Justia Public Benefits Opinion Summaries

Articles Posted in Personal Injury
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Adams, born in 1960, smoked about a pack a day starting at age 18 and worked in coal mines at times between 1979-1995, mostly underground using a “cutting machine” in the “dustiest” areas. Adams struggled to breathe after his retirement. Adams’s 1998 application under the Black Lung Benefits Act, 30 U.S.C. 901(b), was denied because he failed to prove that he had pneumoconiosis. In 2008, Adams sought benefits from Wilgar. His treating physician, Dr. Alam, identified the causes of his 2013 death as cardiopulmonary arrest, emphysema, coal worker’s pneumoconiosis, throat cancer, and aspiration pneumonia.A 2019 notice in the case stated “the Court may look to the preamble to the revised” regulations in weighing conflicting medical opinions. Wilgar unsuccessfully requested discovery concerning the preamble and the scientific studies that supported its conclusions. The ALJ awarded benefits, finding that Adams had “legal pneumoconiosis” and giving Dr. Alam’s opinion that Adam’s coal mine work had substantially aggravated his disease “controlling weight.” All things being equal, a treating physician’s opinion is “entitled to more weight,” 30 C.F.R. 718.104(d)(1). Wilgar's three experts had opined that Adams’s smoking exclusively caused his disease The ALJ gave “little weight” to these opinions, believing that they conflicted with the preamble to the 2001 regulation.The Benefits Review Board and Sixth Circuit affirmed. The preamble interpreted the then-existing scientific studies to establish that coal mine work can cause obstructive diseases, either alone or in combination with smoking. The ALJ simply found the preamble more persuasive than the experts. View "Wilgar Land Co. v. Director, Office of Workers’ Compensation Programs" on Justia Law

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Following a 2013 car accident, Michelle Baptist, then 50 years old, began experiencing significant neck and shoulder pain, as well as headaches. She had one, possibly two, aneurysms. She applied for Disability Insurance Benefits and Supplemental Security Income the following year. After reviewing her medical records and conducting a hearing, an administrative law judge concluded that Baptist retained the capacity to perform light work and, therefore, was not disabled.The Seventh Circuit affirmed the decision as supported by substantial evidence. Despite initial complications from an aneurysm clipping procedure, Baptist’s medical records indicate that she made a full recovery and experienced no ongoing aneurysm-related symptoms. Two doctors reviewed Baptist’s 2018 MRI. Neither recorded any concerns nor did they observe any impact the MRI results would have on Baptist’s functional capacity. They noted that Baptist presented with full upper and lower extremity strength, normal reflexes, a normal gait, and “no overt weakness.” View "Baptist v. Kijakazi" on Justia Law

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The Supreme Court held that because Plaintiff's state-law claims were based on allegations that his father's health maintenance organization (HMO) plan and healthcare services administrator that managed his father's benefits (collectively, Defendants) breached state-law duties that incorporated and duplicated standards established under Medicare Part C, Part C's preemption provision preempted them.Plaintiff brought this action alleging a state statutory claim under the Elder Abuse Act and common law claims of negligence and wrongful death for the alleged maltreatment of his father, a Medicare Advantage (MA) enrollee who died after being discharged from a skilled nursing facility. Plaintiff alleged that the MA HMO and healthcare services administrator breached a duty to ensure his father received skilled nursing benefits to which he was entitled under his MA plan. Defendants demurred, arguing that the claims were preempted by Part C's preemption provision. The trial court sustained the demurrers, and the court of appeal affirmed. The Supreme Court affirmed, holding that because Plaintiff's state-law claims were based on allegations that Defendants breached state-law duties that incorporate and duplicate standards established under Part C, the claims were expressly preempted. View "Quishenberry v. UnitedHealthcare, Inc." on Justia Law

