (and to committing felony perjury in 2000). At sentencing in each case, the trial court ordered Allen to pay direct victim restitution and various fines and fees. In 2018, Allen petitioned pursuant to Penal Code sections 1203.4 and 1203.42 seeking discretionary "expungement" of her convictions on the basis she had been rehabilitated. She also sought to stay, dismiss, or delete her court-ordered fines and fees because she asserted she was unable to pay them. The prosecution opposed the expungement requests because Allen still owed about $9,000 in direct victim restitution; the prosecution did not oppose the request for relief from the fines and fees. The trial court denied Allen's petitions based on her outstanding victim restitution obligations, but did not directly address her request for relief from the fines and fees. On appeal, Allen argued that under the recent decision in California v. Duenas, 30 Cal.App.5th 1157 (2019), the trial court's denial of her expungement petitions violated her due process or equal protection rights because she was financially unable to pay the victim restitution. Alternatively, Allen contended the trial court erred in its conclusion her outstanding restitution obligations deprived the court of the authority to grant discretionary expungement. The Court of Appeal found Duenas was materially distinguishable: it involved revenue-generating assessments and a punitive restitution fine, whereas this case involves voter-mandated direct victim restitution intended to make the victim whole. Furthermore, the Court agreed with the analysis of numerous courts that rejected Duenas's due process framework. On remand, however, the Court directed the trial court to conduct further proceedings: (1) because the trial court did not directly address Allen's request for relief from the court-ordered fines and fees (other than victim restitution); and (2) because the record was unclear regarding whether Allen paid all the victim restitution owed in connection with her convictions in 2000. In all other respects, judgment was affirmed. View "California v. Allen" on Justia Law

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Plaintiff argued that the Housing Authority abused its discretion in terminating her participation in the Section 8 Housing Program in the absence of any fraud, and that the Housing Authority did not have the discretion to terminate plaintiff's participation in the Program based on a misreport.The Court of Appeal held that the Housing Authority may not terminate a participant from the Program for an immaterial misreport, but that a false answer to a question about marital status did not fall within that category. The court affirmed the trial court's finding that plaintiff's false statements support her termination from the Program even in the absence of fraudulent intent, and affirmed the trial court's judgment finding that adequate grounds existed to terminate plaintiff from the Program. The court directed the trial court to remand the case to the Housing Authority to consider whether to exercise its discretion to take into account other circumstances in determining the appropriate remedy for plaintiff's violations. View "Crooks v. Housing Authority of the City of Los Angeles" on Justia Law

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Skelton sustained an ankle injury in 2012, and a shoulder injury in 2014, while working for the DMV. In the latter incident, she also claimed to have sustained an injury to her neck. Skelton filed separate workers’ compensation benefits applications. Skelton sought to be reimbursed for her wage loss for time missed at work for medical treatment and for medical evaluations (temporary disability indemnity (TDI)). Skelton’s work hours were not flexible, and she could not visit her doctors on weekends. She initially used her sick and vacation leave but eventually, her paycheck was reduced for missed time. She was then “forced to miss doctors’ appointments.” Skelton’s shoulder injury was found permanent and stationary in November 2017. Her ankle injury was not yet permanent and stationary at the time of the hearing. DMV contended that Skelton was not entitled to TDI because she had returned to work, citing Labor Code section 4600(e)(1). The Appeals Board affirmed that Skelton was not entitled to TDI for wage loss to attend medical treatment appointments following her return to work but was entitled to TDI for wage loss to attend medical-legal evaluations. The court of appeal affirmed. DMV’s obligation to pay temporary disability benefits is tied to Skelton’s actual incapacity to perform the tasks usually encountered in her employment and the resulting wage loss. View "Skelton v. Workers Compensation Appeals Board" on Justia Law

