Justia Public Benefits Opinion Summaries

Plaintiffs filed a putative class action suit against the Secretary on behalf of Medicare beneficiaries who were placed into "observation status" by their hospitals rather than being admitted as "inpatients." Placement into "observation status" allegedly caused these beneficiaries to pay thousands of dollars more for their medical care. The district court granted the Secretary's motion to dismiss and plaintiffs appealed. The court affirmed the dismissal of plaintiffs' Medicare Act, 42 U.S.C. 1395, claims where plaintiffs lack standing to challenge the adequacy of the notices they received and nothing in the statute entitles plaintiffs to the process changes they seek. However, the court vacated the district court's dismissal of plaintiffs' Due Process claims where the district court erred in concluding that plaintiffs lacked a property interest in being treated as "inpatients," because the district court accepted as true the Secretary's assertion that a hospital's decision to formally admit a patient is "a complex medical judgment" left to the doctor's discretion. The district court's conclusion constituted impermissible factfinding, which in any event is inconsistent with the complaint's allegations that the decision to admit is guided by fixed and objective criteria. View "Barrows v. Burwell" on Justia Law

Babaria, a licensed radiologist and medical director and manager of Orange Community MRI, an authorized Medicare and Medicaid provider, pleaded guilty to one count of making illegal payments (kickbacks), 42 U.S.C. 1320a-7b(b)(2)(A). From 2008 through 2011, he paid physicians to refer patients to Orange for diagnostic testing and billed Medicare and Medicaid for testing that was tainted by the corrupt referrals. Orange received $2,014,600.85 in payments that were directly traceable to the kickback scheme. There was no evidence that Babaria falsified patient records, billed Medicare or Medicaid for testing that was not medically necessary, or otherwise compromised patient care. Babaria objected to the PreSentence Investigation Report, which recommended a two-level adjustment for abuse of a position of trust (USSG 3B1.3) and a four-level adjustment for aggravating role (USSG 3B1.1(a)), resulting in a recommended Guidelines range of 70-87 months’ imprisonment. Ultimately, the Guidelines range was 60 months, capped by the statutory maximum for Babaria’s count of conviction. He argued that the correct range was 37 to 46 months. The court applied both adjustments but granted a downward variance and sentenced Babaria to 46 months’ imprisonment, a fine of $25,000, and forfeiture of the $2,014,600.85. The Third Circuit affirmed the sentence. View "United States v. Babaria" on Justia Law

Todd, born in 1963, was a high school graduate, and worked primarily as a laborer, often for temporary services. Todd’s last employment before seeking disability benefits ended in April 2007 because the temporary job was completed. Todd claimed inability to work due to anxiety, cramping in his feet, and difficulty breathing. Until his death in July 2009, Todd was treated for major depressive disorder, alcoholism, alcohol dependence, emphysema, and generalized anxiety disorder. Todd also experienced tremors of unknown etiology. An ALJ decided: Todd had not engaged in substantial gainful activity since April 14, 2007; Todd suffered from emphysema, tremors, an affective disorder, an anxiety disorder, and alcohol dependence; Todd did not have an impairment or combination of impairments so severe as to meet or equal the criteria of a listed impairment; Todd had the residual functional capacity to perform light work and was capable of performing his past relevant work as a laborer; and Todd was “not under a disability.” The district court agreed. Although the ALJ improperly weighed the medical professionals’ opinions, the error was harmless because substantial evidence supported a finding that Todd’s limitations would not be disabling if he stopped using alcohol. The Eighth Circuit affirmed. View "Bernard v. Colvin" on Justia Law

Systemic juvenile idiopathic arthritis (SJIA), an autoinflammatory disease, has symptoms including arthritis, fever, rash, and muscle and joint pain, caused by dysfunctional production of proteins, which cells release almost immediately after contact with an antigen. Gardasil, a vaccine against HPV administered in three doses, contains virus-like particles created from an HPV protein, and an adjuvant to generate a robust immune response. Vanessia, born in 1995, was healthy until 2008. After receiving two doses of Gardasil, she experienced an all-over rash. Days later, she had joint pain and high fever. The hospital discharged her with a presumptive diagnosis of SJIA. Vanessia’s family history included SJIA. Her rheumatologist communicated these findings to the doctor who administered Vanessia’s third dose of Gardasil on August 19. Vanessia experienced a SJIA flare on August 25. Vanessia’s Vaccine Act injury claim was rejected. Injuries that do not appear on the Vaccine Injury Table, 42 C.F.R. 100.3, require proof of a medical theory causally connecting the vaccination to the injury; a logical sequence of cause and effect; and proximate temporal relationship between the vaccine and injury. The Claims Court and Federal Circuit affirmed, finding that the claim did not meet the burden of demonstrating proximate temporal relationship. View "Koehn v. Sec'y of Health & Human Servs." on Justia Law

