Justia Public Benefits Opinion Summaries

Plaintiff alleged a disability due to gout, arthritis, back pain, diabetes, high blood pressure, and obesity. In this appeal, he challenged the denial of his application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. 405. The ALJ found that plaintiff was capable of performing his past relevant work as a farm worker. The court concluded that the ALJ's determination that plaintiff's residual functioning capacity (RFC) to do medium work, with some limitations, is supported by substantial evidence and that the ALJ sufficiently developed the record. In this case, the objective medical findings do not support the degree of limitation alleged by plaintiff. Finally, the court rejected plaintiff's contention that the ALJ failed to adequately develop the record. Accordingly, the court affirmed the judgment. View "Buford v. Colvin" on Justia Law

Caring Hearts Personal Home Services, Inc. provided physical therapy and skilled nursing services to “homebound” Medicare patients. It sought reimbursement from Medicare for services provided. The definition of who qualified as "homebound" or what services qualified as "reasonable and necessary" was unclear, even to the Centers for Medicare & Medicaid Services (CMS). CMS has developed its own rules on both subjects that had been repeatedly revised and expanded over time. In an audit, CMS purported to find that Caring Hearts provided services to at least a handful of patients who didn’t qualify as “homebound” or for whom the services rendered weren’t “reasonable and necessary.” As a result, CMS ordered Caring Hearts to repay the government over $800,000. It was later found that in reaching its conclusions CMS applied the wrong law: the agency did not apply the regulations in force in 2008 when Caring Hearts provided the services in dispute. Instead, it applied considerably more onerous regulations the agency adopted years later, "[r]egulations that Caring Hearts couldn’t have known about at the time it provided its services." The Tenth Circuit found that Caring Hearts "[made] out a pretty good case that its services were entirely consistent with the law as it was at the time they were rendered" when CMS denied Caring Hearts' request for reconsideration. The Tenth Circuit reversed the district court's judgment affirming CMS' denial to Caring Hearts for reimbursement, and remanded for further proceedings. View "Caring Hearts v. Burwell" on Justia Law

In 2009 Crespo applied for Supplemental Security Income benefits for his mother, representing that she lived with him in Illinois and that he took care of her. He served as her representative payee. By signing the form, Crespo acknowledged that he could be held liable for any improper overpayments he caused. Crespo’s mother was not entitled to those benefits because she lived in Puerto Rico (20 C.F.R. 416.215), which Crespo hid from the Social Security Administration by falsely representing, in three subsequent reports as representative payee, that she lived with him. Airline records established that she resided in Puerto Rico; his mother was serving as representative payee for her own mother’s retirement benefits, declaring herself a resident of Puerto Rico. An ALJ imposed a $114,956 civil penalty on Crespo for misrepresentation. The Departmental Appeals Board of the Department of Health and Human Services dismissed his appeal as untimely. The Seventh Circuit affirmed. The Board did not abuse its discretion in rejecting Crespo’s untimely appeal and finding good cause lacking. Appeals are due 30 days after the ALJ’s initial decision is deemed served. A copy of the regulation is included when the decision is delivered. Crespo offered no reason why he did not request an extension. View "Crespo v. Colvin" on Justia Law

In 2008, Joseph Gerdon was seriously injured in a motor vehicle accident that arose out of and in the course of his employment. He was a passenger in a vehicle being driven by a coworker, who drove off the road. The Industrial Commission awarded Gerdon benefits. Gerdon requested a hearing to determine whether he was also entitled to benefits for a compensable psychological injury. That issue was heard before a referee, who issued proposed findings of fact, conclusions of law, and a recommendation that Gerdon had failed to prove that he was entitled to additional psychological care. The Commission adopted the referee’s proposed findings of fact and conclusions of law and issued an order. Gerdon appealed to the Idaho Supreme Court. Because the Commission’s decision was based upon its constitutional right to weigh the evidence and determine the credibility of conflicting expert opinions, the Supreme Court affirmed the Commission's order. View "Gerdon v. Con Paulos, Inc." on Justia Law

Garbe, an experienced pharmacist, began working at Kmart pharmacy in Ohio in 2007. When Garbe picked up a personal prescription at a competitor pharmacy, he discovered the competitor pharmacy had charged his Medicare Part D insurer far less than Kmart ordinarily charged it for the same prescription. He inspected Kmart’s pharmacy reimbursement claims and discovered that Kmart routinely charged customers with insurance—whether public or private—higher prices than customers who paid out of pocket, even ignoring “discount programs sales. Garbe shared his discovery with the government and filed a qui tam suit in 2008. The government has not intervened. Garbe asserts that Kmart’s “usual and customary” prices should be based on the prices Kmart charged the majority of its cash customers. The district court granted Garbe partial summary judgment. On interlocutory appeal, the Seventh Circuit, reversed in part, holding that Medicare Part D Pharmacy Benefit Managers and Plan Sponsors are not “officers or employees of the United States” for purposes of the False Claims Act, 31 U.S.C. 3729(a). The court agreed that Garbe has satisfied the materiality requirement under the Act for his Medicare Part D claims; and that Kmart’s “discount” prices were offered to the “general public.” View "Garbe v. Kmart Corp." on Justia Law

