Justia Public Benefits Opinion Summaries

John Boman appealed the grant of summary judgment in favor of the City of Gadsden. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. Following his retirement, Boman elected to pay for retiree health coverage through a group plan offered by Gadsden to retired employees. This retired-employee-benefit plan was also administered by Blue Cross and provided substantially similar benefits to those Boman received as an active employee. In 2000, however, Gadsden elected to join an employee-health-insurance-benefit plan ("the plan") administered by the State Employees' Insurance Board ("the SEIB"). When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and severe osteoarthritis of the spine. 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. Boman was hired before March 31, 1986, and, although Gadsden did begin participation in the Medicare program in 2006, Boman's employee group had not opted to obtain Medicare coverage before Boman retired. Consequently, Boman never paid Medicare taxes and did not claim to have Medicare coverage. The SEIB ultimately determined that the plan was the secondary payer to Medicare. Boman sued Gadsden, asserting that it had broken an agreement, made upon his employment, to provide him with lifetime health benefits upon his retirement. Boman also sued the members of the SEIB charged with administering the plan, challenging the SEIB's interpretation of the plan. Finding no reversible error in the grant of summary judgment to Gadsden, the Supreme Court affirmed. View "Boman v. City of Gadsden" on Justia Law

L.J.’s mother filed suit in federal district court to require the school district to provide L.J. with an Individualized Education Plan (IEP) to provide specialized services to assist with what she contends are serious disabilities. The district court reviewed the record and found that L.J. was disabled under three categories defined by the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400 et seq. Nevertheless, the district court concluded that an IEP for specialized services was not necessary because of L.J.’s satisfactory performance in general education classes. The court concluded that L.J. clearly exhibited behavioral and academic difficulty during the snapshot period where he threatened and attempted to kill himself on three occasions in 2012; in the fall, he frequently acted out at school, and continued to have needs associated with his medication regimen; and the district court should not have discounted these facts. The court concluded that they demonstrate that L.J. required special education services. Because L.J. is eligible for special education, the school district must formulate an IEP. The court also concluded that the school district clearly violated important procedural safeguards set forth in the IDEA. In this case, the school district failed to disclose assessments, treatment plans, and progress notes, which deprived L.J.’s mother of her right to informed consent. The school district also failed to conduct a health assessment, which rendered the school district and IEP team unable to evaluate and address L.J.’s medication and treatment related needs. Accordingly, the court reversed and remanded. View "L. J. V. Pittsburg U.S.D." on Justia Law

Presser, who has 20 years of experience as a Wisconsin nurse and a nurse practitioner, began working with Acacia in 2011, providing psychiatric evaluations, managing patient medication, and providing other medical services. Presser alleges that Acacia and its owner, Freund, engaged in “upcoding,” provided unnecessary medical procedures, and then charged the federal and state governments for those expenses. The district court dismissed Presser’s qui tam action under the False Claims Act, 31 U.S.C. 3729 and the Wisconsin False Claims Act. Citing the need for particularity in pleading, the court noted Presser did not allege that the defendants actually sent any of the alleged claims or made any of the alleged statements to the state or federal governments. The Seventh Circuit affirmed that judgment except with respect to the claims regarding the use of an improper billing code, which were stated with sufficient particularity. Presser otherwise provided no medical, technical, or scientific context which would enable a reader of the complaint to understand why Acacia’s alleged actions amount to unnecessary care forbidden by the statute. View "Presser v. Acacia Mental Health Clinic, LLC" on Justia Law

Alvarado was born in 1967. In 1993 he was granted childhood disability benefits and Supplemental Security Income. The Social Security Act requires the Social Security Administration to periodically review whether a recipient remains disabled. Alvarado’s eligibility was reviewed and affirmed in 1999. In a 2004 review, the Administration determined that his disability had ended, so his benefits were discontinued. After a remand, a hearing officer and ALJ each upheld the decision, finding that Alvarado continued to suffer from a severe learning disorder, which prevented him from performing many jobs, but which did not prevent him from doing simple jobs that did not require interaction with the public and that a significant number of such jobs exist in Illinois,. The Appeals Council denied review. The district judge and Third Circuit affirmed, finding the denial supported by substantial evidence. The court noted evidence evidence that Alvarado: had a driver’s license and drove regularly, including long trips; used public transportation; had obtained an associate’s degree and was only a few credits short of a bachelor’s degree; had lived alone, in a different state from his family; assisted at his mother’s flower shop; performed chores at home; and used the internet. View "Alvarado v. Colvin" on Justia Law

The seven consolidated cases in this appeal all involve attempts by assignees of a health maintenance organization (HMO) to recover conditional payments via the Medicare Secondary Payer Act's (MSP Act), 42 U.S.C. 1395y(b)(2)(B)(ii), (b)(3)(A), private cause of action. At issue is whether a contractual obligation, without more (specifically, without a judgment or settlement agreement from a separate proceeding), can satisfy the “demonstrated responsibility” requirement of the private cause of action provided for by the MSP Act. The court held that a plaintiff suing a primary plan under the private cause of action in the MSP Act may satisfy the demonstrated responsibility prerequisite by alleging the existence of a contractual obligation to pay. A judgment or settlement from a separate proceeding is not necessary. Therefore, the court vacated the district courts' judgments and remanded for further proceedings. View "MSP Recovery LLC v. AllState Ins. Co." on Justia Law

