Justia Public Benefits Opinion Summaries

Plaintiff, MSP Recovery Claims, Series LLC (“MSP”) appealed from the district court’s judgment dismissing for lack of standing its putative class action against Defendant Hereford Insurance Company (“Hereford”) and denying leave to amend. MSP has brought several lawsuits around the country seeking to recover from insurance companies that allegedly owe payments to Medicare Advantage Organizations (“MAOs”) under the Medicare Secondary Payer Act (the “MSP Act”). In the putative class action brought here, MSP charges Hereford with “deliberate and systematic avoidance” of Hereford’s reimbursement obligations under the MSP Act.   The Second Circuit affirmed. The court concluded that MSP lacked standing because its allegations do not support an inference that it has suffered a cognizable injury or that the injury it claims is traceable to Hereford. The court also concluded that the district court did not abuse its discretion when it denied MSP leave to amend based on MSP’s repeated failures to cure. The court explained that the plain language of Section 111 provides that when a no-fault insurance provider such as Hereford reports a claim pursuant to Section 111, it does not thereby admit that it is liable for the claim. The statutory context of the section’s reporting obligation and the purpose of the reporting obligation confirms the correctness of this interpretation. Because MSP’s argument that the payments made by EmblemHealth are reimbursable by Hereford rests entirely on its proposed interpretation of Section 111, MSP has not adequately alleged a “concrete” or “actual” injury or that the injury it alleges is fairly traceable to Hereford. View "MSP v. Hereford" on Justia Law

Appellants challenged the appointment of Social Security Administration Acting Commissioner Nancy Berryhill under the Federal Vacancies Reform Act (FVRA). They argue that no one may serve as an acting officer under 5 U.S.C. Section 3346(a)(2), which allows acting service while a nomination is pending in the Senate unless that nomination occurred during the initial 210-day period of acting service allowed by 5 U.S.C. Section 3346(a)(1). Appellants assert that Section 3346(a)(2) serves only to toll Section 3346(a)(1)’s time limit and does not authorize an independent period of acting service.   The Fourth Circuit affirmed. The court rejected Appellants’ argument because Section 3346(a)(1) and Section 3346(a)(2) are, by their plain text, disjunctive and independent. Because Berryhill was legally serving as Acting Commissioner, her appointments of the ALJs who decided Appellants’ cases were valid. The court explained that Appellants’ reading of the statute would shift the balance against the President. It would prevent him from designating anyone to serve as an acting officer if he submits a nomination after the 210-day period has elapsed, thus leaving the office vacant for as long as the Senate takes to consider it. View "Barbara Rush v. Kilolo Kijakazi" on Justia Law

Plaintiff filed a claim under 42 U.S.C 405(g), believing the Social Security Administration miscalculated his benefits. He filed his claim more than one year after the SSA verbally denied his request for review, and after he did not receive the requested written documentation of the SSA's denial.The SSA filed a motion to dismiss, arguing that the district court lacked subject matter jurisdiction because Sec. 405(g)’s waiver of sovereign immunity applied only with respect to judicial review of a “final decision of the Commissioner of Social Security” and that Plaintiff had not obtained a final decision, having refused to exhaust the four-step administrative process. The district court granted SSA’s motion.Finding that Sec. 405(g)’s exhaustion requirement is not jurisdictional, the Fourth Circuit nonetheless concluded that exhaustion is a mandatory requirement of the Social Security Act that may be excused only in a narrow set of circumstances, which were not present in this case. Accordingly, the court affirmed the district court’s dismissal. View "L.N.P. v. Kilolo Kijakazi" on Justia Law

Pickett served in the Army from 1969-1971, including service in Vietnam. In 2004, sought service-connected compensation for an anxiety disorder, which he attributed to exposure to Agent Orange or other herbicides. The VA eventually granted Pickett service-connected compensation for post-traumatic stress disorder (PTSD) and coronary artery disease (CAD) effective 2004. Pickett appealed, seeking a total disability rating based on individual unemployability (TDIU), starting in 2007, the date he last worked. A 2013 VA decision denied the application. The VA notified Pickett that he had a year to appeal. He did not appeal. A 2014 decision listed the 2013 decision and proposed decreasing Pickett’s PTSD rating. Pickett only challenged the proposed reduction.In 2017, Pickett filed a supplemental claim and new TDIU application, again citing service-connected CAD and PTSD. The VA awarded Pickett TDIU due solely to PTSD and increased his ratings, effective January 2017. Pickett filed a notice of disagreement, citing 38 C.F.R. 3.156(b), and arguing he was entitled to “an extra-schedular total rating,” which could include TDIU, effective from 2007.The Board of Veterans’ Appeals, Veterans’ Court, and Federal Circuit denied Pickett an earlier effective date. Pickett’s failure to perfect an appeal following the 2013 or 2014 decisions meant that his 2004 claim for the maximum CAD evaluation—including entitlement to TDIU—became final by 2017. The finalized claim could not provide a basis for an earlier entitlement to TDIU. View "Pickett v. McDonough" on Justia Law

