Justia Public Benefits Opinion Summaries

A veteran who suffered a traumatic brain injury from an improvised explosive device while deployed sought financial assistance under the Traumatic Servicemembers’ Group Life Insurance (TSGLI) program after experiencing a stroke within two years of the injury. The Army denied his claim, determining the stroke was a physical illness or disease, not a qualifying traumatic injury as defined by the relevant statute and regulations. The veteran then petitioned the Department of Veterans Affairs (VA) to amend its rules to include coverage for illnesses or diseases caused by explosive ordnance, arguing these conditions are analogous to those already covered under existing exceptions for injuries resulting from chemical, biological, or radiological weapons.The VA initially denied the rulemaking petition but agreed to further review as part of a program-wide assessment. After several years, extensive consultation with medical experts, and consideration of the petition and supporting materials, the VA issued a final denial. It concluded that expanding coverage to delayed illnesses or diseases linked to explosive ordnance would be inconsistent with TSGLI’s purpose, which focuses on immediate injuries, would deviate from the insurance model underlying the program, and could threaten its financial stability. The VA also found insufficient evidence of a direct causal relationship between explosive ordnance, traumatic brain injury, and downstream illnesses like stroke.The United States Court of Appeals for the Federal Circuit reviewed the VA’s denial under the highly deferential “arbitrary and capricious” standard of the Administrative Procedure Act. The court held that the VA provided a reasoned explanation addressing the petitioner’s arguments and the record, and did not act arbitrarily or capriciously. The petition for review was therefore denied. View "MCKINNEY v. SECRETARY OF VETERANS AFFAIRS " on Justia Law

James Young, a veteran who served in the military during the mid-1980s, initially filed a claim for service-connected disability benefits in 1988, alleging head injuries from an in-service car accident. The Department of Veterans Affairs (VA) regional office denied his claim in 1991, and after several years of proceedings, the Board of Veterans’ Appeals denied the claim in 1999, citing Young’s failure to appear for scheduled medical examinations. Young did not appeal the Board’s 1999 denial. Years later, in 2017, following a new claim and medical examinations, the VA granted service connection for his head injuries effective August 17, 2012.Seeking an earlier effective date linked to his original 1988 claim, Young filed a motion in 2022 with the Board to vacate its 1999 denial, alleging due process violations because the Board had failed to ensure the regional office complied with orders to search for certain records. The Board denied the motion, characterizing the alleged error as a “duty to assist error” rather than a due process error. Young appealed this denial to the United States Court of Appeals for Veterans Claims, which dismissed the appeal. The Veterans Court found that while the appeal was timely regarding the denial of the motion to vacate, such a denial was not an appealable decision under its jurisdictional statute.Upon review, the United States Court of Appeals for the Federal Circuit affirmed the Veterans Court’s dismissal. The Federal Circuit held that the Board’s denial of a motion to vacate under 38 C.F.R. § 20.1000(a), when based solely on alleged material error known at the time of the original decision, does not constitute an appealable “decision” under 38 U.S.C. § 7252. The court determined that allowing appeals from such procedural denials would undermine the statutory time bar and permit indefinite judicial review of Board decisions. View "YOUNG v. COLLINS " on Justia Law

