Justia Public Benefits Opinion Summaries

Bowers served in the Army National Guard 1972-1978, with a continuous period of active duty for training from August 1972 to February 1973. His records do not reflect that he incurred any injury or disease during service. In 2009, shortly after his diagnosis with Lou Gehrig’s disease (ALS), Bowers sought benefits for ALS and secondary conditions. A VA Regional Office denied the claim, finding that his ALS was not incurred or aggravated in service. The Board of Veterans’ Appeals rejected his argument that he was entitled to presumptive service connection for ALS under 38 C.F.R. 3.318, noting that reserve duty and active duty for training of the type Bowers performed does not generally entitle an individual to evidentiary presumptions. While his appeal to the Veterans Court was pending, Bowers died and his wife was substituted as the appellant. The Veterans Court affirmed, finding that Bowers did not achieve “veteran status,” and was not entitled to presumptive service connection. The Federal Circuit affirmed. View "Bowers v. Shinseki" on Justia Law

Marilyn Davidson, an intellectually disabled individual, was in the care of the Massachusetts Department of Developmental Services (DDS) most of her life. In 1985, Marilyn was transferred to the Fernald Developmental Center, an intermediate care facility (ICF). In 2003, the Commonwealth of Massachusetts decided to close Fernald. DDS planned to transfer Marilyn to the Wrentham Developmental Center, another ICF. Plaintiffs, Marilyn’s guardians, filed a complaint in the federal district court, alleging that Marilyn’s transfer violated the federal Medicaid statute and various implementing regulations. Plaintiffs also sought a motion for a preliminary injunction. The district court denied the injunction and held that the statutory and regulatory provisions cited in the complaint did not create a private right of action. Marilyn was subsequently transferred to Wrentham, and Fernald was closed. The First Circuit Court of Appeals remanded the case to the district court with instructions to dismiss Plaintiffs’ complaint, holding (1) Plaintiffs’ claim for damages was barred by the Commonwealth’s Eleventh Amendment immunity from suit for damages in federal court; and (2) Plaintiffs’ claims for declaratory and injunctive relief were moot.View "Davidson v. Howe" on Justia Law

PAMC appealed the district court's affirmance of the Secretary's decision denying PAMC its full Medicare Annual Payment Updated for the fiscal year 2009. PAMC claimed that the Department acted arbitrarily and capriciously when it refused to excuse PAMC's late filing of the required Reporting Hospital Quality Data for Annual Payment Updated (RHQDAPU) program data by the admittedly applicable deadline. The court concluded that PAMC neither pointed to any contrary or antithetical decisions by the Department under similar circumstances, nor otherwise demonstrated that the Board acted arbitrary or capriciously when it denied equitable relief. The court rejected PAMC's argument that the Board should have used the contract doctrine of substantial performance to excuse PAMC's failure to submit data at the proper time. The court did not view the Board's adherence to the policy of strict compliance with a deadline as arbitrary and capricious. Accordingly, the court affirmed the judgment of the district court.View "PAMC, LTD. v. Sebelius" on Justia Law

Forester was awarded benefits under the Black Lung Benefits Act, 30 U.S.C. 901-944, as amended by the Patient Protection and Affordable Care Act, 124 Stat. 119, after the ALJ determined that Forester’s five years of private coal mine employment with Navistar’s predecessor, combined with his16 years of employment as a mine inspector with the U.S. Department of Labor’s Mine Safety and Health Administration , rendered him eligible for the rebuttable presumption that, having been employed for at least 15 years in underground coal mines, and having a totally disabling respiratory or pulmonary impairment, he was totally disabled due to pneumoconiosis, commonly known as black lung disease. The Benefits Review Board upheld the award. The Sixth Circuit vacated, holding that a federal mine inspector is not a “miner” for purposes of the BLBA, and remanding for determination of whether Forester is entitled to an award of BLBA benefits without the benefit of the 15-year presumption. View "Navistar, Inc. v. Forester" on Justia Law

Groups of hospitals in the Cincinnati area and in rural Iowa, challenged the Secretary of Health and Human Services’ calculation of how much to pay those hospitals for inpatient services under Medicare Part A. The hospitals objected to the agency’s decision to include in the calculation the hours associated with a short-term disability program paid from a hospital’s general funds through its payroll system and a program offering a full-time salary for part-time weekend work. The district court entered summary judgment for the Secretary. The Sixth Circuit affirmed, finding the agency’s interpretation was not arbitrary or capricious and referring to “the most completely impenetrable texts within human experience,” statutes and regulations that “one approaches ... at the level of specificity herein demanded with dread.” View "Atrium Medical Ctr. v. U.S. Dep't of Health & Human Servs." on Justia Law