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Robert Procive appealed when a district court dismissed his appeal of an Administrative Law Judge’s order that denied his claim for Workforce Safety and Insurance (“WSI”) benefits. Procive submitted his first claim in 2020, alleging he suffered carpal tunnel syndrome due to injuries to both wrists, elbows, and shoulders resulting from repetitive digging, hammering and driving stakes, steel posts, and iron rods into the ground. He claimed his original injury occurred in western North Dakota, and he notified his employer of his injury in November 2004 and October 2016. WSI accepted liability for Procive’s right carpal tunnel injury, but denied for the left. Later WSI issued its order reversing its acceptance of liability for the right carpal tunnel, finding Procive willfully made false statements about whether he had prior injuries or received treatment. WSI ordered Procive to repay past benefits he received. After a hearing the ALJ affirmed WSI’s decisions denying coverage. Procive appealed to the district court in Stutsman County. WSI moved to dismiss the appeal, arguing the district court lacked subject matter jurisdiction because Procive was required to file his appeal in the county where the injury occurred or the county where he resided. To this, the North Dakota Supreme Court affirmed, finding the district court did not have jurisdiction. View "Procive v. WSI" on Justia Law

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The Supreme Court affirmed the judgment of the circuit court determining what portion of a settlement was subject to the Commonwealth's Medicaid lien, holding that there was no error.Appellant was seriously injured in a car accident. Because the Commonwealth's Medicaid program paid for a portion of Appellant's medical care the Commonwealth was entitled to a lien on the proceeds of an ensuing settlement between Appellant and the driver who caused the accident. At issue was what portion of the settlement was subject to the Medicaid lien. The Supreme Court affirmed, holding that the circuit court's judgment was proper under the deferential standard. View "Farah v. Commonwealth" on Justia Law

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Decker employed Pehringer at its Montana open-pit surface mine, 1977-1999. There were periods when Pehringer did not work, including a roughly three-year-long strike. For most of his mining career, Pehringer was regularly exposed to coal dust while working primarily as a heavy equipment operator. After being laid off in 1999, Pehringer was awarded Social Security total disability benefits. He never worked again. In 2014 a month before his sixty-fifth birthday, Pehringer sought black lung benefits, citing his severe COPD, 30 U.S.C. 923(b). A physician determined that “Pehringer is 100% impaired from his COPD” and that coal “dust exposure and smoking are significant contributors to his COPD impairment.”The Benefits Review Board affirmed a Department of Labor (DOL) ALJ’s award of benefits. The Ninth Circuit affirmed, first rejecting a constitutional challenge to 5 U.S.C. 7521(a), which permits removal of an ALJ only for good cause determined by the Merits Systems Protection Board. DOL ALJ decisions are subject to vacatur by people without tenure protection; properly appointed, they can adjudicate cases without infringing the President’s executive power. The ALJ did not err in adjudicating Pehringer’s claim nor in rejecting untimely evidentiary submissions. Decker did not rebut the presumption of entitlement to benefits after a claimant established legal pneumoconiosis and causation, having worked for at least 15 years in substantially similar conditions to underground coal mines. View "Decker Coal Co. v. Pehringer" on Justia Law

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Kirby received a flu shot in her arm on October 8, 2013. One week later, she complained of persistent arm pain, numbness, and tingling that began immediately after the injection. On October 16, Dr. Henry diagnosed Kirby with radial neuritis and complications due to vaccination. Two weeks later, Kirby reported that her wrist and hand had become “very weak.” On November 12, Kirby began working with a physical therapist. Her physical therapy discharge summary reported that Kirby’s pain was a “0/10,” she had regained full muscle strength except in right thumb extension, and her numbness had decreased by 80%. On December 12, Kirby reported mild right arm pain in the morning, almost normal strength, and occasional tingling, but no numbness in her thumb. Dr. Henry determined she had achieved maximum medical improvement.Kirby visited a nurse practitioner five times in January 2014-July 2015, for reasons unrelated to her vaccine injury and generally reported “feeling fine.” On October 13, 2015, she complained of mild, intermittent pain in her right arm. She had no imitations due to the pain, and no muscle weakness.The Federal Circuit reinstated Kirby’s compensation award under the Vaccine Act, 42 U.S.C. 300aa–1. A finding that Kirby’s vaccine injury lasted more than six months was not arbitrary. A reasonable fact-finder could conclude that Kirby’s testimony is not inconsistent with her medical records from January 2014 through July 2015. The court also rejected an argument concerning causation. View "Kirby v. Secretary of Health & Human Services" on Justia Law