The appellant, a Ventura County Deputy Sheriff, suffered two work-related back injuries in 2014 and 2015. Medical evaluations revealed degenerative disc disease and herniation at the L5-S1 level. Multiple physicians recommended surgical intervention, and the County authorized surgery to address his condition. However, the appellant declined the recommended procedures, citing concerns about surgical outcomes and referencing anecdotal experiences of colleagues. Later, his condition progressed, and more extensive surgery was suggested, but authorization for additional procedures was denied due to insufficient evidence. Despite ongoing pain, the appellant also declined to participate in a recommended home exercise program and a work hardening regimen.After the appellant applied for service-connected disability retirement, his application was challenged by the County and assigned to VCERA’s hearing officer for review. During the administrative hearing, the appellant testified about his refusal of surgery and physical therapy, while medical experts presented conflicting views on his prognosis and ability to return to work. The hearing officer found that the appellant had unreasonably refused recommended medical treatments with a high probability of success, and that his refusal likely worsened his condition, making him ineligible for service-connected disability retirement benefits. The Board adopted these findings and denied his application.The Superior Court of Ventura County denied the appellant’s petition for a writ of administrative mandate, concluding that his unreasonable refusal of authorized surgery and other treatments constituted valid grounds to deny benefits under the doctrine of avoidable consequences/mitigation of damages. The California Court of Appeal, Second Appellate District, Division Six, affirmed this decision. The court held that a disability retirement application may be denied if the disability is caused, continued, or aggravated by an unreasonable refusal to undergo medical treatment, even if the refused treatment is no longer effective due to the passage of time. View "Mendoza v. Bd. of Retirement of the Ventura County" on Justia Law

A longtime deputy sheriff was convicted by a federal jury of mail and wire fraud after she submitted an insurance claim for items stolen during a burglary at her home, some of which she falsely claimed as her own but actually belonged to her employer, the sheriff’s office. She also used her employer’s fax machine and cover sheet in communicating with the insurance company and misrepresented her supervisor’s identity. The criminal conduct arose after a romantic relationship with a former inmate ended badly, leading to the burglary, but the fraud conviction was based on her false insurance claim, not on the relationship or the burglary itself.Following her conviction, the California Public Employees’ Retirement System (CalPERS) determined that her crimes constituted conduct “arising out of or in the performance of her official duties” under Government Code section 7522.72, part of the Public Employees Pension Reform Act, and partially forfeited her pension. The administrative law judge and the San Francisco Superior Court both upheld CalPERS’s decision, reasoning that her actions were sufficiently connected to her employment, particularly in her misuse of employer property and resources and in the context of her relationship with the former inmate.The Court of Appeal of the State of California, First Appellate District, Division One, reversed the trial court’s judgment. The appellate court held that the statute requires a specific causal nexus between the criminal conduct and the employee’s official duties, not merely any job-related connection. The court found that the deputy’s fraudulent insurance claim, although it referenced employer property and resources, did not arise out of or in the performance of her official duties as required by the statute. Accordingly, the pension forfeiture determination was set aside. View "Myres v. Bd. of Admin. for CalPERS" on Justia Law

Florida challenged a federal agency document known as the “Informational Bulletin” that interpreted Medicaid’s hold-harmless rule and threatened to claw back billions in Medicaid funds if certain state practices continued. Florida’s Medicaid funding system relies on a Directed Payment Program, under which local governments assess special fees on private hospitals, pool these fees, and transfer the funds to the state agency, which then uses them to secure additional federal matching funds. The state feared the new federal interpretation could jeopardize its program and moved to preliminarily enjoin the Bulletin’s implementation.The United States District Court for the Southern District of Florida, following a magistrate judge’s recommendation, denied Florida’s motion for a preliminary injunction and dismissed the case for lack of subject matter jurisdiction. The district court held that the Bulletin was not a “final agency action” under the Administrative Procedure Act (APA), and therefore not subject to judicial review.The United States Court of Appeals for the Eleventh Circuit reviewed the case and found that, contrary to the district court’s conclusion, the Bulletin was indeed a final agency action subject to judicial review under the APA. However, the Eleventh Circuit held that Florida was unlikely to succeed on the merits of its challenge, concluding that the Bulletin’s interpretation of the Medicaid hold-harmless rule was consistent with the statutory text, was not arbitrary or capricious, and did not require notice-and-comment rulemaking. The court thus reversed the dismissal of the complaint, affirmed the denial of the preliminary injunction, and remanded the case for further proceedings. View "Florida Agency for Health Care Administration v. Administrator for the Centers for Medicare & Medicaid Services" on Justia Law

