Justia Public Benefits Opinion Summaries

Holder was an Illinois correctional officer since 2006. His wife began to suffer from mental health problems relating to opiate dependency. The Family and Medical Leave Act (FMLA) entitles eligible employees to 12 work weeks of leave during a 12-month period to care for a spouse with a serious medical condition, 29 U.S.C. 2612(a)(1). In October 2007, Holder submitted an FMLA certification form. His wife’s psychiatrist indicated that it would “be necessary for the employee to take off work only intermittently or to work less than a full schedule as a result of the condition,” and that the need for leave would continue for an “unknown” duration. The request was approved. The state never asked for additional medical documentation and paid its share of his health insurance premium until April 18, 2008. About 130 days of absence were recorded on a day-by-day basis. On April 18, 2008, Holder was advised that his FMLA leave had expired and that additional leave would be under the Illinois Family Responsibility Leave program, which allows up to a year of unpaid leave; the state only covers insurance premiums for six months. In April-June 2008, Holder took 29 absences, citing the state program. The Warden disapproved requests for June 8-9 and on the denied form, Holder wrote “last one!!!” Eight months later Central Management Services informed Holder that the state had mistakenly paid for his health insurance premiums beyond his entitlement and began deducting 25% of his earnings until he had refunded $8,291.83. Holder sued, claiming interference with FLMA rights. The jury returned a verdict in favor of the state, but the judge entered judgment awarding Holder $1,222.10 for January 2008, but entered a judgment for the state for the rest of the months. The Seventh Circuit affirmed.View "Holder v. IL Dep't of Corrs." on Justia Law

In consolidated appeals, petitioners, both recipients of home-based long-term care benefits through Vermont's Medicaid-funded Choices for Care (Choices) program, appealed decisions of the Human Services Board disallowing deductions for personal care services from their patient-share obligation under federal and state Medicaid laws. Upon review of the cases, the Supreme Court concluded that to the extent the services in question were medically necessary, expenses for those services must be deducted from petitioners’ patient-share obligation even if they are of a type generally covered by Medicaid. Furthermore, the Court rejected the State’s claim that the decision of the Department of Disabilities, Aging and Independent Living not to provide the personal care services in question under the Choices program constituted a conclusive finding that the services were not medically necessary. View "In re Brett" on Justia Law

The Medicare as a Secondary Payer Act, 42 U.S.C. 1395y(b)(2) precludes Medicare from providing benefits when a “primary plan” could be expected to pay. When the primary plan does not promptly pay medical expenses, Medicare makes conditional payments and is entitled to reimbursement. Under the New Jersey Collateral Source Statute (NJCSS), N.J. Stat. 2A:15–97, a tort plaintiff cannot recover damages from a defendant when she has already received funding from a different source. Taransky was injured when she fell at a shopping center. Medicare conditionally paid for her care. She sued the owner, seeking damages for bodily injury, disability, pain and suffering, emotional distress, economic loss, and medical expenses. She settled for $90,000, granting a full release, stating that liens or subrogation claims would be satisfied from settlement proceeds, and stating that Taransky would indemnify the owner with respect to such claims. Based on the NJCSS, Taransky then claimed that her Medicare expenses were not included in the settlement and obtained an order that the settlement was solely recovery for bodily injury, disability, pain and suffering, emotional distress, and non-economic, otherwise-uncompensated loss. A Medicare contractor demanded reimbursement of $10,121.15. Taransky refused to pay, arguing that a tortfeasor was not a “primary plan” and that reimbursement would be inequitable because she had not recovered medical expenses. An ALJ ruled against Taransky. The Medicare Appeals Council affirmed. The district court dismissed, holding that it lacked jurisdiction over proportionality and due process claims because she had not raised them before the agency; that the NJCSS did not apply to conditional Medicare benefits; and that the MSP Act authorized reimbursement from the settlement. The Third Circuit affirmed. View "Taransky v. Sec'y U.S. Dep't of Heath & Human Servs." on Justia Law

The worker was injured in a 2006 automobile accident near Cordova, where he was working temporarily for Venture. Cordova is 200 miles from Springfield, where he lived and where his plumbers’ and pipefitters’ union was. He was living a motel 30 miles from the worksite with a coworker, also from Springfield, who was driving when the accident occurred. An arbitrator denied his workers’ compensation claim. The Workers’ Compensation Commission reversed; the trial court set aside the Commission’s finding. The Workers’ Compensation Division of the Appellate Court granted relief to the worker. The Illinois Supreme Court reversed, holding that the worker was not a “traveling employee” and could not be compensated. An injury incurred by an employee in going to or returning from the place of employment is not compensable, because it is not arising out of or in the course of employment, unless the worker can be categorized as a “traveling employee.” The employer did not direct the worker to accept the position at the Cordova location; he accepted it with full knowledge of the commute involved. His course or method of travel was not determined by the demands and exigencies of the job. He was not reimbursed for travel time or expenses or told what route to take.View "The Venture-Newberg Perini Stone v. IL Workers' Compensation Comm'n" on Justia Law

The City of Gadsden and certain members of the State Employees' Insurance Board appealed two circuit court orders that granted injunctive relief to John Boman. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. In 2000, Gadsden elected to join the 'Local Government Health Insurance Plan,' a health benefit plan administered by the Board. When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and other ailments. After his 65th birthday, Blue Cross began denying his claims for medical treatment based on the failure to provide Blue Cross with a 'record of the Medicare payment.' However, Boman had no Medicare credits. When the dispute over coverage arose, Boman sought review by the Board. The Board denied Boman's request for an appeal. Boman and 18 other active and retired Gadsden police officers sued Gadsden, alleging, among other things, that they had 'been deprived of Social Security and Medicare protection which other police officers have been provided' and that, after 20 years of service, they were being required to pay a higher pension charge or percentage of base pay than their counterparts who were hired after April 1, 1986. In 2011, Boman filed a 'motion for immediate relief for medical care.' The Supreme Court found that the circuit court issued preliminary injunctive relief against Gadsden without requiring Boman to give security and without making any specific findings. As such, the Supreme Court had "no alternative but to reverse" the preliminary injunction issued against Gadsden and remanded the case for further proceedings.View "City of Gadsden v. Boman " on Justia Law