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The parents were domiciled in Nassau, the Bahamas. Mother traveled to the U.S. five times while pregnant. A.R. was born in November 2015, in Nassau, and lived in Nassau for six months. He received his first two sets of vaccinations in Nassau, with no apparent adverse consequences. During his six-month well-child visit in Nassau, A.R. received his third set of eight vaccinations that are listed in the Vaccine Injury Table and were manufactured by companies with a U.S. presence. Days later, A.R. became ill. A.R. was flown to Nicklaus Children’s Hospital in Miami, Florida, where he was diagnosed with hemophagocytic lymphohistiocytosis, an autoimmune disease of the blood. He remained in Florida as an outpatient, returning to Nassau for Christmas, and months later, was diagnosed with acute myeloid leukemia. A.R. underwent treatment, at Cincinnati Children’s Hospital and at Johns Hopkins before he died.The Federal Circuit affirmed the dismissal of the parents’ Vaccine Act claim (42 U.S.C. 300aa). The parents asserted that the condition that caused A.R.’s death was a complication resulting from the treatment he had received for his vaccine-induced condition. The Act grants standing to a person who “received [a covered] vaccine outside the” U.S. if “such person returned" to the U.S. not later than 6 months after the vaccination. A.R., while living outside of his mother’s body, was never present in the U.S. before his vaccinations such that his entrance for medical treatment could be a “return.” View "Dupuch-Carron v. Secretary of the Department of Health & Human Services" on Justia Law

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In July 2010, L.M. was born at full-term and developed normally for six months. In February 2011, L.M. received childhood vaccines, including the diphtheria-tetanus-acellular pertussis vaccination. By that evening, L.M. had a fever, was lethargic, had poor muscle tone, and would not eat., Any disturbance caused L.M. to scream. L.M. began to have several seizures a day. At seven years of age, L.M. could crawl and walk with the assistance of a walker. She had a poorly coordinated grasp, suffered cortical visual impairments, and was nonverbal, though she could use a few signs to express ideas such as “yes,” and “no.” Testing revealed that L.M. had a genetic mutation.In a claim under the National Vaccine Injury Compensation Program, L.M. alleged that the vaccinations administered to L.M. in February 2011, significantly aggravated L.M.’s pre-existing condition under two alternative theories. The Special Master denied the petition, finding that L.M.’s genetic mutation was “the most compelling explanation for her predisposition to develop a seizure disorder.” The Federal Circuit affirmed the denial of an “on-table” claim, finding no support for an argument that most encephalopathies do not become acute until after vaccination. The court vacated and remanded the denial of an “off-table” claim, which requires determining whether the child’s receipt of vaccinations significantly aggravated her seizure disorder in the face of an underlying genetic mutation. View "Sharpe v. Secretary of Health and Human Services" on Justia Law

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In 2012, Lozano gave birth to a baby. While still hospitalized, Lozano received a tetanus-diphtheria-acellular-pertussis (Tdap) vaccination. Two weeks later, Lozano reported a low-grade fever, body aches, and breast tenderness. Lozano’s symptoms persisted through visits to her physician and the emergency room. She developed abdominal pain, difficulty urinating, weakness, loss of balance, vision changes, neck pain, headache, vomiting, and dizziness. A brain MRI suggested that Lozano possibly had multiple sclerosis (MS), acute disseminated encephalomyelitis (ADEM), or vasculitis. Lozano’s symptoms improved with steroid treatment, following a working diagnosis of MS. After several months, a repeat MRI “showed dramatic improvement, suggesting that ADEM was a more likely etiology, which was confirmed through later serological findings.” Lozano’s doctors opine that ADEM is the likely explanation for her symptoms.Lozano sought compensation under the National Childhood Vaccine Injury Act, 42 U.S.C. 300aa. Lozano’s expert opined that Lozano’s ADEM was the result of her receipt of the Tdap vaccine. The special master granted Lozano’s petition, finding that her expert’s testimony and the supporting medical literature demonstrated that the Tdap vaccine can cause autoimmune diseases such as ADEM and that Lozano offered preponderant evidence of a proximate temporal relationship between the vaccine and her injury. The Claims Court and Federal Circuit upheld the award of a lump-sum payment of $1,199,216.86, finding that the decision was neither an abuse of discretion nor contrary to law and that the fact-findings were neither arbitrary nor capricious. View "Lozano v. Secretary of Health and Human Services" on Justia Law