Justia Public Benefits Opinion Summaries

Watson’s father, Hickle, worked for the Department of Energy, 1954 to 1962. Hickle died of Hodgkin’s disease in 1964. Congress enacted the Energy Employees Occupational Illness Compensation Program Act in 2000 to compensate for illnesses caused by exposure to radiation and other toxic substances while working for the Department of Energy. Covered employees or eligible survivors may receive compensation in a lump sum payment; under specific circumstances, a covered employee’s child is also eligible, 42 U.S.C. 7385s-3(d)(2). When her father died, Watson was 19 years old, not a full-time student; she lived with her parents, worked as a waitress, relied on her parents for support, and was listed as a dependent on their income tax returns. She sought survivor benefits in 2002 and received a lump-sum payment of $150,000. She later claimed further compensation as a “covered child,” under a different section of the Act, arguing that she was “incapable of self-support” at the time of Hickle’s death. The Department of Labor denied her claim. Before the district court, Watson challenged the interpretation of “incapable of self-support,” claiming that the Department impermissibly required a showing of physical or mental incapability. The district court denied her motion for summary judgment. The Sixth Circuit affirmed. View "Watson v. Solis" on Justia Law

Banks worked as a coal miner for 17 years and smoked about one pack of cigarettes per day for 38 years. His employment ended in 1991. After two unsuccessful attempts, in 2003, Banks filed a claim for benefits under the Black Lung Benefits Act, which provides benefits to coal miners who become disabled due to pneumoconiosis, 30 U.S.C. 901. An ALJ found that Banks had shown a change in his condition and that he suffered from legal pneumoconiosis which substantially contributed to his total disability. Banks was awarded benefits and the Benefits Review Board affirmed. The Sixth Circuit affirmed, adopting the regulatory interpretation urged by the Director of the Office of Workers’ Compensation Programs. The ALJ relied on reasoned medical opinions. View "Cumberland River Coal Co. v. Banks" on Justia Law

Shideler suffers osteogenesis imperfecta, “brittle bone disease.” In 2006, at age 48, he applied for Social Security Disability Insurance benefits, 42 U.S.C. 423(d), alleging an onset date of 1995. His date last insured was 2000. The ALJ found that despite Shideler’s limitations, there were a sufficient number of jobs in the regional economy available to a person with his restrictions, and denied his application. The Appeals Council denied review. The district court and Seventh Circuit affirmed. The record supported the vocational expert’s testimony concerning available jobs as a clerk, assuming certain restrictions: never climb ladders, ropes, or scaffolds and only occasionally climb ramps or stairs; never crouch, kneel or crawl; never perform overhead reaching; avoid exposure to extreme heat and cold; and perform work that includes occasional, but not frequent, use of fingers. Despite his testimony that he had broken at least 55 bones over the course of his life, the record showed that Shideler had only four surgeries and made a full recovery. The record contained no evidence that Shideler visited any doctors between May 2000 and December 2006. View "Shideler v. Astrue" on Justia Law

The Secretary of the Department of Health and Human Services (HHS) imposed a civil money penalty on Greenbrier Nursing and Rehabilitation Center, a skilled nursing facility in Arkansas, for noncompliance with Medicare participation requirements. The Eighth Circuit Court of Appeals denied Greenbrier's petition for review, holding (1) substantial evidence supported HHS's finding that Greenbrier was not in substantial compliance with 42 C.F.R. 483.25; (2) the finding that Greenbrier's noncompliance with section 483.25 rose to the level of immediate jeopardy was not erroneous; and (3) judicial review of two of Greenbrier's objections to the monetary penalty was barred, and Greenbrier received adequate notice of its noncompliance. View "Greenbrier Nursing v. U.S. Dep't of Health & Human Servs." on Justia Law

Locane, born in 1983, was adopted and does not know her family medical history. She suffered her first symptoms within two weeks of being vaccinated in 1997 and was diagnosed with Crohn’s Disease. She sought compensation under the National Childhood Vaccine Injury Act, 42 U.S.C. 300aa-1 to -34, alleging that she suffered Crohn’s disease as a result of hepatitis B vaccination. A special master denied the claim, finding Locane’s disease began before her vaccination and that Locane failed to prove by a preponderance of the evidence that the vaccine caused or significantly aggravated her disease. The Federal Circuit affirmed. View "Locane v. Sec'y of Health & Human Servs." on Justia Law

