Justia Public Benefits Opinion Summaries

Roddy, born in 1964, suffers from several serious medical problems, including severe lower back pain attributable to degenerative disc disease. When her pain became unbearable, she stopped working and applied for disability insurance benefits. She was unsuccessful before the Social Security Administration. An administrative law judge found that there were jobs in the national economy within her capabilities, although she no longer could perform her old job as a shift manager at a Taco Bell restaurant. The district court affirmed. The Seventh Circuit vacated and remanded. The ALJ improperly discounted the opinion of a physician and improperly considered Roddy’s testimony about her ability to do housework. View "Roddy v. Astrue" on Justia Law

The 57-year-old woman, diagnosed with frozen shoulder and later with chronic obstructive pulmonary disease, stopped medical treatment in 2003, having no health insurance and income of $4500 to $9000 a year as a clerical worker. Her last significant employment, as a hotel night-clerk, ended in 2007. She got another clerical job, but was immediately fired because unable to lift a box of paper. She sought social security disability benefits and resumed treatment. She had regained the full range of motion, but muscles in her arms and shoulders were weak and she had chronic obstructive pulmonary disease, causing bronchitis, respiratory infections, and shortness of breath. The ALJ decided that she was capable of performing as hotel clerk and was not disabled; he disregarded findings by a doctor whom he had appointed and with whom the applicant had no prior relationship. He noted the “lack of aggressive treatment” and that she smoked, overlooking that she stopped smoking 30 years earlier. The ALJ focused on her ability to do laundry, take public transportation, and grocery shop. The Appeals Council declined review. The Seventh Circuit remanded, stating that: “Really the Social Security Administration and the Justice Department should have been able to do better.” View "Hughes v. Astrue" on Justia Law

The plaintiff claimed that an influenza vaccination he received n 2004 at the age of 34 resulted in the onset of multiple sclerosis or significantly aggravated his preexisting, but asymptomatic, multiple sclerosis. A special master denied his claim for compensation under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. 300aa-1 to -34. The Claims Court and the Federal Circuit affirmed. View "W.C. v. Sec'y of Health & Human Servs." on Justia Law

Sexton, a smoker, spent 25 years working in coal mines. He first applied for Black Lung Act (30 U.S.C. 901) benefits in 1973. The application was unsuccessful as were two other claims. In 2001, two years after the denial became final, Sexton filed a subsequent claim. The district director recommended an award of benefits. Buck Creek Coal requested a formal hearing. While his claim was pending Sexton died. His widow filed her own claim and the district director issued a proposed order awarding benefits in the survivor claim. Buck Creek requested a hearing. The administrative law judge considered four medical opinions, and based on that new evidence, determined that Sexton suffered a total disability from clinical and legal pneumoconiosis and that Sexton established a change in an applicable condition of entitlement pursuant to 20 C.F.R. 725.309 and awarded benefits. The Benefits Review Board affirmed with respect to Sexton’s claim and affirmed in part and vacated in part with respect to the survivor claim. The Sixth Circuit affirmed, holding that 20 C.F.R. 725.309 is valid and was correctly applied and that the Board’s decision did not violate principles of finality or res judicata. View "Buck Creek Coal Co. v. Sexton" on Justia Law

In the four cases giving rise to these eleven consolidated appeals, the Secretary of the Department of Health and Human Services (HHS) and the Director of the California Department of Health Care Services (DHCS), appealed the district court's grant of preliminary injunctions to plaintiffs, various providers and beneficiaries of California's Medicaid program (Medi-Cal). At issue was the implementation of Medi-Cal reimbursement rate reductions. The court held that Orthopaedic Hospital v. Belshe did not control the outcome in these cases because it did not consider the key issue here - the Secretary's interpretation of 42 U.S.C. 1396a(a)(30)(A); the Secretary's approval of California's requested reimbursement rates were entitled to Chevron deference; and the Secretary's approval complied with the Administrative Procedures Act, 5 U.S.C. 500 et seq. The court further held that plaintiffs were unlikely to succeed on the merits on their Supremacy Clause claims against the Director because the Secretary had reasonably determined that the State's reimbursement rates complied with section 30(A). The court finally held that none of the plaintiffs had a viable takings claim because Medicaid, as a voluntary program, did not create property rights. View "Managed Pharmacy Care, et al v. Sebelius, et al" on Justia Law

