Justia Public Benefits Opinion Summaries

Articles Posted in Injury Law
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Nealy was hired by Santa Monica in 1996 and became a recycling worker. Nealy injured his knee on the job in 2003. A doctor declared him temporarily totally disabled until 2005, when he was released to “light duty” with the restriction that he could not push large trash bins. Nealy requested a clerical or refuse collection vehicle operator position, but began working as a groundskeeper. Nealy met with the accommodations committee again in 2006 because of difficulty climbing or descending stairs. The city did not have any office work available; Nealy never returned to work after a 2006 emergency room visit. After additional accommodation meetings, in 2010, the city indicated that it was unable to provide reasonable accommodation into an alternative position because Nealy was not minimally qualified for the only available position that was not a promotion. The city filed a disability retirement application but, in 2011, CalPERS canceled the application for failure to submit necessary information. Nealy obtained a right-to-sue notice from the California Department of Fair Employment and Housing. The court entered judgment for the city on disability discrimination, failure to provide reasonable accommodation, failure to engage in the interactive process, and retaliation. Meanwhile, an ALJ awarded Nealy $36,260 on his workers’ compensation claim. The court of appeal affirmed, in favor of the city. View "Nealy v. City of Santa Monica" on Justia Law

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Zirnsak was involved in a motor vehicle accident. She sustained head and lung injuries and skeletal fractures and was hospitalized from October 8 through November 14, 2001, temporarily on life support. Upon her discharge, she was sent to a rehabilitation facility, where she was treated from January 16, 2002 through October 18, 2005. In 2003, she suffered a seizure. She was prescribed medication and did not suffer any further seizures. Between January 5, 2005 and August 11, 2006, Zirnsak underwent plastic surgery for lipoma reductions. Zirnsak sought treatment from several medical professionals, including treatment for “traumatic brain injury, left hemiparesis cognitive impairments with short-term memory deficits, organic affective changes[,] and a seizure disorder.” In 2010, Zirnsak applied for Social Security Disability Insurance benefits alleging a disability commencing on May 11, 2006. Zirnsak’s date last insured was December 31, 2007. The SSA denied Zirnsak’s application, finding that Zirnsak was capable of performing certain jobs available in the national economy, so long as those jobs were sedentary and routine. The district court and Third Circuit affirmed. Substantial evidence supports Zirnsak’s ability to perform jobs widely available in the national economy: order clerk, food and beverage; charge account clerk; and telephone clerk. View "Zirnsak v. Colvin" on Justia Law

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In 1992, Fugate, receiving workers’ compensation, obtained disability benefits from the Social Security Administration. In such cases, SSA reduces payments until the total benefits equal 80 percent of the recipient's “average current earnings.” Using Fugate’s December 1991 pay stub, SSA calculated “one-twelfth of the total of his wages . . . for the calendar year in which he had the highest such wages,” on which FICA taxes are paid. Fugate had 1991 gross earnings of $22,964.41. After subtracting pretax benefits and retirement contributions (not subject to FICA), SSA calculated his covered earnings as $21,693.30. Fugate complained that SSA should have used pay stubs from his three highest months of earnings in 1991. In 2004, after a periodic review, SSA erroneously determined that Fugate’s covered earnings should have been $22,964.41 and paid Fugate an extra $8,875. In 2006, after another periodic review, SSA realized its mistake and asked Fugate to refund the $8,875. Instead of requesting a refund waiver, Fugate sought reconsideration of calculation of benefits for the same reasons he had cited since 1993. An ALJ declined to reconsider the 2004 decision, but erroneously held that Fugate was entitled to a waiver even though he had not requested one. Fugate nonetheless appealed. The Appeals Council vacated. The district court granted the Administration summary judgment. The Eighth Circuit affirmed. View "Fugate v. Comm'r of Social Sec." on Justia Law

