Justia Public Benefits Opinion Summaries

Dotson died in August 1998. An administrative law judge determined that his wife was entitled to survivor’s benefits under the 2010 Black Lung Amendments, Pub. Law 111-148, 1556(a)–(c). The Sixth Circuit denied the company’s petition for review of the Benefits Review Board decision. The company filed a petition for rehearing, arguing that its case involved an additional issue: whether an award of benefits should commence the month the miner died. The Sixth Circuit denied the petition. The regulation says: “Benefits are payable to a survivor who is entitled beginning with the month of the miner’s death, or January 1, 1974, whichever is later.” 20 C.F.R. 725.503(c). This language was clear before Congress enacted the Amendments, and, by its terms, the widow is entitled to benefits beginning with the month of the miner’s death: August 1998. Rejecting an argument concerning retroactive application, the court stated that “imposition of liability for the effects of disabilities bred in the past is justified as a rational measure to spread the costs of the employees’ disabilities to those who have profited from the fruits of their labor—the operators and the coal consumers.” View "McCoy Elkhorn Coal Corp. v. Dotson" on Justia Law

Figueroa received the flu vaccine in 2008. Within 20 days, he developed numbness in his face, impaired speech, and weakness. He was diagnosed with Guillain-Barré Syndrome, a sometimes fatal nervous system disorder. Because GBS is not listed on the Vaccine Injury Table, 42 U.S.C. 300aa-14(a), it requires proof of causation, although flu vaccine GBS cases have been compensated under the National Childhood Vaccine Injury Act. Figueroa had 36 months from the onset of symptoms to file a petition under the Act (until November, 2011), but, in 2010, he died of pancreatic cancer. His widow timely sought compensation for the vaccine-related neurological injuries suffered prior to his death. A special master dismissed, reasoning that because Figueroa had died of pancreatic cancer, a non-vaccine-related cause, Ms. Figueroa lacked standing to seek injury compensation. The Court of Federal Claims affirmed. The Federal Circuit reversed, interpreting a section that provides: “any person who has sustained a vaccine-related injury, the legal representative of such person if such person is a minor or is disabled, or the legal representative of any person who died as the result of the administration of a vaccine ... may ... file a petition for compensation,” 42 U.S.C. 300aa-11(b)(1)(A) View "Figueroa v. Sec'y of Health & Human Servs." on Justia Law

Plaintiffs claimed that PacifiCare was not entitled to any reimbursement payments out of the wrongful death benefits paid by an insurance policy to them. PacifiCare counterclaimed, arguing that it was entitled to reimbursement under both the terms of its contract with the deceased (Count I) and directly under the Medicare Act (Count 11), 42 U.S.C. 1395. At issue was whether a private Medicare Advantage Organization (MAO) plan could sue a plan participant's survivors, seeking reimbursement for advanced medical expenses out of the proceeds of an automobile insurance policy. Because interpretation of the federal Medicare Act presented a federal question, the district court had subject matter jurisdiction to determine whether that act created a cause of action in favor of PacifiCare against plaintiffs. The district court properly dismissed the causes of action arising under the Medicare Act for failure to state a claim where section 1395y(b)(2) did not create a federal cause of action in favor of a MAO and where, under section 1395y(b)(3)(A), the Private Cause of Action applied in the case of a primary plan which failed to provide for primary payment, which was not applicable in this instance. The court affirmed the district court's dismissal of Count II for failure to state a claim as well as its decision to decline to exercise supplemental jurisdiction over Count 1. View "Parra v. Pacificare of Arizona" on Justia Law

Vazquez-Claudio is a Vietnam veteran. Following his service, Vazquez-Claudio filed a claim with the VA seeking disability compensation for post-traumatic stress disorder. In 2005, after finding that his PTSD was service- connected, the VA granted his request for benefits with an effective date in June, 1994. The VA rated Mr. Vazquez-Claudio’s PTSD as 50 percent disabling, Vazquez-Claudio appealed, arguing entitlement to a 70 percent rating. He had been unable to work since 1994, when he left his job as a police officer as the result of an emotional breakdown following a prisoner’s suicide. The Board of Veterans’ Appeals found that other than occasional suicidal ideation, social isolation, and some difficulty adapting to stressful situations, none of his symptoms corresponded to impairment greater than 50 percent. The Veterans Court agreed, stating that “[t]he issue before the Board was not how many ‘areas’ Mr. Vazquez-Claudio has demonstrated deficiencies in but, rather, ‘the frequency, severity, and duration of the psychiatric symptoms, the length of remissions, and Mr. Vazquez-Claudio’s capacity for adjustment during periods of remission.’” The Federal Circuit affirmed. View "Vazquez-Claudio v. Shinseki" on Justia Law