A neurologist submitted a Freedom of Information Act (FOIA) request to the United States Social Security Administration (SSA) seeking documents about how the SSA evaluates disability claims for migraines and other headache disorders. The SSA determined that this request was not directly related to the administration of any of its benefit programs. Relying on a provision in the Social Security Act (42 U.S.C. § 1306(c)), the SSA required the requester to pay the full cost of processing the request, which totaled $2,908. The requester paid the fee but later objected because the SSA did not respond within the statutory deadline set by FOIA.The United States District Court for the District of Vermont found in favor of the requester. The district court concluded that FOIA’s provision prohibiting fees when the agency fails to respond on time superseded the Social Security Act’s cost-reimbursement clause. As a result, the court ordered the SSA to refund the fee and awarded the requester attorneys’ fees and costs. The court reasoned that allowing the SSA to charge fees despite late responses would undermine the FOIA amendments designed to ensure agency timeliness.On appeal, the United States Court of Appeals for the Second Circuit considered whether the Social Security Act’s cost-reimbursement provision or FOIA’s fee-preclusion provision controlled. The Second Circuit held that the plain language of § 1306(c), which begins with a “notwithstanding” clause, explicitly exempts the SSA from FOIA’s fee rules for requests not directly related to program administration. The court agreed with the SSA’s determination that the request was not program-related and found the statute unambiguous. Therefore, the court reversed the district court’s judgment and vacated the award of attorneys’ fees and costs. View "Shapiro v. U.S. Soc. Sec. Admin." on Justia Law

Rosa A. Camacho, a retired Class II member of the Northern Mariana Islands Retirement Fund, claimed that she was entitled to cost-of-living allowances (COLAs) as part of her retirement benefits. When Camacho entered the Retirement Fund in 1980, COLAs were not part of the retirement package. In 1989, the Commonwealth legislature amended the Retirement Fund Act to provide a two percent COLA. Over the years, this provision was repeatedly modified, suspended, and ultimately repealed in 2011. The Commonwealth’s financial difficulties led to a class action and a subsequent settlement agreement in 2013, which entitled participants to 75% of their “Full Benefits,” as defined by statute or guaranteed by the Commonwealth Constitution.The United States District Court for the Northern Mariana Islands held that Camacho was not entitled to COLAs under the settlement agreement, reasoning that COLAs were not constitutionally protected benefits at the time she joined the Retirement Fund and were discretionary by statute as of 2013. Camacho appealed, arguing that the statutory introduction of COLAs during her membership created a protected right under Article III, section 20(a) of the Commonwealth Constitution.The United States Court of Appeals for the Ninth Circuit certified to the Supreme Court of the Commonwealth of the Northern Mariana Islands the question of whether section 8334(e) of the Retirement Fund Act conferred a constitutionally protected accrued benefit in the form of COLAs for Class II members employed when the Act took effect. The Commonwealth Supreme Court answered in the negative, finding that COLAs were legislative policy adjustments and not protected contractual benefits. In accordance with this interpretation, the Ninth Circuit held that Camacho did not acquire a constitutionally protected right to COLAs under section 8334(e). The district court’s decision was affirmed. View "Camacho v. Northern Mariana Islands Settlement Fund" on Justia Law

Tamica Rainey, a Chicago police officer, was injured in duty-related car accidents in 2013 and 2015. She was awarded duty disability benefits in 2017 based on injuries to her neck and shoulder. As required by statute, Rainey’s disability status was periodically reviewed, and in 2022, after multiple hearings and submissions of medical records, the Retirement Board of the Policemen’s Annuity and Benefit Fund of the City of Chicago discontinued her duty disability benefits, concluding she was no longer disabled from her duty-related injuries. However, when Rainey attempted to return to work, the police department determined she could not perform her duties.Rainey sought administrative review in the Circuit Court of Cook County, which reversed the Board’s decision, relying on precedent that an officer remains disabled if the department cannot provide a position with needed accommodations. The circuit court also awarded Rainey attorney fees and costs under section 5-228(b) of the Illinois Pension Code. The Board appealed, and the Appellate Court of Illinois, First District, affirmed both the restoration of Rainey’s benefits and the award of attorney fees and costs.The Supreme Court of Illinois reviewed the Board’s challenge to the attorney fees and costs award. The court held that section 5-228(b) of the Illinois Pension Code authorizes an award of attorney fees and costs not only to police officers who successfully challenge the initial denial of duty or occupational disease disability benefits, but also to those who successfully challenge the discontinuation of such benefits. The court rejected the Board’s argument that statutory attorney fee awards are limited to initial applications, finding the statute’s plain language and legislative intent favor such awards for both denial and discontinuation challenges. The Supreme Court affirmed the judgments of the appellate and circuit courts and reversed the Board’s decision. View "Rainey v. Retirement Board of the Policemen & Annuity and Benefit Fund of the City of Chicago" on Justia Law