Attorneys employed by the Franklin County Public Defender sought membership and service credit in the Ohio Public Employees Retirement System for their years of service prior to January 1999, and challenged a decision the Ohio Public Employees Retirement Board’s denial of service credit. Persons hired by the Franklin County Public Defender on or before December 31, 1984, are public employees entitled to PERS benefits; effective January 1, 1999, the Franklin County Public Defender’s employees have been enrolled in and considered to be members of PERS. During the intervening years, pursuant to the Ohio Public Defender Act (R.C. Chapter 120), the Franklin County Public Defender Commission and its employees paid Social Security taxes on wages and did not consider the office to be a county agency. The Court of Appeals denied relief. The Supreme Court of Ohio granted a writ of mandamus to compel the board to award service credit, rejecting an argument that “there was no person holding the office of Franklin County Public Defender between 1985 and 1999 because a person was appointed as the ‘Director’ of the corporation. The plain language in R.C. 120.14(A)(1) indicates that the attorneys were employed by a public official, and hence, were public employees. View "Altman-Bates v. Pub. Emps. Retirement Bd." on Justia Law

Paso Robles was responsible for providing Luke, a child with autism, with a free appropriate public education (FAPE) under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400–1487. At the time of Luke’s initial evaluation, Paso Robles was aware that Luke displayed signs of autistic behavior, and therefore, autism was a suspected disability for which it was required to assess him. Paso Robles chose not to formally assess Luke for autism because a member of its staff opined, after an informal, unscientific observation of the child, that Luke merely had an expressive language delay, not a disorder on the autism spectrum. The court held that, in so doing, Paso Robles violated the procedural requirements of the IDEA and, as a result, was unable to design an educational plan that addressed Luke’s unique needs. Accordingly, the court held that Paso Robles denied Luke a free appropriate public education, and remanded for the determination of an appropriate remedy. View "Timothy O. v. Paso Robles USD" on Justia Law

A class of Tennessee residents who applied for Medicaid sought declaratory and injunctive relief, alleging that the delays they have experienced in receiving eligibility determinations on their applications violate 42 U.S.C. 1396a(a)(8) of the Medicaid statute, and that the state’s failure to provide a fair hearing on their delayed applications violates that statute and the Due Process Clause. Regulations implementing the statute provide that “the determination of eligibility for any applicant may not exceed” 90 days for those “who apply for Medicaid on the basis of disability” and 45 days for all other applicants. The district court certified a class and granted a preliminary injunction, which requires the state to grant a fair hearing on delayed applications to class members who request one. The Sixth Circuit affirmed the preliminary injunction, holding that the matter is not moot and that the federal government is not a required party. The court noted that the federal government submitted an amicus brief, supporting plaintiffs’ position. Despite the passage of the Affordable Care Act, states remain ultimately responsible for ensuring their Medicaid programs comply with federal law. View "Wilson v.Gordon" on Justia Law

Plaintiff, on behalf of herself and her son, K.T., filed suit under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400 et seq., against the DOE. At issue is the adequacy of three individualized education programs (IEP), which were characterized by a pattern of procedural violations of the IDEA committed by the DOE, and whether these errors deprived K.T. of a free appropriate public education (FAPE) for a period of three consecutive years. The court concluded that the procedural violations in formulating each IEP, when taken together, deprived K.T. of a FAPE for each school year. The DOE displayed a pattern of indifference to the procedural requirements of the IDEA and carelessness in formulating K.T.’s IEPs over the period of many years, repeatedly violating its obligations under the statute, which consequently resulted in the deprivation of important educational benefits to which K.T. was entitled by law. Accordingly, the court reversed the judgment of the district court and remanded for further proceedings. On remand, the district court is directed to consider, in the first instance, what, if any, relief plaintiff is entitled to as an award for K.T.'s FAPE deprivations. View "L.O. ex rel. K.T. v. N.Y.C. Dep’t of Educ." on Justia Law

A.M. was born in1993, and was raised in a predominately Polish-speaking household. At A.M.’s 15-month routine examination, the pediatrician noted that A.M. was a “well child.” When A.M. was two years old, his pediatrician noted that A.M. used 4 to 10 words and walked independently. When A.M. was four years old, he received his second MMR vaccination. Days later, A.M. returned to the office with a sore throat. Later episodes concerned limping and limited language skills. A doctor gave A.M. a provisional diagnosis of “Ataxia/Unsteadiness and Developmental Delay.” An MRI showed “diffuse white matter demyelination which is consistent with demyelinating process most likely some form of leukodystrophy.” By 2011, A.M. was wheelchair-bound and unable to care for himself. In 2012, at age 18, A.M. saw a specialist who opined that “[t]he finding of apparently normal development followed by a sudden loss of abilities following an insult with severe demyelination is suggestive of vanishing white matter disease. This often presents during childhood with ataxia following infection or fright.” A special master denied compensation under the National Childhood Vaccine Injury Act, 42 U.S.C. 300aa, finding that the Miliks failed to prove by a preponderance of the evidence that a vaccine caused A.M.’s conditions. The Claims Court and Federal Circuit upheld the denial as not arbitrary, capricious, an abuse of discretion. View "Milik v. Sec'y of Health & Human Servs." on Justia Law