Justia Public Benefits Opinion Summaries

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 brought a putative class action under the Employee Retirement Income Security Act, 29 U.S.C. 1001, to recover benefits under long-term disability benefit plans maintained by their former employers. The plans provide for reduction of benefits if the disabled employee also receives benefits under the Social Security Act, as both plaintiffs do. They dispute calculation of the reduction, claiming that the plans do not authorize inclusion in the offset of benefits paid to dependent children. Both plans require offsets for "loss of time disability" benefits. The district court dismissed. The Seventh Circuit affirmed, holding that children's Social Security disability benefits paid based on a parent's disability are "loss of time disability" benefits under the language of the plans. View "Schultz v. Aviall Inc. Long Term Disability Plan" on Justia Law

Firefighters, who suffered career-ending injuries during required training exercises, obtained line-of-duty disability pensions and sought continuing health coverage under the Public Safety Employee Benefits Act, 820 ILCS 320/10, which requires employers of full-time firefighters to pay health insurance premiums for the firefighter and family if the firefighter suffers a catastrophic injury as a result of a response to what is reasonably believed to be an emergency. The trial court dismissed a declaratory judgment action by one firefighter and affirmed denial of the insurance benefit for one firefighter. The appellate court affirmed. The supreme court held that an "emergency" means an unforeseen circumstance calling for urgent and immediate action and can arise in a training exercise. The other firefighter had obtained a declaratory judgment, which was affirmed by the appellate court. The supreme court distinguished the situation because, although he was instructed to "respond as if it were an actual emergency," he was not injured while making an urgent response to unforeseen circumstances involving an imminent danger to person or property. View "Gaffney v. Bd. of Tr. of Orland Fire Prot. Dist." on Justia Law

ESBC, billing agent for the Fire Department, determined that each of the individual defendants owned a vehicle involved in a collision to which the Fire Department responded and each had insurance coverage, and billed response costs incurred for each collision. The defendants refused to pay and ESBC sought a declaration that defendants were liable under the Comprehensive Environmental Response, Compensation, and Liability Act, 42 U.S.C. 9601. Under CERCLA, the owner of a “facility” from which hazardous substances have been released is responsible for response costs that result from the release. Insurer-defendants counterclaimed for injunctive relief from ESBC’s billing practices and alleging violation of the Fair Debt Collection Practices Act, 15 U.S.C. 1692, unjust enrichment, unlawful fee collection, fraud, constructive fraud, and insurance fraud. The district court granted defendants judgment on the pleadings and dismissed counterclaims without prejudice. The Seventh Circuit affirmed. Motor vehicles for personal use fall under the "consumer product in consumer use” exception to CERCLA’s definition of facilityView "Emergency Serv. Billing Corp., Inc. v. Allstate Ins. Co." on Justia Law

Alohacare, a health maintenance organization (HMO), submitted a proposal to the Department of Human Services to bid for a Quest Expanded Access contract to provide healthcare services for participants in the state's Medicaid program. The Department of Human Services awarded Quest contracts to United HealthCare Insurance (United) and WellCare Health Insurance (Ohana) but not to Alohacare. Alohacare petitioned the Insurance Commissioner of the Department of Commerce and Consumer Affairs for declaratory relief that the Quest contracts required the accident and health insurers to carry an HMO license. The Commissioner concluded that the license was not required to offer the Quest managed care product because the services required under the contracts were not services that could be provided only by an HMO. The circuit court affirmed. The Supreme Court affirmed, holding (1) AlohaCare had standing to appeal the Commissioner's decision; (2) both accident and health insurers and HMOs were authorized to offer the model of care required by the Quest contracts; and (3) this holding did not nullify the Health Maintenance Organization Act. View "Alohacare v. Ito" on Justia Law

This case involved Commonwealth Care, a state-initiated program that provided structured premium assistance for low-income Massachusetts residents. In 2009, the Legislature made certain changes to the eligibility requirements of Commonwealth Care, enacted in a two-part supplemental appropriation for fiscal year 2010. Section 31(a) of the appropriation excluded all aliens who were federally ineligible under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), 8 U.S.C. 1601-1646, from participation in Commonwealth Care. Plaintiffs were individuals who either have been terminated from Commonwealth Care or have been denied eligibility solely as a result of their alienage. The court held that section 31(a) could not pass strict scrutiny and that the discrimination against legal immigrants that its limiting language embodied violated their rights to equal protection under the Massachusetts Constitution. View "Finch & others v. Commonwealth Health Ins. Connector Auth. & others" on Justia Law

The issue on appeal to the Tenth Circuit was whether Plaintiff Altheia Allen was disabled when her employer SouthCrest Hospital allegedly failed to accommodate her disability and terminated her employment. Because the Tenth Circuit concluded after review of the trial court record that Plaintiff failed to demonstrate a genuine issue of material fact concerning her alleged disability, the Court affirmed the district court's grant of summary judgment in favor of SouthCrest. View "Allen v. Southcrest Hospital, et al" on Justia Law

Hit by a vehicle in 2004, plaintiff had medical bills of $82,036 that were paid in full by Medicare. The owner of the vehicle settled with plaintiff for $125,000. Medicare sought reimbursement of $62,338 under 42 U.S.C. 13955y(b)(2)(B)(i)., which plaintiff paid under protest. An ALJ rejected plaintiff's argument that an unknown motorist was responsible for 90 percent of the damage so that only 10 percent of the settlement was for medical expenses and the rest was for pain and suffering. The Medicare Appeals Council, district court, and Sixth Circuit affirmed, noting that plaintiff presented no evidence of hardship. View "Hadden v. United States" on Justia Law

Claimant David Tarbet worked for Employer J.R. Simplot Company for thirty-six years until an accident in 2007 left him totally and permanently disabled. The issue before the Industrial Commission (Commission) was whether Employer was liable for all or only a part of Claimant’s income benefits. If Claimant’s total disability resulted solely from the last accident, Employer would be liable for all of the income benefits. If his total disability resulted from the combined effects of both that injury and impairments that pre-existed that injury, then Employer was liable only for that portion of the income benefits for the disability caused by the accident, and the Industrial Special Indemnity Fund (ISIF) would be liable for the remainder. The Industrial Commission found that the April 2007 accident was Claimant’s final industrial accident, that he was totally and permanently disabled as a result of the final accident, and that the impairments that existed prior to that accident did not contribute to his total disability. It found that ISIF was not liable for Claimant’s benefits and dismissed the complaint against it. Employer then appealed. Upon review of the Commission's record, the Supreme Court affirmed the Industrial Commission's order. View "Tarbet v. J.R. Simplot Co. " on Justia Law

A worker was involved in a fight in a logging camp bunkhouse. He did not file a report of injury related to the fight for over a year. When he finally filed a report of injury, he alleged that he had injured his hip, lower back, and ear in the fight. His employer denied the worker benefits because he did not give timely notice of the injury. The worker then alleged that he had verbally informed his supervisor of the injuries. After a hearing, the Alaska Workers’ Compensation Board determined that the worker’s claim was barred because he did not give his employer timely notice of the injury. The Board performed an alternative analysis assuming the worker had given timely notice and decided that the claim was not compensable. The Alaska Workers’ Compensation Appeals Commission affirmed the Board’s decision. Because the Commission correctly determined that substantial evidence in the record supports the Board’s decision on the compensability of the claim, the Supreme Court affirmed the Commission’s decision.