Justia Public Benefits Opinion Summaries

After the Appeals Board denied plaintiff's request for review of the denial of social security disability benefits, plaintiff sought judicial review of the ALJ's decision in federal district court. The district court found in favor of plaintiff and the Acting Commissioner appealed. The court held that the district court did not err in its application of Listing 1.04A. Listing 1.04A is the listing identifying disorders of the spine that merit a conclusive presumption of disability and an award of benefits. The court concluded, however, that the district court abused its discretion in directing an award of benefits rather than remanding for further explanation by the ALJ of why plaintiff did not meet Listing 1.04A. Accordingly, the court vacated and remanded for further proceedings. View "Radford v. Colvin" on Justia Law

Geib, a World War II veteran, suffers from multiple disabilities connected to his combat service. He developed trenchfoot as a result of exposure to extreme cold weather conditions while stationed in Germany; an enemy artillery shell exploded close to Geib, causing hearing damage. The VA granted Geib disability benefits. He was assigned a 10% disability rating for trenchfoot when he was discharged in 1946. The VA increased the disability rating to 20% in 2003 to account for trenchfoot on his other foot. In 2005, Geib was assigned a 70% combined disability rating after he was diagnosed with service-connected bilateral hearing loss and tinnitus. In 2007, Geib applied for total disability based on individual unemployability, stating that he had worked as a self-employed carpet consultant, 1984-1989, prior to becoming too disabled to work. The regional office denied the claim. On remand, following medical examinations, Geib’s combined disability rating increased to 90%. The Board determined that Geib was not entitled to total disability. The Veterans’ Court and Federal Circuit affirmed. View "Geib v. Shinseki" on Justia Law

At age four months, Elias received a Diptheria-Tetanus-acellular-Pertussis (DTaP) vaccine. Elias developed a seizure disorder shortly afterwards. While a petition for compensation under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. 300aa-1, was pending, Elias died as a result of his seizure disorder at the age of seven. A special master determined that the DTaP vaccine caused Elias’ epilepsy and resulting death. The Secretary of Health and Human Services and the estate agreed to a $250,000 death benefit plus $175,000 for actual pain and suffering and past unreimbursable expenses. The estate also sought future lost earnings under section 300aa-15(a)(3)(B). The special master determined that the estate was entitled to future lost earnings. Subject to the right to seek review, the Secretary proffered, and the estate accepted the sum of $659,955.61 as a measure of the lost earnings. The Claims Court affirmed the special master’s future lost earnings award. The Federal Circuit reversed, holding that an estate cannot recover lost future earnings under section 300aa-15(a)(3)(B) when the person injured by a vaccine dies before entry of a compensation judgment. View "Tembenis v. Sec'y of Health & Humans Servs." on Justia Law

A nursing home resident and her community spouse (husband) were penalized based on husband’s purchase of an annuity for himself using funds from his IRA. The district court granted summary judgment in favor of the director of the Ohio Department of Job and Family Services, holding that 42 U.S.C. 1396r-5(f)(1) precluded the transfer of assets because it exceeded husband’s community spouse resource allowance. Section 1396p(c) requires a state to impose a transfer penalty (a period of restricted coverage) if either spouse disposed of assets for less than fair market value during the look-back period. The Sixth Circuit reversed, reasoning that the transfer occurred before the Ohio agency determined that wife was eligible for Medicaid coverage and section 1396p(c)(2)(B)(i) permits an unlimited transfer of assets “to another for the sole benefit of the individual’s spouse.” View "Hughes v. Colbert" on Justia Law

Sprinkle served in the U.S. Army, 1973-1974. While in the service, he was diagnosed with schizophrenia and prescribed a high dose of Thorazine®. In 1990, Sprinkle was diagnosed with mitral valve prolapse and chorea, a movement disorder similar to benign familial myoclonus. He succeeded in establishing entitlement to disability compensation before the Social Security Administration, the VA Regional Office awarded. Sprinkle a non-service-connected pension on effective 1990. In 2001, he sought a service connection for mitral valve prolapse and myoclonus, claiming that he was incorrectly diagnosed with schizophrenia and that the high doses of Thorazine® worsened his mitral valve prolapse and caused his myoclonus.The Regional Office denied the application. The Board of Veterans’ Appeals agreed and the Veterans’ Court affirmed. The Federal Circuit affirmed, holding that Sprinkle was not denied fair process as it related to responding to a medical exam ordered by the Board.View "Sprinkle v. Shinseki" on Justia Law