A VA regional office awarded King disability compensation for residuals of a left knee surgery and right knee arthritis. King later sought disability compensation for disabilities of the back and hips on a direct basis and as secondary to his service-connected knee disabilities. Records revealed no treatment for back or hip problems during King's active duty service 1973-1974. King underwent a VA spine examination in 2000. The examiner diagnosed minimal degenerative joint disease of both hips and lumbosacral spine, related to age. A private physician disagreed. In 2007, the Board of Veterans denied King's appeal. The Veterans Court remanded. Additional evidence was developed and, in 2008, the Board obtained an opinion from a Veterans Hospital Administration orthopedist that it was not likely that King’s back and bilateral hip disabilities were directly caused or permanently worsened by the service-connected knee disabilities. The Board and Court of Appeals for Veterans Claims affirmed the denial. The Federal Circuit affirmed, rejecting an argument that the Veterans Court erred by discounting lay testimony offered by King and his wife. The Veterans Court did not fail to consider the proffered lay evidence, so King’s appeal was merely a challenge to the weight given his evidence.View "King v. Shinseki" on Justia Law

Hibbard, then 41 years old and working as a teacher, received a flu vaccination in 2003. She claims that the flu vaccine caused her to develop a neurological disorder known as dysautonomia, a dysfunction of the autonomic nervous system and sought compensation under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C.300aa-1 to 300aa-34. Following a two-day hearing, a special master found that Hibbard had failed to show that her dysautonomia resulted from autonomic neuropathy caused by the vaccine she received in 2003. The Court of Federal Claims upheld the decision. The Federal Circuit affirmed, finding substantial evidence to support the denial. View "Hibbard v. Sec'y Health & Human Servs." on Justia Law

In 2004, Illinois enacted Hospital Provider Funding Legislation imposing a tax on hospital providers, except for certain categories of exempt hospitals, for fiscal years 2004 and 2005, 305 ILCS 5/5A-2(a). The Centers for Medicare and Medicaid Services disallowed the reimbursement of Medicare expenses (42 U.S.C. 1395f(b)(1)) to a group of Illinois hospitals, finding that the amount of a tax assessment paid by the hospitals was a reasonable cost, but was subject to offset by any payments those hospitals received from an Illinois State fund. The district court and Seventh Circuit affirmed, finding that the decision was not inconsistent with established policy. The court rejected an argument that the hospitals incurred the full cost of the tax, as they were billed by and wrote checks to the state, reasoning that the argument ignored the real net impact of the tax and of Access Payments by the state.View "Abraham Lincoln Mem'l Hosp. v. Sebelius" on Justia Law

A dialysis provider created a wholly-owned subsidiary, RCGSC, which supplied dialysis equipment for home use, to take advantage of the Medicare reimbursement scheme and increase profits. In 2005 former employees filed a qui tam action under the False Claims Act, 31 U.S.C. 3729-33, alleging that RCGSC was not a legitimate and independent durable medical equipment supply company, but a “billing conduit” used to unlawfully inflate Medicare reimbursements. The United States intervened and the relators’ claim was voluntarily dismissed. The government alleged that defendants submitted claims, knowing that RCGSC was a sham corporation created solely for increasing Medicare reimbursements; knowing that RCGSC was not in compliance with Medicare rules and regulations; knowing that RCGSC was misleading patients over their right to choose between Method I and Method II reimbursements; and for facility support charges for services rendered to home dialysis patients who had selected Method II reimbursements. The government also brought common law theories of payment by mistake and unjust enrichment. The district court granted summary judgment in favor of the United States. The Sixth Circuit reversed on all counts and remanded some. Defendants did not act with reckless disregard of the alleged falsity of their submissions to Medicare.View "United States v. Renal Care Grp., Inc." on Justia Law

Tasis and his brother ran a sham medical clinic, recruited homeless Medicare recipients who had tested positive for HIV, hepatitis or asthma, paid the “patients” small sums in exchange for their insurance identification, then billed Medicare for infusion therapies that were never provided. During four months in 2006, the Center billed Medicare $2,855,785 and received $827,000 in return. The scheme lasted 15 months, during which Tasis and his collaborators submitted $9,122,159.35 in Medicare claims. An auditor notified the FBI. After an investigation, prosecutors indicted Tasis on fraud and conspiracy claims. Over Tasis’s objection, co-conspirator Martinez testified that she and Tasis had orchestrated a a similar scam in Florida. The court instructed the jury to consider Martinez’s testimony about the Florida conspiracy only as it related to Tasis’s “intent, plan and knowledge.” The jury found Tasis guilty, and the trial judge sentenced him to 78 months in prison and required him to pay $6,079,445.93 in restitution. The Sixth Circuit affirmed, rejecting various challenges to evidentiary rulings. View "United States v. Tasis" on Justia Law