Roane served in the Navy from 1981-1991. In 2013, he underwent vocational rehabilitation for disabilities, including sciatic nerve paralysis, degenerative spinal arthritis, and limited knee flexion. In 2017, he applied for total disability based on individual unemployability (TDIU), alleging that he was unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. He then had a combined disability rating of 70 percent, 38 U.S.C. 1117. Between 2016-2019, several VA examinations established his inability to sit or stand for extended periods and difficulty changing positions from sitting to standing. In 2017, a peripheral nerve examiner opined that despite these limitations, he should be able to “seek and maintain a substantially gainful light physical or sedentary type of employment.” The VA regional office denied his TDIU claim. Roane submitted additional evidence, including a private vocational assessment where the expert opined that his difficulties with prolonged sitting, standing, and walking “affect his ability to perform any type of substantially gainful employment, even sedentary employment.”The Board found that Roane’s service-connected disabilities met the rating requirement of 70 percent for TDIU, noting Roane’s college education, skills, and experience. The Veterans Court and Federal Circuit affirmed. The Veterans Court properly interpreted the benefit-of-the-doubt rule under 38 U.S.C. 5107 and applied the appropriate standard of review to the Board’s application of that rule under 7261(b)(1). View "Roane v. McDonough" on Justia Law

Military-Veterans Advocacy (MVA) filed suit under 38 U.S.C. 502, seeking review and revision of certain instructions and practices set forth in the Veterans Affairs Adjudication Procedures Manual (M21-1 Manual), which provides guidance and instructions to the administrators of veterans’ benefits and claims, by interpreting and coordinating the application of statutes, regulations, policies, and judicial decisions. The M21-1 Manual “limits VA staff discretion, and, as a practical matter, impacts veteran benefits eligibility for an entire class of veterans.”The Federal Circuit dismissed challenges to presumptions and procedures concerning Vietnam-era exposure to the Agent Orange defoliant. MVA waived its challenge to the “Thailand Rules.” The VA’s interpretation of the “Blue Water Navy Rule” of 2019 did not unduly narrow the presumption of exposure and service connection as applied to shipboard service. MVA’s challenge to the “Airspace Rule” is barred by the six-year limit provided in section 2401(a) because the rule has been in full force and effect since 1993. Even if the time bar did not apply, Congress has consistently preserved the high-altitude exception to the presumption of exposure since its adoption in 1993. View "Military-Veterans Advocacy Inc. v. Secretary of Veterans Affairs" on Justia Law

Plaintiff initiated a civil action in district court contesting the denial of her claim for disability insurance benefits by Defendant Commissioner of the Social Security Administration (the “SSA”). Plaintiff has asserted that the SSA Commissioner erred in multiple ways. Her arguments include that, pursuant to precedents of this Court, the Commissioner should have accorded substantial weight to a prior determination by the Department of Veterans Affairs (the “VA”) that Plaintiff is 100% disabled, but the Commissioner instead followed contrary new SSA rules providing that such a determination need not be considered, much less given any weight. As Rogers would have it, the new SSA rules cannot — and thus do not — abrogate this Court’s precedents. The district court concluded, however, that the new SSA rules supersede our precedents and that the Commissioner acted appropriately in adhering to those rules. After then addressing many, but not all, of Plaintiff’s other arguments, the court affirmed the Commissioner’s decision. Plaintiff appealed from the court’s judgment.   The Fourth Circuit vacated the court’s judgment and remanded for the court to further remand this matter for administrative proceedings. The court concluded that by omitting the menstrual cycle evidence from the residual functional capacity assessment as to Plaintiff, the ALJ’s decision is sorely lacking in the analysis needed for the court to review meaningfully the ALJ’s conclusions. That legal error alone demands further administrative proceedings. View "Shanette Rogers v. Kilolo Kijakazi" on Justia Law

