Justia Public Benefits Opinion Summaries

Following multiple surgeries for back injuries and multiple, unsuccessful, claims for disability benefits, the applicant asserted, in a 2008 hearing, that she had been disabled since 2004 and was still disabled but had returned to work because she needed the money. An ALJ found that she had been disabled by chronic back pain but after four years showed "medical improvement." and returned to full-time work.The ALJ awarded benefits for a closed period. The Seventh Circuit reversed and remanded. The ALJ never evaluated whether that work constituted an authorized, and encouraged, trial work period and, therefore, could not be labeled as substantial gainful activity. View "Tumminaro v. Astrue" on Justia Law

From 2007 to 2008, Dorothy Rogers received Medicare benefits through Pacificare's federally-approved Medicare Advantage Plan, Secure Horizons. Rogers and Pacificare entered into separate contracts each year providing the terms and conditions of coverage. After receiving treatment from the Endoscopy Center of Southern Nevada (ECSN), a facility approved by Pacificare for use by its Secure Horizons plan members, Rogers tested positive for hepatitis C. Rogers sued Pacificare, alleging that Pacificare should be held responsible for her injuries because it failed to adopt and implement an appropriate quality assurance program. Pacificare moved to dismiss her claims and compel arbitration based on a provision in the parties' 2007 contract. The district court determined that the 2007 contract governed, but held that the arbitration provision was unconscionable and, thus, unenforceable. The Supreme Court reversed, holding (1) because the parties in this case did not expressly rescind the arbitration provision at issue, the provision survived the 2007 contract's expiration and was properly invoked; and (2) as the Medicare Act expressly preempts any state laws or regulations with respect to the Medicare plan at issue in this case, Nevada's unconscionability doctrine was preempted to the extent that it would regulate federally-approved Medicare plans. View "Pacificare of Nevada v. Rogers" on Justia Law

Husband worked as a miner from 1970 to 1987. In 2000, he was found to be totally disabled by coal workers' pneumoconiosis and was awarded benefits under the Black Lung Benefits Act, 30 U.S.C. 901. He died in 2005. His widow sought survivor’s benefits. At the time, she was required to prove that pneumoconiosis caused, contributed to, or hastened husband's death. An ALJ denied the claim. The Board vacated. On remand, the ALJ again denied benefits. While appeal was pending, Congress amended the Act, retroactively applicable to claims filed after January 1, 2005. The Board reversed and remanded for an order awarding survivor's benefits, holding that section 932(l), as amended, entitled the widow to benefits because husband was receiving black lung benefits at the time of his death and her claim was filed after January 1, 2005. The First Circuit denied the company's petition for review. Under the amendment, the widow is entitled to benefits without having to file a new claim or otherwise revalidate husband's claim because she filed her claim after January 1, 2005. The company's claim that she failed to establish the cause of death is irrelevant. Section 932(l) as amended does not violate the Due Process Clause or Takings Clause. View "B&G Constr. Co Inc. v. Dir., Office of Workers Comp. Programs" on Justia Law

Plaintiff suffered a back injury in a work-related vehicle accident in 1994, developed depression, then sought social security disability benefits. The Commissioner of Social Security adjudged him not to be disabled for purposes benefits. The district court affirmed. The Sixth Circuit reversed. The ALJ did not apply the "treating physicians" or "good reasons" rules in rejecting the treating doctor's opinion. That opinion was not patently wrong, so the ALJ's decision was not supported by substantial evidence.

Employer Ethan Allen, Inc. appealed the Commissioner of the Department of Labor's decision that Claimant Robin Houle's right shoulder condition was compensable under the Workers' Compensation Act.  Claimant experienced pain and weakness in her left shoulder and arm, and her job duties as a furniture refinisher were modified to account for her medical restrictions.  Claimant was assigned to an inventory control/stockroom clerk position where she engaged in a variety of duties.  Interspersed among these duties, claimant also wrapped finished shelves to prepare them for shipping. Claimant was initially treated for the increased symptoms in her shoulder and neck by her primary care provider.  The primary care provider referred her to an orthopedist for further evaluation.  The orthopedist suspected that her left shoulder complaints were most likely due to her repetitive work for Ethan Allen.  He attributed claimant's right shoulder pain to normal wear and tear to be expected of someone claimant's age.  Claimant was dissatisfied with this evaluation and was then referred to an orthopedic surgeon for further evaluation and treatment. In view of the competing expert medical opinions, the Commission relied on a traditional five-part test to evaluate their persuasiveness. Ethan Allen raised numerous arguments on appeal to the Supreme Court. Principal among them, Ethan Allen challenged the Commissioner's use of the five-part test to evaluate competing medical opinions, both as applied in this case and in general.  According to the Employer, the use of this test improperly shifts the burden of proof from claimant to employer, unfairly places employers at a disadvantage, and erroneously employs a "winner take all" approach to evaluating a claimant's expert testimony. Upon review, the Supreme Court concluded that Ethan Allen failed to show that the Commissioner's findings were clearly erroneous or that her conclusions were unsupported by the findings. The Court affirmed the Commissioner's decision in this case.