When an insurance company authorized to transact business in Illinois becomes insolvent and unable to pay claims, the Illinois Insurance Guaranty Fund pays those claims after an order is entered liquidating the company, 215 ILCS 5/532. A cap on individual claims is inapplicable to workers compensation claims under the Workers’ Compensation Act, 820 ILCS 305/1. The plaintiff is the successor to Wells, a manufacturer. A Wells employee was seriously injured on the job in 1985, and, in 1993, the Industrial Commission ordered weekly lifetime benefits for total, permanent disability. Wells began to make the payments directly to the employee. Wells was self-insured, but had excess insurance from Home Insurance. After Wells’ payments to the injured employee reached $200,000, Home paid benefits until Home became insolvent in 2003 and was liquidated. The Illinois Insurance Guaranty Fund took over Home’s obligations, but stopped paying the employee in 2005, arguing that payments to an excess, rather than a primary, insurer were not payments of “workers’ compensation claims” exempted from the cap. Wells continued paying the employee and sought a declaration that the Fund’s payments should continue. The circuit court agreed with Wells, awarding summary judgment, and the appellate court affirmed. The Illinois Supreme Court affirmed, rejecting the distinctions made by the Fund between excess and primary coverage and between payments made directly or indirectly to employees. View "Skokie Castings, Inc. v. IL Ins. Guar. Fund" on Justia Law

After Insured sustained injuries in a car accident he sought MRIs from Virtual Imaging Services. Virtual Imaging obtained an assignment of personal injury protection (PIP) benefits under Insured's policy with GEICO and billed GEICO $3600 for the MRIs. GEICO paid the bill but limited its reimbursement to eighty percent of 200 percent of the applicable Medicare fee schedule in accordance with the formula described in Fla. Stat. 627.736(5)(a). This statutory provision became effective on January 1, 2008 as part of Florida's PIP statute. Virtual Imaging subsequently sued GEICO, alleging that GEICO's reimbursement was insufficient. The county court granted Virtual Imaging's motion for summary judgment. The court of appeal affirmed then certified a question of law to the Supreme Court, which answered by holding that GEICO was required to give notice to Insured by electing the permissive Medicare fee schedules in its policy before taking advantage of the Medicare fee schedule to limit reimbursements.View "Geico Gen. Ins. Co. v. Virtual Imaging Servs., Inc." on Justia Law

Holline and William Parsons (Plaintiffs) were enrolled in Today's Option, a Medicare Advantage Plan sponsored by the Pyramid Life Insurance Company (Pyramid). After Plaintiffs were each disenrolled from their respective plans, they brought suit against Pyramid, asserting numerous state law claims. The circuit court granted Plaintiffs' motion for summary judgment in part declaring that the Medicare Act did not provide the exclusive remedy for Plaintiffs' claims in this case. Pyramid then moved for Ark. R. Civ. P. 54(b) certification and a stay pending appeal, requesting permission to file an interlocutory appeal on the issues of whether Plaintiffs' state-law claims arose under the Medicare Act and whether their claims, to the extent they did not arise under the Act, were expressly preempted by the Act. The circuit court certified this appeal pursuant to Rule 54(b). The Supreme Court dismissed the appeal without prejudice, holding that the finding supporting Rule 54(b) certification was in error. View "Pyramid Life Ins. Co. v. Parsons" on Justia Law

This appeal by Dorothy Knight arose from a 2011 circuit court order. In it, the circuit court affirmed an administrative decision by the Public Employees Retirement System (PERS) denying disability benefits. Upon review, a majority of the Supreme Court concluded that Knight met her burden, and that PERS' decision to deny her claim was not supported by substantial evidence. Accordingly, the Court reversed the appellate and circuit courts' rulings and remanded the case for further proceedings. View "Knight v. Public Employees' Retirement System of Mississippi" on Justia Law

Petitioner Vincent James Hogg, Sr. sought review of a Workers' Compensation Court order which denied his workers' compensation benefits based upon the court's interpretation of 85 O.S. 2011, section 312 (3). Petitioner was employed by the Oklahoma County Juvenile Detention Center when in late 2011, he sustained an injury to his right shoulder and neck while subduing an unruly and combative juvenile. Petitioner was given a post-accident drug screen and a follow-up screen the next day. Both screens showed a "positive" result for the presence of marijuana in his system. Petitioner did not dispute the test results but Petitioner denied ever smoking marijuana. The trial court ultimately found there was no evidence presented to establish Petitioner was "high," nor was there any evidence to establish the marijuana in his system was the "major cause" of the accidental injury. The trial court did, however, deny Petitioner's eligibility for workers' compensation benefits by reason of its interpretation of the newly created 85 O.S. 2011, section 312 (3). The dispositive issue presented to the Supreme Court was whether the trial court erred in its interpretation of the statute. The trial court found the last sentence of paragraph 3 expressed the legislative intent of the entire paragraph without giving any weight to the other sentences in the same paragraph. In its order, the trial court indicated this sentence created an irrebuttable presumption. Upon review, the Supreme Court disagreed. The Court concluded that Petitioner overcame the rebuttable presumption of ineligibility for workers' compensation benefits. The case was reversed and remanded for further proceedings. View "Hogg v. Oklahoma Cty. Juvenile Bureau" on Justia Law