Crews served in the Air Force from 1954-1958. In connection with his service, he was originally granted a 100% disability rating for schizophrenia. In 1960, his disability rating was lowered to 70%. In 2006, Crews sought an increased schizophrenia rating, which was denied in 2007. In 2009, Mrs. Crews (Yvonne) submitted a letter stating that Crews was 100% disabled and requested further evaluation; she did not mention an effective date. The VA responded that it would not consider the letter a notice of disagreement (NOD) with the 2007 decision because it was filed more than one year after that decision. It construed the letter as a new “claim for an increased rating. In March 2010, the VA increased his schizophrenia rating from 70% to 100% effective from September 2009. In October 2010, Crews died. In 2011, Yvonne moved to be substituted as the appellant and filed a notice of disagreement with the 2009 effective date, alleging clear and unmistakable error (CUE) in the 1960 rating decision.The VA rejected her request for substitution because Crews had no claim or NOD pending at the time of his death. Yvonne was not eligible to seek benefits on past decisions that had been finalized; the 1960 rating decision became final once the appeal window closed. The Veterans Court and Federal Circuit affirmed. Yvonne’s CUE allegation is not part of a “pending” claim for which she could substitute under 38 U.S.C. 5121A. View "Crews v. McDonough" on Justia Law

Stephanie Owens appealed a district court’s order affirming the findings of fact and conclusions of law made by the Ada County Board of Commissioners (the “Board”) in which it determined that Owens was an “applicant” under the Medical Indigency Act (the “Act”) and, therefore, required to pay reimbursement for the medical expenses incurred by her two children at public expense. In 2017, Owens’s children were involved in a serious car accident and suffered substantial injuries, which later resulted in the death of one of the children. Because the children’s father, Corey Jacobs, was unable to pay for the children’s medical bills, he filed two applications for medical indigency with the Board. Owens and Jacobs were never married and did not have a formal custody agreement for their children. At the time of the accident, the children resided with their father. The Board determined that Owens and her children met the statutory requirements for medical indigency. Although Jacobs filed the applications for medical indigency, the Board concluded that Owens was also an “applicant” under the Act and liable to repay the Board. As a result, the Board “recorded notices of statutory liens” against Owens’s real and personal property and ordered Owens to sign a promissory note with Ada County to repay the medical bills. Owens refused to sign the note and instead challenged the sufficiency of her involvement with the applications via a petition for reconsideration with the Board and a subsequent petition for judicial review. Both the Board and the district court ultimately concluded that Owens was an “applicant” and liable for repayment of a portion of the children’s medical bills. Owens timely appealed. The Idaho Supreme Court reversed: because she never signed the medical indigency applications for her children and she did not affirmatively participate in the application process, Owens was not an "applicant" as defined by the Act. As a result, the Board acted outside its authority when it ordered Owens to reimburse Ada County for its expenses and when it placed automatic liens on her property. View "Owens v. Ada County Board of Commissioners" on Justia Law

Bakke, a Wisconsin beef farmer, began suffering from serious back pain in 2017. He has had temporary relief from epidural steroid injections, spinal fusion surgery, physical therapy, and pain medications. Bakke sold his farm because the upkeep was too physically demanding and applied for disability benefits in 2019. Two state agency physicians examined him and concluded that Bakke was capable of light, full-time work. His general practitioner concluded that he could tolerate no more than four hours of work per day. At a hearing, Bakke testified about intense pain, with some days so bad he could not get out of bed; that he could not sit for more than two hours; that pain often required him to lay down during the day; that he could not lift or carry much weight; and that he was unsteady on his feet.An ALJ performed the Social Security Administration’s five-step disability analysis and agreed that Bakke could not engage in substantial gainful activity due to his back injury and obesity but concluded that his impairments were not as severe as those listed in 20 C.F.R. 404. Considering residual functional capacity, he determined that Bakke could still perform light, full-time work. Citing the vocational expert’s testimony, the ALJ decided that light, full-time work was available in significant numbers in the national economy, precluding a finding that Bakke was disabled. The district court and Seventh Circuit affirmed the denial as supported by substantial evidence. View "Bakke v. Kijakazi" on Justia Law