Justia Public Benefits Opinion Summaries

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

Plaintiff enrolled her son at a private school after she decided that the individualized education program (IEP) proposed by the DOE for the 2010-2011 school year failed to provide her son with a free appropriate public education (FAPE) under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400 et seq. Plaintiff filed suit seeking tuition reimbursement, the IHO granted her relief, but the SRO reversed the decision, and the district court affirmed. The court deferred to the IHO's well-reasoned determination that the son required the services of a 1:1 paraprofessional for longer than the transitional three-month period afforded him by his IEP. Because the DOE failed to offer him a FAPE, the court reversed and remanded to the district court to consider the appropriateness of plaintiff's private placement and the balance of the equities. View "Reyes v. NYC Dept. of Educ." on Justia Law

The survivors of eight firefighters who died in 2003 sought survivors’ benefits under the Public Safety Officers’ Benefits Act, 42 U.S.C. 3796. The eight were employed by First Strike, a private company that works with governmental and private entities to help suppress wildfires, under agreements that characterized them as independent contractors. The Public Safety Officers’ Benefits Office denied the claims, and they requested redetermination by the Director of the Bureau of Justice Assistance (BJA), which also denied the claims. The Federal Circuit affirmed, finding that the BJA did not err in concluding that the firefighters were not public safety officers within the meaning of the Benefits Act. View "Moore v. Dep't of Justice" on Justia Law

The Attorney General for the State of Louisiana brought an action against the defendant pharmaceutical companies alleging, among other things, violations of the Louisiana Medical Assistance Programs Integrity Law (MAPIL). The district court entered a judgment upon the jury's verdict in favor of the Attorney General, finding the defendants' alleged misconduct in marketing certain drugs had violated provisions of MAPIL as it read in November 2003, and awarding civil penalties of $257,679,500.00, $70,000,000.00 in attorney fees, and $3,000,200.00 in costs. The court of appeal affirmed the district court's judgment. After its review, the Supreme Court found the Attorney General failed to establish sufficient facts to prove a cause of action against the defendants under MAPIL because no evidence was presented that any defendant made or attempted to make a fraudulent claim for payment against any Louisiana medical assistance program within the scope of MAPIL. Accordingly, the Court reversed the district court's judgment in favor of the Attorney General.View "Caldwell v. Janssen Pharmaceutical, Inc." on Justia Law

Mrs. Rusick is the surviving spouse of veteran George Rusick, who served on active duty in the U.S. military 1942-1943. In 1983, a Veterans Administration regional office issued a decision continuing a 30-percent rating for Rusick’s service-connected anxiety disorder. With a service-connected hearing loss rated at 40 percent, Rusick’s combined rating was 60 percent. In 1996, the regional office increased the rating for his anxiety disorder to 100 percent. Rusick died in April 2000, with no pending claims for benefits. In May 2000, Mrs. Rusick filed a claim seeking dependency and indemnity compensation (DIC) and accrued benefits. The Department of Veterans Affairs denied both claims and she did not appeal. In September 2006, Mrs. Rusick filed another claim, asserting clear and unmistakable error in that Rusick should have received a 100 percent rating in 1983 because he was unemployable. The Board of Veterans’ Appeals agreed that the regional office’s failure to assign a 100 percent rating in 1983 constituted CUE and that Mrs. Rusick was entitled to DIC benefits under 38 U.S.C. 1318. The regional office implemented the Board’s decision by awarding DIC, but it denied accrued benefits under 38 U.S.C. 5121. The Board, Veterans Court, and the Seventh Circuit affirmed. View "Rusick v. Gibson" on Justia Law

