Justia Public Benefits Opinion Summaries

The National Organization of Veterans’ Advocates (NOVA), sought review under 38 U.S.C. 502. The Knee Joint Stability Rule, promulgated in 2018 and set forth in the Veterans Affairs Adjudication Procedures Manual, assigns a joint instability rating under Diagnostic Code (DC) 5257, 38 C.F.R. 4.71a, based on the amount of movement that occurs within the joint. The Knee Replacement Rule provides that evaluation under DC 5055, 38 C.F.R. 4.71a, is not available for partial knee replacement claims. The Replacement Rule was published in the Federal Register in 2015, stating that section 4.71a was amended to explain that “‘prosthetic replacement’ means a total, not a partial, joint replacement.” It was published in a 2016 Manual provision, which informs regional office staff that evaluation under DC 5055 is not available for partial knee replacement claims filed on or after July 16, 2015.The Federal Circuit referred the case for adjudication on the merits. NOVA has standing because it has veteran members who are adversely affected by the Rules. The Manual provision is an interpretive rule reviewable under 38 U.S.C. 502 and constitutes final agency action. The Knee Replacement Rule is a final agency action. The merits panel will determine whether the Manual provision or the Federal Register publication constitutes the reviewable agency action. The challenge is timely under the six-year statute of limitations, 28 U.S.C. 2401(a); Federal Circuit Rule 15(f), establishing a 60-day time limit for bringing section 502 petitions, is invalid. View "National Organization of Veterans’ Advocates, Inc. v. Secretary of Veterans' Affairs" on Justia Law

Dr. Korban and his medical practice Delta, practice diagnostic and interventional cardiology. In 2007, Dr. Deming filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729(a)(1)(A)–(C), (G) against Korban, Jackson Regional Hospital, and other Tennessee hospitals, alleging “blatant overutilization of cardiac medical services.” The United States intervened and settled the case for cardiac procedures performed in 2004-2012. Korban entered into an Integrity Agreement with the Office of Inspector General, effective 2013-2016 that was publicly available and required an Independent Review Organization. The U.S. Department of Justice issued a press release that detailed the exposed fraudulent scheme and outlined the terms of Korban’s settlement. In 2015, Jackson Regional agreed to a $510,000 settlement. The Justice Department and Jackson both issued press releases.In 2017, Dr. Maur, a cardiologist who began working for Delta in 2016, alleged that Korban was again performing “unnecessary angioplasty and stenting” and “unnecessary cardiology testing,” paid for in part by Medicare. In addition to Korban and Jackson, Maur sued Jackson’s corporate parent, Tennova, Dyersburg Medical Center, and Tennova’s corporate parent, Community Health Systems. The United States declined to intervene. The district court dismissed, citing the FCA’s public-disclosure bar, 31 U.S.C. 3730(e)(4). The Sixth Circuit affirmed. Maur’s allegations are “substantially the same” as those exposed in a prior qui tam action and Maur is not an “original source” as defined in the FCA. View "Maur v. Hage-Korban" on Justia Law

Plaintiffs filed suit alleging discrimination under Government Code section 11135 based on a requirement that all San Diego County applicants eligible for the state's CalWORKs (welfare) program participate in a home visit. The County demurred, arguing there was no discriminatory effect on of the program, no disparate impact caused by the home visits, and the parties lacked standing to sue. The superior court granted the demurrer without leave to amend, and entered judgment. Plaintiffs argued on appeal that their complaint stated a viable cause of action. The Court of Appeal disagreed, finding the complaint did not allege a disparate impact on a protected group of individuals and could not be amended to do so. Therefore, the Court affirmed the superior court. View "Villafana v. County of San Diego" on Justia Law

Alleging debilitating pain in her back, legs, and hands, Zoch sought disability insurance benefits, 42 U.S.C. 413, 423. An ALJ denied the application, finding that, based on the opinions of three of her four treating physicians, a consulting physician, and the objective medical evidence, she could perform sedentary work.The district court and Seventh Circuit affirmed, rejecting Zoch’s arguments that the ALJ improperly discounted her assertions and an opinion by a physician who relied on those assertions. Substantial evidence supports the ALJ’s decision. Zoch’s testimony of incapacitating pain conflicted with the objective medical evidence, including normal test results: lumbar MRI, wrist x-rays, range of motion, straight-leg raising, strength in extremities, and pressure on her nerves. Zoch’s testimony that she usually walked with a cane conflicted with the doctors’ reports that at all but one appointment she walked normally. Zoch’s testimony that she could not raise her arms or bend over to dress conflicted with a doctor’s observation that Zoch could comfortably bend over to touch her fingertips to her knees. Zoch’s hearing testimony that she could not perform the usual activities of daily living was inconsistent with her assertions in her application. View "Zoch v. Saul" on Justia Law

While plaintiffs sought judicial review in federal district court of their denial of Social Security disability benefits, the Supreme Court issued its opinion in Lucia v. Securities and Exchange Commission, 138 S. Ct. 2044 (2018), which elucidated a possible constitutional objection to administrative proceedings pursuant to the Appointments Clause. At issue in this appeal is whether plaintiffs may raise an Appointments Clause challenge in federal court that they did not preserve before the agency.The Fourth Circuit held that claimants for Social Security disability benefits do not forfeit Appointments Clause challenges by failing to raise them during their administrative proceedings. Balancing the individual and institutional interests at play, including considering the nature of the claim presented and the characteristics of the ALJ proceedings, the court declined to impose an exhaustion requirement. Therefore, the court affirmed the judgments of the district courts remanding these cases for new administrative hearings before different, constitutionally appointed ALJs. View "Probst v. Saul" on Justia Law