Keathley retired from working at strip mines. His health deteriorated. He sought Black Lung Benefits Act benefits, 30 U.S.C. 901. Keathley established eligibility under the 15 -year presumption; he had worked in mines for more than 16 years and was able to show a totally disabling impairment by medical opinion testimony and tests showing poor pulmonary function. His employer rebutted this presumption by offering testimony by Dr. Broudy, who diagnosed Keathley with “a combination of chronic obstructive asthma and pulmonary emphysema and chronic bronchitis” caused by smoking. Conceding that “coal dust may have contributed,” Broudy concluded that “it’s far more likely that the impairment was due to obstructive airways disease from cigarette smoking and some predisposition to asthma or bronchospasm.” On remand, the ALJ awarded benefits; the Benefits Review Board affirmed, rejecting Broudy’s opinion that “bronchitis associated with coal dust exposure usually ceases with cessation of exposure,” as contrary to federal regulations, which state that “pneumoconiosis” may be “latent and progressive” and arise after exposure ceases. The Sixth Circuit denied the employer’s petition for review. The employer did not challenge the evaluation of individual tests, identify any factor the ALJ overlooked, or offer any basis for distinguishing among the tests. View "Sunny Ridge Mining Co., Inc. v. Keathley" on Justia Law

Yurt suffers from a psychotic disorder which causes him to experience auditory hallucinations and bouts of uncontrollable rage. He also has obsessive compulsive disorder, moderately severe chronic obstructive pulmonary disease (COPD), and chronic bifrontal tension headaches. He has worked as a cook and a janitor, last working in May 2010, when he suffered a mental break and was terminated for threatening a coworker with a knife. He applied for Disability Insurance Benefits from the Social Security Administration, but an ALJ denied his application. The Appeals Council declined review. The district court affirmed. The Seventh Circuit reversed and remanded, agreeing that the ALJ erred by failing to include many of his medical limitations in the hypothetical that she posed to the vocational expert. View "Yurt v. Colvin" on Justia Law

Townsend applied for social security disability benefits and supplemental security income in 2003, at age 44, claiming that she had become incapable of full‐time gainful employment in May 2002 when she had stopped working as a result of multiple physical and psychiatric ailments, including fibromyalgia. In 2012 an ALJ decided that she had become totally disabled in November 2008. By the time that decision was rendered she had died (of pulmonary diseases apparently unrelated to the ailments alleged to have made her totally disabled). Her father was substituted for her. The district court upheld the decision. The Seventh Circuit reversed and remanded, noting multiple errors in determining the onset of total disability.View "Williams v. Colvin" on Justia Law

Gienapp worked at Harbor Crestnursing care facility. In January 2011 she told Chattic, its manager, that she needed leave to care for her daughter, who was being treated for thyroid cancer. Chattic granted leave under the Family and Medical Leave Act, 29 U.S.C. 2612(a)(1). While on leave, Gienapp submitted an FMLA form, leaving blank a question about the leave’s expected duration. Harbor Crest did not ask her to fill in the blank, nor did it pose written questions as the 12-week period progressed. A physician’s statement on the form said that the daughter’s recovery was uncertain, and that if she did recover she would require assistance at least through July 2011. Chattic inferred from this that Gienapp would not return by April 1, her leave’s outer limit, and hired a replacement. When Gienapp reported for work on March 29, Chattic told her that she no longer had a job. The district court entered summary judgment, ruling that Gienapp had forfeited her FMLA rights by not stating exactly how much leave she would take. The Seventh Circuit reversed. Gienapp could not give a firm date; Department of Labor regulations call her situation “unforeseeable” leave, governed by 29 C.F.R. 825.303, which does not require employees to tell employers how much leave they need. View "Gienapp v. Harbor Crest" on Justia Law

Plaintiffs, Medicaid beneficiaries with near total disabilities, filed suit after being denied coverage for ceiling lifts under a categorical exclusion in the state's implementing Medicaid regulations. The district court granted summary judgment for the state. The court concluded that, under binding precedent, plaintiffs have an implied private cause of action under the Supremacy Clause to pursue their challenge; the state must comply with the requirements of the Medicaid Act, 42 U.S.C. 1396 et seq., but the Act does not preempt the state's categorical exclusions; and therefore, the court affirmed the grant of summary judgment and denied the motion to vacate.View "Detgen, et al. v. Janek" on Justia Law

Gilbert served in the Navy. His reported medical history upon entry into service revealed no psychiatric defects. After leaving service, Gilbert was diagnosed with major depression and required treatment for psychiatric illness and alcohol dependence. Gilbert acknowledged that he experienced depressive episodes and suicidal ideation throughout his life, that he has been abusing drugs and alcohol since he was a teenager, and that he continued to abuse alcohol while in the Navy. Gilbert sought compensation for psychiatric disability and other conditions with the VA. Multiple psychiatric examinations produced conflicting opinions. The VA denied service connection; the Board affirmed. The statutory “[p]resumption of sound condition” was applicable because no psychiatric condition was noted upon entry into service, 38 U.S.C. 1111; to rebut the presumption, the government had to provide clear and unmistakable evidence demonstrating that the disease existed before enrollment and was not aggravated by service. Based on Gilbert’s acknowledged history, the Board concluded that the government proved that his psychiatric illness pre-existed enrollment, but that the government failed to establish that Gilbert’s “pre-existing depression was not aggravated by active service,” and did not rebut the presumption of soundness. The Board nevertheless denied service connection, concluding that Gilbert failed to prove that his post-service psychiatric conditions “were correlated to [his] military experiences.” The Veterans Court and Federal Circuit affirmed.View "Gilbert v. Shinseki" on Justia Law