Heino, a veteran, is prescribed a daily dose of 12.5 milligrams of Atenolol. The lowest strength available for the prescription is a 25 milligram tablet, so his physician instructed him to split each tablet in half. Heino paid a $7 copayment for a 30-day supply of 15 tablets, which he claimed was excessive in light of the fact that some veterans paid the same co-payment for twice the medication. The VA refused his request for adjustment. The Veterans Court affirmed, rejecting arguments that the regulation the VA uses to calculate his copayment amount, 38 C.F.R. 17.110, conflicts with 38 U.S.C. 1722A(a)(2), which prohibits the VA from charging a copayment “in excess of the cost to the Secretary for medication,” because the actual cost of his Atenolol prescription was well below $7.3, and that his copayment was excessive. The Federal Circuit affirmed. View "Heino v. Shinseki" on Justia Law

Humana sued, alleging that Glaxo was obligated to reimburse Humana for expenses Humana had incurred treating its insureds’ injuries resulting from Glaxo’s drug, Avandia. Humana runs a Medicare Advantage plan. Its complaint asserts that, pursuant to the Medicare Act, Glaxo is in this instance a “primary payer” obligated to reimburse Humana as a “secondary payer.” The district court dismissed, agreeing with Glaxo that the Medicare Act did not provide Medicare Advantage organizations with a private cause of action to seek such reimbursement. The Third Circuit reversed and remanded. The Medicare Secondary Payer Act, in 42 U.S.C. 1395y(b)(3)(A), provides Humana with a private cause of action against Glaxo. Even if the provision is ambiguous, regulations issued by the Centers for Medicare and Medicaid Services make clear that the provision extends the private cause of action to MAOs. View "Humana Med. Plan Inc. v. GlaxoSmithKline LLC" on Justia Law

Plaintiffs appealed from the district court's dismissal of their amended complaint against Florida government defendants, SBHD, AHCA, and DCF. Plaintiffs alleged that defendants' billing practice violated both 42 U.S.C. 1396a(a)(25)(C), the "balance billing" provision of the federal Medicaid Act, and a similar Florida statute. The court concluded that section 1396a(a)(25)(C) did not confer upon plaintiffs a federal right enforceable under 42 U.S.C. 1983 and therefore, affirmed the district court's decision to dismiss the amended complaint. View "Martes, et al. v. CEO of South Broward Hospital Dist., et al." on Justia Law

Heinzelman, born in 1971, received a flu vaccine in 2003, and within 30 days, was hospitalized for Guillain-Barre syndrome, a disorder affecting the peripheral nervous system. She was previously employed full-time as a hairstylist earning $49,888 per year. Due to her injury, Heinzelman will never be able to work again and is eligible to receive SSDI benefits of approximately $20,000 per year. In 2007, she sought compensation under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. 300aa-1 to 300aa-34. A special master rejected the government’s argument that her eligibility for SSDI benefits should be considered in determining compensation under the Vaccine Act, finding that SSDI is not a "federal . . . health benefits program" within the meaning of section 300aa-15(g), and awarded $1,133,046.08, plus an annuity to cover future medical expenses. According to the government, Heinzelman's lost earnings award would have been roughly $316,000 less had the special master taken her anticipated SSDI benefits into account. The Claims Court and the Federal Circuit affirmed. View "Heinzelman v. Sec'y Health & Human Servs." on Justia Law

Five Medicaid recipients filed a class action against the District, alleging that the District systematically denied Medicaid coverage of prescription medications without providing the written notice required by federal and D.C. law. The district court dismissed the case on the pleadings, concluding that plaintiffs lacked standing to pursue their claims for injunctive and declaratory relief. At least with regard to one plaintiff, John Doe, the allegations sufficiently established injury, causation, and redressability and the court concluded that Doe had standing to pursue his claims for injunctive and declaratory relief. Therefore, the court had no need to decide whether the other plaintiffs had standing and reversed the judgment, remanding for further proceedings. View "NB, et al. v. DC, et al." on Justia Law