During a government shutdown that began on October 1, 2025, the United States Department of Agriculture (USDA) announced it would not provide November Supplemental Nutrition Assistance Program (SNAP) benefits, affecting millions of Americans who rely on these funds for food. Despite having approximately $6 billion in contingency funds appropriated by Congress for emergencies, USDA stated it would not use these funds, arguing they were unavailable once regular appropriations lapsed. Plaintiffs, including nonprofits, local governments, a union, and a food retailer, filed suit, alleging that USDA’s suspension of benefits was arbitrary, capricious, and contrary to law under the Administrative Procedure Act (APA).The United States District Court for the District of Rhode Island granted a temporary restraining order (TRO) requiring USDA to provide either full or partial November SNAP payments by specified dates. The government chose to provide partial payments but failed to do so in a timely manner, as many recipients would not receive benefits by the court’s deadline. The district court found the government had not complied with its order, both by failing to resolve administrative burdens and by not ensuring timely disbursement. As a result, the court ordered USDA to make full November SNAP payments, including by using funds from the Section 32 fund in combination with contingency funds. The government appealed and sought a stay of the district court’s order.The United States Court of Appeals for the First Circuit reviewed the government’s request for a stay pending appeal. The court held that the government had not met its burden to justify a stay, finding it had failed to show a likelihood of success on the merits or that irreparable harm would result from compliance. The court emphasized the immediate and substantial harm to SNAP recipients if benefits were withheld and denied the government’s motion for a stay. View "Rhode Island State Council of Churches v. Rollins" on Justia Law

A personal care assistance provider agency in Minnesota was audited by the Department of Human Services (DHS) for recordkeeping deficiencies related to its provision of services under the state’s Medicaid program. The agency, which served both traditional and PCA Choice recipients, was found to have various documentation errors, including missing or incomplete care plans and timesheets, as well as timesheets lacking required elements. DHS did not allege fraud or that services were not provided, but sought to recover over $420,000 in payments, arguing that these deficiencies constituted “abuse” under state law and justified monetary recovery.After an evidentiary hearing, an administrative law judge (ALJ) recommended limited recovery for some missing documentation but rejected most of DHS’s claims, finding that DHS had not shown the deficiencies resulted in improper payments. The DHS Commissioner disagreed, ordering full repayment. The Minnesota Court of Appeals reversed the Commissioner’s decision, holding that DHS must prove not only that the provider engaged in “abuse” but also that the abuse resulted in the provider being paid more than it was entitled to receive. The court also determined that provider agencies must maintain care plans for both traditional and PCA Choice recipients in their files.The Minnesota Supreme Court affirmed in part, reversed in part, and remanded. It held that, to obtain monetary recovery under Minn. Stat. § 256B.064, subd. 1c(a), DHS must prove either: (1) the provider engaged in conduct described in subdivision 1a and, had DHS known of the conduct before payment, it would have been legally prohibited from paying under a statute or regulation independent of subdivision 1a; or (2) the payment resulted from an error such that the provider received more than authorized by law. The Court also held that provider agencies must keep care plans for all PCA services, including PCA Choice, in their files. View "In the Matter of the SIRS Appeal by Best Care, LLC" on Justia Law