The Supplemental Nutrition Assistance Program (SNAP), overseen by the USDA, is administered by the states, 7 U.S.C. 2011–2036c. An individual is ineligible for SNAP benefits if he is “fleeing to avoid prosecution, or custody or confinement after conviction . . . for a crime, or attempt to commit a crime, that is a felony under the law of the place from which the individual is fleeing.” Michigan’s implementation barred assistance to anyone “subject to arrest under an outstanding warrant arising from a felony charge against that individual.” Michigan had an automated program that compared the list of public-assistance recipients with a list of outstanding felony warrants maintained by the Michigan State Police; when the program identified a match, it automatically closed the recipient’s file and generated a notice of the termination of benefits. In 2015 the Secretary of Agriculture promulgated 7 C.F.R. 273.11(n), clarifying disqualification of fugitive felons. Plaintiffs challenged Michigan's automatic disqualification and notice process. The court certified a class, held that Michigan policy violated the SNAP Act and the Constitution, and issued an injunction requiring Michigan to refrain from automatic disqualifications based solely on the existence of a felony warrant and to provide adequate notices of valid disqualification. The Sixth Circuit affirmed, rejecting claims that the plaintiffs lacked standing, of mootness, that there is no SNAP Act private right of action, and that Michigan's methods were valid. View "Barry v. Lyon" on Justia Law

Charles Wimberly filed an application for disability retirement benefits with the Kentucky Retirement Systems (KERS). A hearing officer recommended that Wimberly's application be denied and, before KERS could render a final decision, Wimberly filed a second application pursuant to Kentucky Revised Statute (KRS) 61.600(2). Following the recommendation of another hearing officer, KERS denied that application. Wimberly sought judicial review; the circuit court reversed KERS. KERS appealed to the Court of Appeals, which affirmed the circuit court. The Supreme Court granted discretionary review to address the parties' arguments regarding the application of the doctrine of res judicata and to determine whether the consumption of alcohol was or could be a pre-existing condition. Having reviewed the record and the arguments of the parties, the Supreme Court affirmed. View "Kentucky Retirement Systems v. Wimberly" on Justia Law

Dianne Carson first filed an application for retirement disability benefits in November 2007. Based on the recommendation of a hearing officer, the Kentucky Retirement Systems (KERS) denied Carson's claim. Carson did not seek judicial review of KERS's order, choosing instead to file a second application in October 2009. Based on a recommendation of a different hearing officer, KERS again denied Carson's claim. Carson sought judicial review and the circuit reversed and remanded with instructions for KERS to consider all of the medical evidence Carson submitted. The Court of Appeals affirmed. KERS argued that Carson's second application should have been dismissed under the doctrine of res judicata. "If res judicata applied to this action, Carson would have been barred from filing a second application that was based on the same claim as her first application. However, KRS 61.600(2) requires KERS to accept an employee's timely filed "reapplication based on the same claim of incapacity" and to reconsider the claim 'for disability if accompanied by new objective medical evidence.'" This case was remanded for KERS to undertake the correct review of the evidence. The Supreme Court affirmed the Court of Appeals. View "Kentycky Retirement Systems v. Carson" on Justia Law

Plaintiff appealed the denial of her Social Security benefits, arguing that the ALJ's determination that she is not disabled is not supported by substantial evidence on the record as a whole. Plaintiff claimed that she was unable to work due to osteoarthritis, lumbago, a congenital back defect, chronic stomach pain, and pulmonary restrictions. The court concluded that the Commissioner gave good reasons for discounting the opinion of plaintiff's treating physician and that substantial evidence in the record as a whole supports the Commissioner’s decision that plaintiff was not disabled. Accordingly, the court affirmed the denial of benefits. View "Reece v. Colvin" on Justia Law

In 1985-1986, Kerrigan was a Navy carpenter. He injured his back and was awarded workers’ compensation benefits by the Office of Workers Compensation (OWCP). In 1993, Kerrigan raised concerns regarding his benefits. Over several years, Kerrigan made multiple requests, some of which were denied. In 2001, Kerrigan contacted the Department of Labor Office of Inspector General (OIG) alleging that DOL employees had based one denial on a form that they falsified or destroyed. The OIG did not investigate, but forwarded the letter to OWCP. Kerrigan pursued, over several years, a suit against DOL for illegal termination of benefits and a suit against the physician who reviewed his medical records. Both were dismissed. In 2013, Kerrigan filed a complaint with the U.S. Office of Special Counsel, which chose not to investigate, but referred him to the Merit Systems Protection Board, where Kerrigan alleged retaliatory termination of benefits. The ALJ dismissed Kerrigan’s appeal, stating that the Whistleblower Protection Act only covers actions taken by an agency concerning its own employees. The Board stated that 5 U.S.C. 8128(b) provides that benefits determinations are within the exclusive jurisdiction of the DOL and are unreviewable and that Kerrigan failed to nonfrivolously allege that his protected disclosures were a contributing factor in the decision to terminate benefits. The Federal Circuit affirmed. While 5 U.S.C. 8128(b) does not bar review, Kerrigan failed to nonfrivolously allege that his protected disclosure was a contributing factor in the decision. View "Kerrigan v. Merit Sys. Protection Bd." on Justia Law