In 2001, Wagner, who served in the Navy for 23 years, sought disability compensation for a thyroid disorder that he claimed was contracted or aggravated in the line of duty. He finally prevailed in 2009, then timely filed an application for $11,710.57 in fees pursuant to the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412.In October, 2009, the Veterans Court awarded $8,601.80, which gave the government all the reductions it sought except for 3.2 hours of work. Wagner filed his first supplemental application 12 days later, seeking $2,458.90 in fees for defending the original application against the government’s reasonableness challenges. The Veterans Court vacillated, then denied entry of judgment on the October 2009 fee award on the original fee application, and denied the first supplemental application. The Federal Circuit reversed in April 2011. On remand the Veterans Court granted Wagner’s first supplemental application for $2,458.90. The Federal Circuit vacated the denial of Wagner’s motion for the entry of a judgment and mandate regarding the 2009 and 2011 fee awards and affirmed the judgment regarding Wagner’s second supplemental application. View "Wagner v. Shinseki" on Justia Law

Williams had worked at Marathon’s Ashland, Kentucky, facility for 25 years, most recently as a senior barge welder. Williams alleged that he sustained a long thoracic nerve injury to his right shoulder while replacing parts of a barge in 2003. His injury was likely the result of the cumulative effect of his heavy lifting. Williams has not returned to work and has been seen by several physicians, but they do not agree on a common diagnosis. Following a remand the Benefits Review Board of the U.S. Department of Labor affirmed an administrative law judge’s award of permanent and total disability benefits under the Longshore and Harbor Workers’ Compensation Act, 33 U.S.C. 901. On a second appeal, the Sixth Circuit affirmed, finding that Williams is permanently and totally disabled and is unable to perform the alternative employment identified by Marathon’s vocational expert. The court granted Williams leave to seek attorney fees under 33 U.S.C. 928(a). View "Marathon Ashland Petroleum v. Williams" on Justia Law

Orillo, her husband (a doctor), and another owned Chalice, a home health care provider. Chalice was an enrolled provider with Medicare and could seek reimbursement of home health care through that program. Orillo falsified forms by altering the codes and information that had been completed by the Chalice nurses to make the patient’s condition appear worse and the health care needs greater than the actuality. Those alterations caused Medicare software to generate different reimbursement rates Orillo also aided her husband in paying kickbacks to a Chicago doctor in return for referrals of Medicare patients. Orillo pled guilty to healthcare fraud, 18 U.S.C. 1347 and paying kickbacks to physicians for patient referrals under a federal health care program, 42 U.S.C. 1320a-7b and 18 U.S.C. 2, and was sentenced to 20 months’ imprisonment. Orillo conceded that her scheme caused a loss, to Medicare, in excess of $400,000, and agreed to entry of a $500,000 forfeiture judgment.The district court determined that the loss amount for the healthcare fraud count was $744,481 and ordered her to pay that amount in restitution. The Seventh Circuit affirmed, rejecting Orillo’s argument that the loss and restitution amount should be limited to only those stemming from visible alterations. View "United States v. Orillo" on Justia Law

Philpot, former Clerk of Lake County, Indiana, took $25,000 in incentive payments from a federally funded child‐support fund (42 U.S.C. 658a(a)) without the required approval of the county fiscal body. The Indiana Department of Child Services disburses those federal funds to the counties, Ind. Code 31‐25‐4‐23(a), which have a relatively free hand in directing the money, although “amounts received as incentive payments may not, without the approval of the county fiscal body, be used to increase or supplement the salary of an elected official.” Philpot had used the funds to provide himself and staff members with bonuses. Convicted of mail fraud, 18 U.S.C. 1341, and theft from a federally funded program 18 U.S. 666(a)1A, he was sentenced to 18 months in prison. The Seventh Circuit affirmed, despite claims concerning whether Philpot “knowingly” violated the statute and the fact that Philpot had voluntarily returned the funds. View "United States v. Philpot" on Justia Law

Southern Rehabilitation Group and its medical director sued the Secretary of Health and Human Services and past and present Medicare contractors, seeking review of the Secretary’s final decision on 6,200 claims for Medicare reimbursement. The district court remanded so that the Secretary could pay the disputed amount. After payment, the case returned to the district court, which concluded that the claims for payment were moot and dismissed remaining constitutional and statutory claims as barred by jurisdictional provisions of the Medicare Act. The court also held that plaintiffs did not show that they were eligible to collect interest on their claims and that it did not have jurisdiction over 8,900 other claims that plaintiffs alleged were still in the administrative process. The Sixth Circuit affirmed summary judgment to defendants on plaintiffs’ federal and state law claims and on the 8,900 claims still in the administrative process, but reversed summary judgment on plaintiffs’ claims for interest. The Secretary could not rely on her unreasonable interpretation of the “clean-claims” statute as a basis for summary judgment concerning interest. View "S. Rehab. Grp. v. Sec'y of Health & Human Servs." on Justia Law