The Randolph-Sheppard Act, 20 U.S.C. 107(a), provides economic opportunities by granting blind persons priority to operate vending facilities at certain government properties. When a blind vendor, Belsha, was awarded certain vending operations in Racine County, Wisconsin, a different blind vendor, Taylor, became unhappy and challenged the award. The Act is administered by state licensing agencies; Taylor’s challenge traveled first through Wisconsin’s regulatory process. Although Taylor achieved some success through the Wisconsin Division of Vocational Rehabilitation, she commenced federal administrative proceedings with the Secretary of Education. An arbitration panel awarded Taylor money damages and a permanent vending machine services contract for a site in Racine.The district court vacated the arbitration decision, ruling that there were no material deficiencies in the choice of Belsha for the Racine site, that the arbitration panel’s key factual findings were not supported by substantial evidence, and the arbitration panel’s ultimate conclusion was arbitrary and capricious. The Seventh Circuit affirmed. The arbitration panel mistakenly substituted the APA standard of review for the burden of proof of a disappointed vendor under the Act. View "Wisconsin Department of Workforce Development v. Taylor" on Justia Law

The Supreme Judicial Court affirmed in part and vacated in part the judgment of the superior court affirming the decision of the Commissioner of the Department of Health and Human Services (Department) accepting the recommendation of an administrative presiding officer that the Department correctly established and maintained a recoupment claim for $116,852 against Appellant, an oral surgeon, holding that remand was required as to one aspect of the Department's decision.Appellant was a MaineCare provider whose practice was based in Auburn. After Appellant retired, the Department issued a notice of violation, alleging that Appellant had been overpaid. After an administrative hearing, the Department reduced its claim to $116,852. The presiding officer upheld the Department's recoupment claim. The Commissioner adopted the presiding officer's recommended decision in full. The Supreme Judicial Court reversed in part and remanded the case, holding (1) because the Department failed to explain its decision imposing the maximum allowable penalties for Appellant's failure properly to document time spent with patients following his administration of anesthesia, the Court was unable to determine whether the Department properly exercised its discretion; and (2) Appellant was not entitled to relief on his remaining allegations of error. View "Palian v. Department of Health and Human Services" on Justia Law

Community Mental Health modified the methodology through which it allocated funding to individuals with disabilities receiving community living support services under a Medicaid waiver received by Michigan. Individuals receiving those services, together Advocacy, challenged that methodology as violating the Medicaid Act, 42 U.S.C. 1396a(a)(8), (a)(10)(A), (a)(10)(B), 1396n(c)(2)(A) and (C); Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. 12132; section 504 of the Rehabilitation Act, 29 U.S.C. 794; the Michigan Mental Health Code; and the terms of Michigan’s Medicaid Habilitation Supports Waiver and the contracts implementing it. The district court dismissed the claims in full.The Sixth Circuit reversed, first holding that the plaintiffs have standing, that the defendants are not entitled to Eleventh Amendment immunity, that the plaintiffs were not required to exhaust their administrative remedies provided by the state under the Medicaid Act, and that the plaintiffs have a private right of action under sections 1396a(a)(8) and (a)(10). The plaintiffs’ allegations suffice to state plausible claims that they are being denied sufficient necessary medical services; that feasible alternatives that provide them a meaningful choice between institutionalized and at-home or community-based care exist and are not being ensured; and that they face a serious risk of institutionalization. View "Waskul v. Washtenaw County Community Mental Health" on Justia Law

Veterans sought certification for the class of veterans whose disability claims had not been resolved by the Board of Veterans Appeals within one year of the filing of a Notice of Disagreement (NOD), requesting judicial action to compel the Secretary of Veterans Affairs to decide all pending appeals within one year of receipt of a timely NOD. The Veterans Court requested that they separate or limit the requested class action into issues that meet the Federal Rule of Civil Procedure 23(b)(2) “commonality” standard. The veterans declined, stating that “systemic delay” exists in the VA claims system, and broad judicial remedy is required.The Veterans Court denied the requested class certification. While the case was pending, the Veterans Appeals Improvement and Modernization Act of 2017, 131 Stat. 1105 purportedly improved processing times by allowing claimants to choose: higher-level review, a supplemental claim, board review with a hearing and opportunity to submit additional evidence, board review without a hearing, but with an opportunity to submit additional evidence, or board review without a hearing or additional evidence, based on their priorities on appeal.The Federal Circuit affirmed the denial of class certification, citing the lack of proof of commonality. When Congress has crafted a comprehensive remedial structure, that structure warrants evaluation in practice before judicial intervention is contemplated. View "Monk v. Wilkie" on Justia Law

The issue presented in this declaratory action before the South Carolina Supreme Court in its original jurisdiction was a challenge to the constitutionality of Governor Henry McMaster's allocation of $32 million in federal emergency education funding for the creation of the Safe Access to Flexible Education ("SAFE") Grants Program. Petitioners contended the program violated South Carolina's constitutional mandate prohibiting public funding of private schools. The Supreme Court held the Governor's decision constituted the use of public funds for the direct benefit of private educational institutions within the meaning of, and prohibited by, Article XI, Section 4 of the South Carolina Constitution. "Even in the midst of a pandemic, our State Constitution remains a constant, and the current circumstances cannot dictate our decision. Rather, no matter the circumstances, the Court has a responsibility to uphold the Constitution." View "Adams v. McMaster" on Justia Law