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Minnick suffers from several serious medical problems, including fibromyalgia, chronic obstructive pulmonary disease (COPD), and degenerative disc disease. Minnick was a truck driver for 24 years until taking short term leave in 2008 due to pain in his legs and hip. After returning to work, he was laid off. In 2010, he applied for disability insurance benefits under the Social Security Act. After the Disability Determination Bureau denied Minnick’s claim, an Administrative Law Judge determined that Minnick is not disabled within the meaning of the Social Security Act. The Appeals Council denied review. The district court affirmed. The Seventh Circuit reversed, finding that the ALJ did not fully develop the record nor adequately articulate her analysis in discrediting the testimony of one of Minnick’s treating physicians. View "Minnick v. Colvin" on Justia Law

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Navarro served in the Army from 1958-1960. He is not a combat veteran, but served near the demilitarized zone after the Korean War. In 2005, Navarro sought service connection for PTSD. He established the condition under 38 C.F.R. 4.125(a). He provided testimony about hearing shots, seeing injured soldiers, and hearing noises while on night guard duty. The Board of Veterans’ Appeals denied the claim in 2008. While appeal was pending, the VA amended 38 C.F.R. 3.304(f) with respect to evidence required to establish claimed in-service stressors for PTSD claims. The Veterans Court vacated. On remand, the Board found that revised 3.304(f) did not apply because Navarro had been diagnosed by a therapist, not a “VA psychiatrist or psychologist” and that Navarro was not entitled to a VA medical examination because “none of his claimed stressor events have been sufficiently corroborated by credible supporting evidence and his account of having a continuity of PTSD symptomatology since service is not deemed credible.” The Veterans Court affirmed. The Federal Circuit remanded for determination of whether Navarro’s “claimed stressor[s are] consistent with the places, types, and circumstances of the veteran’s service.” If so, he is entitled to examination by a VA psychiatrist or psychologist. View "Sanchez-Navarro v. McDonald" on Justia Law

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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

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Warner, insured by State Farm, was involved in an automobile accident. Following the accident, Michigan Spine provided Warner with about $26,000 of neurological treatment. State Farm denied coverage, stating that Warner’s condition was the result of a preexisting condition. Michigan Spine submitted the claim to Medicare, which approved a conditional payment of $5,000 under the Medicare Secondary Payer Act, 42 U.S.C. 1395y. Michigan Spine sued State Farm under Michigan’s No-Fault Act and the Medicare Secondary Payer Act, which permits private causes of action against primary plans that fail to pay medical expenses for which they are responsible. The district court dismissed, holding that a private party can recover under the Secondary Payer Act only if a “primary plan” has failed to provide appropriate reimbursement only because the planholder is entitled to Medicare benefits, and State Farm did not deny coverage on that basis. The Sixth Circuit reversed and remanded. Although the text of the Secondary Payer Act is unclear as to whether a private cause of action is available against a non-group health plan that denies coverage on a basis other than Medicare eligibility, accompanying regulations and congressional intent indicate that the requirement applies only to group health plans and not to non-group health plans. Michigan Spine may pursue its claim under the Secondary Payer Act. View "MI Spine & Brain Surgeons, PLLC v. State Farm Mut. Auto Ins Co" on Justia Law

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Spicer served on active duty in the Navy from 1984 until 1987. In 1986, Spicer fractured his left little finger when a door closed on his hand while aboard ship. The fracture required surgery, which resulted in the finger joint fusing. In 2007, a VA examiner diagnosed Spicer as having degenerative arthritis of the distal interphalangeal joint in that finger. A VA regional office denied Spicer a compensable rating. The Board of Veterans’ Appeals found that although Spicer’s left finger disability was manifested by pain and limitation of motion, he failed to meet the criteria for a compensable evaluation for a left finger disability under either Diagnostic Code (DC) 5227 or 5230. The Veterans Court rejected Spicer’s argument that DC 5003 assigns a 10% rating for either a single affected major joint or a group of affected minor joints and that 38 C.F.R. 4.45(f) does not mandate that multiple minor joints be involved. The Veterans Court stated that “the DIP joint is not a major joint or minor joint group for the purpose of rating disabilities from arthritis.” The Federal Circuit affirmed. View "Spicer v. Shinseki" on Justia Law

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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

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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