Murphy had a stroke in April 2007. Before leaving the hospital, Murphy was examined by Dr. Mayer, who noted a past history of headaches and diminished fluency in speech. Murphy started seeing a physical therapist but did not complete the program. A year later, Dr. Mayer noted that Murphy still had difficulty speaking and “some significant loss of sensation.” In September 2008, Murphy applied for social security disability benefits. Her application was denied. At a hearing, a vocational expert testified that there were no sedentary jobs in the regional economy for a person who could neither work with the general public nor use her hands more than occasionally for fine manipulation, but that there were a significant number of jobs for a person who had the capacity to do light, unskilled work, but who could only occasionally perform fine hand manipulation. The ALJ ruled that Murphy was not disabled. The Appeals Council adopted that decision. The district court affirmed. The Seventh Circuit reversed and remanded, finding that the ALJ erroneously excluded information about Murphy’s potential inability to perform light work and by not questioning Murphy further about her failure to comply with her home exercise program and the activities she participated in while on vacation. View "Murphy v. Colvin" on Justia Law

Plaintiff filed a motion asking the court to approve the contingency fee arrangement he agreed to with his lawyer, following a successful claim for social security benefits. The magistrate judge determined that a fee in the amount of $11,876.65 was reasonable under 42 U.S.C. 406(b)(1). Plaintiff appealed. The court concluded that the magistrate judge correctly started with the fee agreement, and after determining that the early retirement benefits were not past-due benefits "owed," went on to conclude an independent review of the resulting fee for reasonableness. Accordingly, the court affirmed the fee award because the court agreed with the magistrate judge's interpretation of the contract and found no error in his review of the fee. View "Keller v. Commissioner of Social Security" on Justia Law

Robertson voluntarily enlisted in the Army in 1963.After serving confinement for being absent without leave on two occasions for a total of about 340 days, Robertson was discharged in 1967 under conditions other than honorable, a character of discharge that can foreclose the receipt of veterans’ benefits. He later participated in President Ford’s clemency program, completed alternative service, and received a presidential pardon and a new clemency discharge. Despite his pardon and clemency discharge, the Department of Veterans Affairs has continued to deny Robertson’s claim for veterans’ benefits. The Federal Circuit affirmed, holding that the Department of Veterans Affairs properly considered the misconduct underlying his pardoned offense to deny his application for benefits. Entitlement to veterans’ benefits under the clemency program was meant to be the exception, not the rule. View "Robertson v. Gibson" on Justia Law

Four cases challenged the constitutionality of Senate Bill (SB) 822, which was passed by the 2013 Legislative Assembly during its regular session, and SB 861, passed during a special session in October 2013. Both bills changed certain statutory provisions of the Public Employees Retirement System (PERS) and, in doing so, affected the retirement benefits of some current and former public employees. Central Oregon Irrigation District (the District), an intervenor in these proceedings, filed a motion to disqualify the sitting judges of the Oregon Supreme Court from hearing these cases. The District also filed a separate motion to disqualify the circuit judge appointed by the Supreme Court to serve as a special master for purposes of conducting evidentiary proceedings and preparing recommended findings of fact. Because disqualification would leave petitioners without a tribunal to decide their claims, and in light of the legislature's express grant of jurisdiction to the Supreme Court to decide challenges to the 2013 PERS legislation, the Court concluded that the rule of necessity applied and that the members of Court were not disqualified from deciding these cases because of any interest in the proceeding. Further, the application of the rule of necessity in these circumstances was not a denial of due process. Central Oregon Irrigation District's motions to disqualify the members of the Supreme Court and the Special Master on this matter was denied. View "Moro v. Oregon" on Justia Law

Arnold and Vesta Melby were trustors of separate irrevocable trusts. Both Arnold and Vesta received Medicaid benefits. After the Melbys’ deaths, the Iowa Department of Human Services notified Arnold’s estate that it would seek reimbursement for all Medicaid expenses it had paid on behalf of Arnold and Vesta. The Department then filed an application in the estate seeking a judgment declaring the Melbys had interests in the corpus of their trusts that should be counted as assets available for repayment of the Department’s Medicaid claim. The district court concluded (1) the Melbys’ interests in the trusts were limited to their right to receive the net income from the trusts’ assets, and (2) the Department’s right to recover the Medicaid payments could be enforced against such income, but not against the corpus of the trusts. The Supreme Court reversed, holding (1) the Department’s right to recover Medicaid payments under the facts of this case extended beyond the Melbys’ net income interests; and (2) the district court erred in determining the scope of medical assistance for which recovery was authorized by the general assembly. Remanded.View "In re Estate of Melby" on Justia Law