Scrogham, then age 53, applied for disability benefits under the Social Security Act, submitting medical conditions including degenerative discs, spinal stenosis, sleep apnea, hypertension, arthritis, atrial fibrillation and restless leg syndrome. An ALJ denied the application and the Appeals Council denied his request for review. The district court affirmed, holding that the ALJ did not err in giving less weight to the opinion of a treating physician than to the opinions of nontreating physicians, that the ALJ permissibly found Scrogham not to be credible and that the ALJ’s decision otherwise was supported by substantial evidence. The Seventh Circuit reversed and remanded. The ALJ impermissibly ignored a line of evidence demonstrating the progressive nature of Scrogham’s degenerative disc disease and arthritis and inappropriately undervalued the opinions of Scrogham’s treating physicians, whose longitudinal view of Scrogham’s ailments should have factored prominently into the ALJ’s assessment of his disability status. Even considering only “the snapshots of evidence that the ALJ considered,” that limited evidence does not build the required logical bridge to her conclusions. The ALJ apparently misunderstood or at least considered only partially some of the evidence about Scrogham’s daily activities, rehabilitation efforts and physicians’ evaluations. View "Scrogham v. Colvin" on Justia Law

Two nurses, formerly employed by Momence, alleged that, during their employment at Momence, they uncovered evidence that Momence knowingly submitted "thousands of false claims to the Medicare and Medicaid programs” in violation of the False Claims Act (FCA) and Illinois Whistleblower Reward and Protection Act. They filed a qui tam action on behalf of the government and alleged that Momence retaliated against them for reporting its fraud. A jury awarded the government more than $3 million in compensatory damages and imposed about $19 million in fines for the qui tam claims. Pursuant to the FCA, the compensatory damages were trebled to more than $9 million. The district court set aside the fines as violating the Excessive Fines Clause of the Eighth Amendment. The jury also awarded the nurses $150,000 and $262,320, respectively, on their retaliation claims. The Seventh Circuit vacated. Both claims failed as a matter of law. Rejecting claims of “worthless services” and false certification, the court stated that, at best, a reasonable jury might be able to say that some of Momence’s claims were false, but that is not enough to satisfy the burden of proof. The employment of one nurse was not terminated, the other’s employment was terminated for an unrelated matter. View "Absher v. Momence Meadows Nursing Ctr., Inc." on Justia Law

To compensate teaching hospitals for the extra financial burden of providing training, the Medicare program provides additional reimbursement for expenses beyond the immediate costs of patient care, including for “indirect medical education” (IME) costs to account for the time medical interns and residents spend in ways that enhance their ability to provide patient care but that are not connected to the treatment of any particular patient, 42 U.S.C. 1395ww(d)(5)(B)(ii). The district court held that time spent by interns and residents in research activities wholly unrelated to the diagnosis or treatment of patients could be counted as part of this indirect-education time and that Rush University Medical Center, was entitled to Medicare reimbursements for these activities between the years 1983 and 2001. The Seventh Circuit reversed and remanded, noting that the Secretary of Health and Human Services has interpreted the Medicare Act consistently since 1983 to exclude pure research activities from compensable IME costs. Congress codified this exclusion for Fiscal Years 2001 onward in the Patient Protection and Affordable Care Act of 2010, but explicitly declined to lay down a rule for the years 1983 to 2001. The Secretary has now promulgated a regulation excluding pure research from the IME cost calculation for all years since 1983. View "Rush Univ. Med. Ctr v. Sebelius" on Justia Law

The Hospital filed suit against various federal agencies and officials, seeking a declaratory judgment that 18 U.S.C. 4006(b)(1), where Congress has elected to impose the Medicare rate as full compensation for medical services rendered to federal detainees, is unconstitutional as applied. The court concluded that the Hospital voluntarily opted into the Medicare program and is, as a result, required to provide emergency services to federal detainees. Consequently, the Hospital was foreclosed from challenging this compensation scheme as an unconstitutional taking under the Fifth Amendment. The court noted that the Hospital's most effective remedy may lie with Congress rather than the courts. Accordingly, the court affirmed the district court's dismissal of the action. View "Baker County Medical Services v. U.S. Attorney General, et al." on Justia Law

Groves worked as a strip miner for more than 20 years and a smoker who accumulated more than 50 pack-years. His first claim for black lung benefits, in 1998, was denied. Groves filed his current application in 2006. The ALJ awarded benefits in 2009. The Benefits Review Board vacated and remanded so that the ALJ could provide more detailed explanations. On remand, the ALJ again granted benefits after a careful review of the medical opinions of several different doctors who evaluated Groves’ lung disease, Chronic Obstructive Pulmonary Disease (COPD). The Board affirmed. The Sixth Circuit remanded. While substantial evidence supported the determination that Groves’s COPD arose at least in part out of coal mining employment, the ALJ apparently did not apply the correct standard in determining that his total disability was due to pneumoconiosis.View "Arch on the Green, Inc. v. Groves" on Justia Law