In 2008, Pepper, then 54 years old, applied for Supplemental Security Disability Insurance Benefits, alleging that she became unable to work in November 1998 as a result of numerous physical and mental impairments. The alleged onset date was later amended to October 2002, when Pepper last worked. Extensive medical records show that Pepper sought treatment for numerous health concerns over the years. At various times, Pepper has been assessed as having ongoing neck pain and limited range of motion in her neck, degenerative disc disease in her spine, left knee problems, migraine headaches, problems with her vision, diabetes, asthma, mitral valve prolapse, sciatica, dyslipidemia, hyperglycemia, hypertension, allergic rhinitis, obesity, plantar fasciitis in her left heel, caregiver stress, and depression. An ALJ denied the claim and the district court affirmed. The Seventh Circuit affirmed, rejecting arguments that the ALJ erred when addressing Pepper’s residual function capacity and that the ALJ’s credibility determination was inadequately supported and patently wrong. Substantial evidence supported denial of benefits. View "Pepper v. Astrue" on Justia Law

The Medicaid statute’s anti-lien provision, 42 U. S. C. 1396p(a)(1), pre-empts state efforts to take any portion of a tort judgment or settlement not “designated as payments for medical care.” A North Carolina statute requires that up to one-third of damages recovered by a beneficiary for a tortious injury be paid to the state to reimburse it for payments made for medical treatment on account of the injury. E. M. A. suffered serious birth injuries that require her to receive 12 to 18 hours of skilled nursing care per day and that will prevent her from working or living independently. North Carolina’s Medicaid program pays part of the cost of her ongoing care. E. M. A. and her parents filed a medical malpractice suit against the physician who delivered her and the hospital where she was born and settled for $2.8 million, due to insurance policy limits. The settlement did not allocate money among medical and nonmedical claims. The state court placed one-third of the recovery into escrow pending a judicial determination of the amount owed by E. M. A. to the state. While that litigation was pending, the North Carolina Supreme Court held in another case that the irrebuttable statutory one-third presumption was a reasonable method for determining the amount due the state for medical expenses. The federal district court, in E.M.A.’s case, agreed. The Fourth Circuit vacated. The Supreme Court affirmed. The federal anti-lien provision pre-empts North Carolina’s irrebuttable statutory presumption that one-third of a tort recovery is attributable to medical expenses. North Carolina’s irrebuttable, one-size-fits-all statutory presumption is incompatible with the Medicaid Act’s clear mandate View "Wos v. E. M. A." on Justia Law

While working at a Ford Motor plant, Rudisill was hit in the face by a piece of equipment, was knocked against a wall, fell to the floor, and rolled forward through the floor opening into the hot pit below. He lay there unconscious, being burned, until coworkers pulled him out of the pit. Rudisill had gained consciousness by this time and was screaming in pain. Rudisill sustained a head injury that required several staples to close. He was also burned on his arms and legs, abdomen, and left hand. Rudisill continues to experience pain, dizzy spells, ringing in the ears, and memory problems. He has had numerous surgeries and has undergone physical and occupational therapy. After a safety review immediately following the incident, Ford decided to modify the process so that employees slide metal grates over the pit before removing the guard rails. After receiving workers’ compensation benefits, Rudisill sued Ford, alleging intentional tort; his wife asserted a derivative claim of loss of consortium. The district court granted summary judgment for Ford. The Sixth Circuit affirmed, finding insufficient evidence that Ford acted with deliberate intent to injure Rudisill, as required by Ohio statute. View "Rudisill v. Ford Motor Co." on Justia Law

Walker served in the U.S. Army Air Force, 1943 to 1945, as a four-engine airplane pilot and flight instructor. The VA Regional Office denied his 2007 disability claim for bilateral hearing loss. Walker appealed to the Board of Veterans Appeals, including sworn statements from his son and wife that his hearing loss began in service and continued throughout his life. Walker was examined by a VA audiologist. Walker’s service medical records were not available due to a fire. The audiologist concluded that the hearing loss was “less likely as not caused primarily by military service as a pilot,” that age could not be excluded as the primary etiology, and that Walker was exposed to recreational noise by hunting game without use of hearing protection. The Board concluded that Walker failed under the three-element test to establish service connection for his hearing loss. The Federal Circuit affirmed. View "Walker v. Shinseki" on Justia Law

Viegas served in the U.S. Army, 1965-1967. After leaving the service, he was injured in a diving accident, resulting in “incomplete” quadriplegia. In 2004, Viegas participated in a prescribed aquatic therapy session at a VA medical center. He used a restroom in the VA facility. The grab bar he used to lift himself into his wheelchair came loose from the wall and he fell to the ground. As a result of the fall, Viegas sustained injuries to his upper and lower extremities. Viegas’ medical condition deteriorated after his fall. Prior to his fall, Viegas could sometimes walk with a walker, but since the accident he can only stand with assistance. Viegas sought disability benefits under 38 U.S.C. 1151. A VA regional office denied the claim. The board affirmed, stating that such benefits are available only if additional disability results from injury that was part of the natural sequence of cause and effect flowing directly from the actual provision of hospital care, medical or surgical treatment, or examination furnished by the VA and such additional disability was directly caused by that VA activity. The Veterans Court affirmed. The Federal Circuit reversed, holding that the Veterans Court misinterpreted the causation requirement. View "Viegas v. Shinseki" on Justia Law

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