Justia Public Benefits Opinion Summaries

In 2006-2008, plaintiffs each applied, unsuccessfully, for Social Security disability benefits, 42 U.S.C. 423(d)(2)(A), 1382c(a)(3)(B). Each plaintiff retained Kentucky attorney Conn to assist with a subsequent hearing. Each plaintiff’s application included medical records from one of four examining doctors. In each case, ALJ Daugherty relied exclusively on the doctor's opinion to conclude, without a hearing, that plaintiffs were disabled and entitled to benefits. Daugherty took bribes from Conn to assign Conn’s cases to himself and issue favorable rulings. Nearly 10 years after the agency learned of the scheme, it initiated “redeterminations” of plaintiffs’ eligibility for benefits and held new hearings, disregarding all medical evidence submitted by the four doctors participating in Conn’s scheme. Plaintiffs had no opportunity to rebut the assertion of fraud as to this evidence. Each plaintiff was deemed ineligible for benefits as of the date of their original applications; their benefits were terminated. Plaintiffs sued, alleging violations of the Due Process Clause and the Social Security Act. The Sixth Circuit held that the plaintiffs are entitled to summary judgment on their due-process claim and the agency is entitled to summary judgment on the Social Security Act claims. The agency must proffer some factual basis for believing that the plaintiffs’ evidence is fraudulent. Plaintiffs must have an opportunity to “rebut the Government’s factual assertions before a neutral decisionmaker.” Congress has already told the agency what to do when redetermination proceedings threaten criminal adjudications; the answer is not to deprive claimants of basic procedural safeguards. View "Griffith v. Commissioner of Social Security" on Justia Law

The Tennessee Hospital Association and three hospitals sued, challenging efforts by the Centers for Medicare and Medicaid Services (CMS) to direct states to recoup certain reimbursements made under the Medicaid program. The hospitals serve a disproportionate share of Medicaid-eligible patients and are thereby entitled to supplemental payments under the Medicaid Act, (DSH payments), 42 U.S.C. 1396a(a)(13)(A)(iv); 1396r-4(b). The Act limits the amount of DSH payments each hospital can receive in a given year. CMS contends that the hospitals miscalculated their DSH payment-adjustments for fiscal year 2012 and received extra payments. Plaintiffs argued, and the district court agreed, that CMS’s approach to calculating DSH payment adjustments is inconsistent with the Act and the regulations that CMS implemented in 2008. The Sixth Circuit affirmed, agreeing that CMS’s policy is inconsistent with its 2008 rule and cannot be enforced unless it is promulgated pursuant to notice-and-comment rulemaking. The court disagreed with the district court’s conclusion that CMS’s policy exceeds the agency’s authority under the Medicaid Act. CMS’s payment-deduction policy is a reasonable interpretation of an ambiguous section of the Act but is not a valid interpretative rule. CMS attempted to exercise its delegated discretion to “determine[]” the “costs incurred” in serving Medicaid-eligible patients—precisely the sort of agency action that requires notice-and-comment rulemaking. View "Tennessee Hospital Association v. Azar" on Justia Law

Cook served on active duty in the Navy, 1972-1973. Cook’s service records indicate that he experienced back pain. In 2000, Cook sought service connection for back problems and later filed a claim for total disability based on individual unemployability (TDIU), also back-related. The regional office (RO) denied both claims. Cook appealed and testified at a Board hearing in 2012. The Board remanded; the RO again denied both claims. Cook again appealed and requested an additional hearing to present further evidence. The Board denied Cook that additional hearing and denied both of his claims. The Veterans Court, upon joint motion, vacated and remanded because the Board did not adequately explain its decision. On remand, Cook again requested another Board hearing. The Board denied a hearing and denied Cook’s claims for service connection and TDIU. The Veterans Court vacated and ordered a hearing. The Federal Circuit affirmed. The Veterans’ Judicial Review Act codified a veteran’s longstanding right to a Board of Veterans’ Appeals hearing, 38 U.S.C. 7107(b). The courts concluded that the statute entitles an appellant to an opportunity for a hearing whenever the Board decides an appeal, including on remand. View "Cook v. Wilkie" on Justia Law