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Plaintiff-relator Matthew Omlansky, by virtue of knowledge gleaned as a state employee involved with the Medi-Cal program, brought this qui tam action in the name of the State of California alleging that defendant Save Mart Supermarkets (Save Mart) had violated the False Claims Act in its billings to Medi-Cal for prescription and nonprescription medications, charging a higher price than cash customers paid in violation of 2009 statutory provisions capping Medi-Cal charges at a provider’s usual and customary price (“statutory cap”). Per the trial court, the gist of the alleged fraud upon Medi-Cal, Save Mart generally offered a lower price for medications to cash customers, and would also match a lower price that a competitor was offering (although it appears from an exhibit to the complaint that the latter applied only to prescriptions), but did not apply these discounts from its list prices in the billings it submitted to Medi-Cal. The State declined to intervene. The trial court sustained a demurrer to the original complaint because all of the alleged violations occurred during a period when the 2009 statutory cap was subject to a federal injunction. Plaintiff then filed an essentially identical amended complaint. The only significant change was an allegation in paragraph 45 that Save Mart’s billing practices favoring cash customers continued from December 2016 to March 2017 after the expiration of the injunction, specifying six examples of “illegal pricing.” The court sustained Save Mart’s demurrer to this pleading as to two of the six grounds raised, and denied leave to amend. It entered a judgment of dismissal. Plaintiff timely appealed, but the Court of Appeal concurred with the grounds for the trial court’s ruling, thereby affirming dismissal of Plaintiff’s complaint. View "Omlansky v. Save Mart Supermarkets" on Justia Law

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Rodriguez, a Gulf War veteran, served as a Santa Cruz police officer. 1995-2007. He applied for industrial disability retirement in 2011 with the California Public Employee’s Retirement System based on his PTSD diagnosis that was caused in part by his work for the city. After litigation, the city granted Rodriguez disability retirement but denied his claim of industrial causation. He began receiving benefits in December 2016. Rodriguez requested a finding that his disability was industrial from the Workers’ Compensation Appeals Board in April 2017. The Board concluded that Rodriguez’s disability was industrial, but that he was barred from receiving industrial disability retirement benefits because his claim for a finding of industrial causation was untimely under the five-year time limitation in Government Code section 21171. The court of appeal reversed. Section 21171 applies only to rescind, alter or amend an earlier industrial determination. Section 21174 applies to initial determinations and states that a retiree claiming an industrial disability that is disputed will not receive the additional benefits “unless the application for that determination is filed with the Workers’ Compensation Appeals Board... within two years after the effective date of the member’s retirement.” If a claimant applies for a determination of industrial causation within two years of retirement but more than five years after the injury, the Board cannot modify its determination that an injury is industrial or not; nothing precludes the Board from making the initial determination of industrial causation. View "Rodriguez v. Workers' Compensation Appeals Board" on Justia Law

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In February 2015, Johnson’s landlord under the Housing and Community Development Act Section 8 housing assistance program (42 U.S.C. 1437f(o)) served a “lease violation notice” informing Johnson that she had violated her lease by following another tenant to his apartment and using profanity. In June 2015, Landlord issued a “notice to cease” stating that management had received a complaint from a resident alleging that she had used pepper spray against him. On February 29, 2016, Landlord served a “ninety-day notice of termination of tenancy.” In June, when Johnson failed to vacate, Landlord filed an unlawful detainer action. In August, the action was settled by a stipulation; Landlord agreed to reinstate Johnson’s tenancy on the condition that she conform her conduct to the lease. Landlord retained the right to apply for entry of judgment based on specified evidence of breach. In October, Landlord applied for entry of judgment, claiming that Johnson violated the stipulation. Johnson was evicted in January 2017. In February, the Oakland Housing Authority, which administers the Section 8 program, terminated Johnson's benefits. The court of appeal found no violation of Johnson’s procedural due process rights in terminating her from the program. Johnson was given sufficient notice of the grounds for termination: she failed to supply the Authority with required eviction documentation; she committed and was evicted for serious repeated lease violations. The hearing officer did not abuse its discretion in refusing to excuse the violation. View "Johnson v. Housing Authority of City of Oakland" on Justia Law