Appellant Anne Marie Morack worked for Appellee Gentex Corporation for over thirty years. In 2005, she left when swelling and pain in her hands were too overwhelming for her to continue work. She sought medical help, and notified her employer of the pain. In early 2005, Appellant applied for short-term disability, noting on her application for benefits that she did not believe her injury was work-related. After consultation with a specialist, Appellee learned that her injury was work-related. Gentex ultimately appealed the Workers' Compensation Appeal Board's decision granting Appellant's claim to the Commonwealth Court, contending that Appellant did not timely notify her supervisor of the injury nor aptly describe the injury to comply with the state workers' compensation act. The Commonwealth Court reversed, finding Appellant did not aptly describe her injury nor give Gentex adequate notice. The Supreme Court granted allocatur to determine what constitutes sufficient notice under the Act, and to "speak to" an employer's duty to conduct reasonable investigations into the circumstances surrounding a work-related injury. Under the Act, notice is a prerequisite to receive workers' compensation benefits, and the claimant bears the burden of demonstrating that proper notice was given. Upon review of the applicable case law in this instance, the Court found that, "consistent with the humanitarian purposes of the Act, [the Court] made it clear that even imperfect notice can satisfy" its strictures. The Court employed a "totality of the circumstances" approach to determining whether Appellant in this case both satisfied the notice and description of the injury in making her claim for benefits. In reversing the Commonwealth Court, the Supreme Court found that Appellant's collective communications with Gentex satisfied the notification requirements of the Act.

Donovan Donald (Don) was incapacitated in an accident and received several treatment in Kalispell Regional Medical Center (KRMC). Later, a dispute arose between Don's estate and KRMC over KRMC's acceptance or rejection of Medicaid's payments for Don's care. KRMC filed liens against the Estate. The Estate, in turn, sued KRMC and MASH, a company that had provided Medicaid application forms to the Estate, under several theories of liability. The district court granted Defendants' motions for summary judgment. The Supreme Court affirmed, holding the district court (1) did not err in granting summary judgment to KRMC and MASH; (2) correctly interpreted and applied the Montana Medicaid Act; (3) correctly awarded KRMC prejudgment interest but incorrectly included interest KRMC received from its interest-bearing account; and (4) did not abuse its discretion by awarding KRMC attorney fees and costs. Remanded with instructions to offset the prejudgment interest award by the amount of interest KRMC received from the interest-bearing account.

Plaintiff was in a work-related vehicle accident that injured his back in 1994. He worked on and off until 2000 when back pain prevented him from continuing as a truck driver. A 2001 claim for social security disability benefits was denied. Plaintiff had some relief following surgery in 2001 and was released to work in 2002. When the pain increased he began mental health treatment. In 2004 an ALJ found that plaintiff was not disabled. In 2007, following remand, an ALJ again denied benefits. The appeals council denied jurisdiction. The district court affirmed. The Sixth Circuit reversed and remanded, finding that the decision was not supported by substantial evidence because the ALJ failed to properly apply the treating physician rule and the good reasons rule in disregarding the conclusion of a treating psychiatrist and testimony of a treating counselor. Agency procedural rules require that the ALJ balance factors to determine what weight to give a treating source and to give good reasons for the weight actually assigned.

Plaintiff, the mother of a developmentally disabled high school student, alleged that the several sexual encounters her daughter had with another developmentally disabled student in a school bathroom were the result of the school's failure to properly supervise her daughter. At issue was whether plaintiff, individually and on behalf of her daughter, had a cognizable Fourteenth Amendment due process claim against the daughter's special education teacher. The court held that the district court properly dismissed plaintiff's 42 U.S.C. 1983 civil rights claim at summary judgment where the special-relationship exception and the state-created danger exception did not apply in this case. The court held that whatever liability the special education teacher faced, that liability must come from state tort law, not the Fourteenth Amendment. Accordingly, the judgment of the district court was affirmed.

Plaintiff brought a Federal Tort Claims Act (FTCA), 28 U.S.C. 2671-2680, action on behalf of her minor son against the government for injuries allegedly related to his exposure to potentially dangerous, high levels of formaldehyde in their Federal Emergency Management Agency (FEMA) provided emergency housing unit (EHU). At issue was whether the district court properly dismissed plaintiff's claim for lack of subject matter jurisdiction because the claim was time-barred. The court held that neither the discovery rule, equitable estoppel, or the continuing tort doctrine applied in this case and therefore, plaintiff's FTCA claim accrued in May 2006 and her July 2008 administrative filing was untimely. Accordingly, the court affirmed the district court's dismissal of the case for lack of subject matter jurisdiction.