Hardy, a 55-year old man who worked previously as a maintenance mechanic, had a discectomy in 2005 and a lumbar spinal fusion in 2006. His previous application for Disability Insurance Benefits was denied in 2012. Hardy filed another application for DIB benefits, claiming an onset date of April 2012. The agency denied Hardy’s claim; state-agency doctors reviewed Hardy’s file and determined that he had postural limitations, could frequently lift up to 10 pounds and could stand or walk for six hours during a workday so that Hardy could perform light work. His treating doctors reported that Hardy was unable to work and that his “legs give out and he tends to fall.” In concluding that Hardy was not disabled, an ALJ determined that Hardy had not engaged in substantial gainful employment since his alleged onset date; that his conditions were severe impairments; that these conditions did not equal a listed impairment; that he had the residual functional capacity to perform light work, with limitations; and that he could work as a wire assembler, assembly press operator, circuit board screener, or finish assembler. The Seventh Circuit vacated the denial of benefits. A treating doctor’s opinion generally is entitled to controlling weight if it is consistent with the record, and it cannot be rejected without a “sound explanation.” The ALJ impermissibly discounted the opinions of Hardy’s treating neurosurgeon. View "Hardy v. Berryhill" on Justia Law

This matter stemmed from a lawsuit filed by the State of Mississippi against the defendant pharmacies. The State alleged deceptive trade practices and fraudulent reporting of inflated “usual and customary” prices in the defendant’s reimbursement requests to the Mississippi Department of Medicaid. The State argued that Walgreens, CVS, and Fred’s pharmacies purposefully misrepresented these prices to obtain higher prescription drug reimbursements from the State. Finding that the circuit court was better equipped to preside over this action, the DeSoto County Chancery Court transferred the matter to the DeSoto County Circuit Court in response to the defendants’ request. Aggrieved, the State timely filed an interlocutory appeal disputing the chancellor’s decision to transfer the case. After a thorough review of the parties’ positions, the Mississippi Supreme Court found that though the chancery court properly could have retained the action, the chancellor correctly used his discretion to transfer the case, allowing the issues to proceed in front of a circuit-court jury. As a result, the Supreme Court affirmed the chancellor’s decision. View "Mississippi v. Walgreen Co." on Justia Law

Spicher suffers from osteoarthritis, degenerative disc disease, chronic obstructive pulmonary disease, fibromyalgia, and morbid obesity. In 2010, Spicher applied for Social Security Disability Insurance Benefits and Supplemental Security Income dating back to 2003. After a 2012 hearing, an ALJ found that Spicher was not disabled from 2003-2012. The district court remanded because the ALJ had not properly considered the limitations imposed by Spicher’s obesity, independently and in combination with her other impediments. On remand, Spicher focused on whether she had been disabled since December 2008, when her insured status expired. The ALJ consulted a second doctor who essentially adopted the findings of the medical reports already in the record. The ALJ stated that further consideration of Spicher’s obesity had not motivated her to change her conclusion, finding that Spicher could hold a sedentary position and perform three jobs identified by a vocational expert, and could occasionally crouch, crawl, balance, stoop, and kneel. The Seventh Circuit reversed, finding that the decision was not supported by substantial evidence. The ALJ did not address contradictory medical evidence when determining the types of sedentary jobs that Spicher could hold and failed to consider the interaction between her obesity and her non‐severe impairments. The court rejected a claim that the ALJ displayed antagonism toward Spicher in violation of her due process rights. View "Spicher v. Berryhill" on Justia Law

Memorial Hospital at Gulfport and Singing River Health System (“Hospitals”) sought judicial review of a June 24, 2016 administrative decision which found the Division of Medicaid’s (“DOM’s”) 2014 Fiscal Year Methodology “correctly interprets statutes and regulations and is neither arbitrary or capricious.” The chancellor affirmed the decision of DOM. Finding no evidence in the record before it that DOM failed to comply with Sections 43-13-117 and 43-13-145 in allocating and distributing supplemental payments to Mississippi hospitals, the Mississippi Supreme Court affirmed. View "Memorial Hospital at Gulfport v. Dzielak" on Justia Law

On July 11, 2013, the Idaho Department of Labor (“IDOL”) mailed an eligibility determination for unemployment benefits (the “2013 determination”) to William Wittkopf. This determination found Wittkopf underreported his wages for several weeks, which resulted in an overpayment in unemployment benefits. As a result, Wittkopf was: (1) ordered to repay the overpayment; (2) ineligible for any unemployment benefits for a fifty-two week period; and (3) assessed a civil penalty. Additionally, Wittkopf was told that he would remain ineligible for unemployment benefits until all amounts were repaid. Pursuant to Idaho Code section 72– 1368(3) the last day for Wittkopf to file a protest to the 2013 determination was July 25, 2013, which he failed to do. IDOL attempted to collect on the 2013 determination over the next year without success. Subsequently in early 2016, Wittkopf filed for Chapter 7 bankruptcy. The debt he owed to the state of Idaho was included in his bankruptcy and was discharged by order of the Bankruptcy Court. In September 2016, Wittkopf began filing new claims for unemployment benefits with IDOL because he worked a seasonal job and was not receiving any income in the winter months. After not receiving benefits for several weeks, Wittkopf called IDOL which informed him he was ineligible for unemployment benefits because he had failed to pay back his overpayment, civil penalty, and interest he owed IDOL, even though those amounts were discharged in bankruptcy. Wittkopf mailed a letter to IDOL protesting the denial of his unemployment benefits. Wittkopf claimed in this letter that he was eligible for unemployment benefits because his bankruptcy discharged any amount he owed to IDOL. An Appeals Examiner construed Wittkopf’s 2016 letter as a protest of the 2013 determination. Two days later the Appeals Examiner issued a written decision finding there was no jurisdiction to hear Wittkopf’s protest because it was not filed within fourteen days of when it was issued on July 25, 2013, as required by Idaho Code section 72-1368. On November 3, 2016, Wittkopf appealed the Appeals Examiner’s decision to the Industrial Commission. On January 27, 2017, the Industrial Commission affirmed the Appeals Examiner’s decision. The Idaho Supreme Court determined the Industrial Commission erred in affirming the examiner without having determined first whether: (1) the bankruptcy discharge voided IDOL's 2013 determination; (2) whether the discharge operated as an injunction against any effort to collect, recover or offset the 2013 debt; and if yes, (3) why the Department's denial of current benefits on the basis of the 2013 debt wasn't a violation of the injunction. The matter was remanded back to the Industrial Commission for further proceedings. View "Wittkopf v. Idaho Dept of Labor" on Justia Law

In 2007, Chavez, then 21, was diagnosed with a brain tumor and underwent five surgeries. Chavez experienced depression and anxiety. She struggled to maintain concentration to complete simple household tasks and suffered from migraine headaches, back pain (caused by degenerative disc disease), and numbness in her feet and hands. Chavez had no prior work experience. In 2010 Chavez applied for Social Security supplemental security income. Chavez could perform only simple, routine tasks with significant restrictions on how much she could lift. The vocational expert enlisted by the agency to estimate the number of jobs suitable for Chavez testified that for one particular job there were either 800 or 108,000 existing positions but preferred the larger estimate. The administrative law judge agreed and denied Chavez’s claim. The district court affirmed. The Seventh Circuit vacated. The decision was not supported by substantial evidence; the ALJ failed to ensure that the vocational expert’s job estimates were reliable. The vocational expert offered no explanation for why his estimates (or his method) were reliable, instead reaching a conclusion by determining that the estimates yielded by an alternative method seemed too low. By affording such broad deference to the vocational expert’s chosen estimates, the ALJ relieved the agency of its evidentiary burden at the final step of the analysis, impermissibly shifting the burden to Chavez. View "Chavez v. Berryhill" on Justia Law

Three disabled individuals who formerly received cash general assistance benefits from the Pennsylvania Department of Public Welfare filed a complaint alleging that the manner in which the Pennsylvania General Assembly enacted Act 80 of 2012, a piece of legislation which, inter alia, made sweeping changes to the administration of the state's human services programs, violated Article III, Sections 1, 3 and 4 of the Pennsylvania Constitution. The Pennsylvania Supreme Court determined the Act was in violation of Section 4. The provisions of H.B 1261, P.N. 1385 were entirely removed from the bill by the Senate, inasmuch as they had been enacted by another piece of legislation, Act 22 of 2011. Since the original provisions were gone when the new provisions were added by the Senate, it was factually and legally impossible for the new provisions to work together with the deleted provisions to accomplish a single purpose. The Court held the amendments "to such enfeebled legislation" were not germane as a matter of law. Consequently, the Senate amendments were not germane to the provisions of H.B. 1261, P.N. 1385, and, accordingly, the three times that H.B. 1261, P.N. 1385 was passed by the House in 2011 could not count towards the requirements of Article III, Section 4. View "Washington, et al. v. Dept. of Pub. Welfare" on Justia Law