Justia Public Benefits Opinion Summaries

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

A 66-year -old arrived at petitioner's center with complex ailments, but oriented, able to feed herself and able to speak. During her 18 days at the center, she was sent to the hospital twice with serious medical complications. Upon investigation, the center was found to have failed to maintain substantial compliance with federal regulations for facilities that participate in Medicare and Medicaid (42 U.S.C. § 1395) in its treatment of the resident and appealed the resulting civil money penalty. An administrative law judge, the Departmental Appeals Board, and the Sixth Circuit affirmed. The ALJ acted properly in requiring submission of written testimony, properly weighed the evidence, and found violation of the federal hydration standard, laboratory services requirement, and mandate of a care plan, resulting in "immediate jeopardy."

Appellee applied for supplemental security income under Title XVI of the Social Security Act, 42 U.S.C. 1382. The Commissioner of the Social Security Administration subsequently appealed the district court's decision, arguing that the ALJ permissibly discounted appellee's testimony and that the district court substituted its own judgment for that of the ALJ in concluding otherwise. In the alternative, the Commissioner asserted that even if the ALJ erred, the district court should have remanded for additional proceedings and erred in directing the entry of an award of benefits. The court held that valid reasons supported the ALJ's adverse credibility determination and that substantial evidence in the record supported the ALJ's determination that appellee could perform sedentary work as long as he had the option of alternating between sitting and standing. Therefore, the court reversed the district court's decision and remanded for the district court to affirm the decision of the Commissioner.

Appellee sued the Commissioner of the Social Security Administration (SSA), seeking review of the SSA's denial of benefits to her daughter. At issue was whether a child conceived through artificial insemination more than a year after her father's death qualified for benefits under the Social Security Act, 42 U.S.C. 402, 416. The Commissioner interpreted the Act to provide that a natural child of the decedent was not entitled to benefits unless she had inheritance rights under state law or could satisfy certain additional statutory requirements. The court held that the Commissioner's interpretation was, at a minimum, reasonable and entitled to deference, and that the relevant state law did not entitle the applicant in this case to benefits. Therefore, the court reversed the district court's judgments.

Plaintiff, an unincorporated association made up of homeless and formerly homeless people that advocated for their rights, sued defendants, alleging that defendants had conspired to establish the Conrad Center on Oliver Hill Way, a site removed from Richmond's downtown community, for the purpose of reducing the presence of the homeless population in the downtown area by providing services for them in a remote location. Plaintiff claimed that the relocation of homeless services to the Conrad Center violated 42 U.S.C. 1983 and 1985(3); the Americans with Disabilities Act (ADA), 42 U.S.C. 12101 et seq.; the Equal Protection Clause of the Fourteenth Amendment; and the Fair Housing Act (FHA), 42 U.S.C. 3601 et seq. The court held that plaintiff did not state a valid section 1985(3) conspiracy claim; plaintiff's 1983 and equal protection claims were barred by the applicable statute of limitations; plaintiff's FHA claims were barred by the two-year statue of limitations and, more fundamentally, they failed to state a claim upon which relief could be granted; and plaintiff's ADA retaliation claim was properly dismissed. Accordingly, the court affirmed the judgment of the district court.

Plaintiffs, a class of economically vulnerable Arizonians who receive public health care benefits through the state's Medicaid agency, sued the U.S. Secretary of Health and Human Services (Secretary) and the Director of Arizona's medicaid agency (director)(collectively, defendants), alleging that the heightened mandatory co-payments violated Medicaid Act, 42 U.S.C. 1396a, cost sharing restrictions, that the waiver exceeded the Secretary's authority, and that the notices they received about the change in their health coverage was statutorily and constitutionally inadequate. The court affirmed the district court's conclusion that Medicaid cost sharing restrictions did not apply to plaintiffs and that Arizona's cost sharing did not violate the human participants statute. The court reversed the district court insofar as it determined that the Secretary's approval of Arizona's cost sharing satisfied the requirements of 42 U.S.C. 1315. The court remanded this claim with directions to vacate the Secretary's decision and remanded to the Secretary for further consideration. Finally, the court remanded plaintiffs' notice claims for further consideration in light of intervening events.

Father was ordered to pay child support and soon developed child support arrearages. Later, Father became disabled. Father and his children received lump sum Social Security disability benefits payments for the period retroactive to the date Father became eligible for the benefits. In a series of orders, the district court gave Father credit (1) against his child support arrearages back to the date he became eligible for benefits, and (2) for amounts that had been withheld from his monthly disability payments under an income withholding order for the period after he became disabled but before he became eligible to receive benefits. The court, however, refused to credit any of the disability payments against arrearages existing on the date Father became disabled. The Supreme Court affirmed, holding that the district court may not credit Social Security disability benefits paid to dependent children against child support arrearage owed before the obligor became disabled. Because such benefits belong to the children, not the obligor, they are not available to be applied as a credit or offset to amounts owed by the obligor.

Doctors filed suit, alleging violations of the False Claims Act, 31 U.S.C. 3279 and the Michigan Medicaid False Claim Act, as qui tam relators on behalf of the United States/ The claimed that the business defrauded the government by submitting Medicare and Medicaid billings for defective radiology studies, and that the billings were also fraudulent because the business was an invalid corporation. The federal government declined to intervene. The district court dismissed. Sixth Circuit affirmed. The doctors failed to identify any specific fraudulent claim submitted to the government, as is required to plead an FCA violation with the particularity mandated by the FRCP. A relator cannot merely allege that a defendant violated a standard (in this case, with respect to radiology studies), but must allege that compliance with the standard was required to obtain payment. The doctors had no personal knowledge that claims for nondiagnostic tests were presented to the government, nor do they allege facts that strongly support an inference that such billings were submitted.

This case was a direct appeal in a workers' compensation matter from a master's order reversing the Full Commission and finding respondent's decedent was totally disabled as the result of an occupational disease. On appeal, Appellant W. L. Gore & Associates contended this matter should have been dismissed because Respondent's admittedly untimely appeal to the Commission deprived the Commission of jurisdiction. Upon review of the Commission's record, the Supreme Court agreed that the untimely appeal to the Commission required it to vacate both the master's order and the decision of the Full Commission.

Defendant Daniel Cadle appealed a district court order that confirmed an arbitration award against him on Plaintiff Kerry Hicks’s claims of defamation and intentional infliction of emotional distress. Defendant’s objections concerned whether the dispute was properly referred to arbitration. The district court rejected Defendant’s objections for various reasons, holding that he was judicially estopped from challenging the arbitrator’s authority and that the dispute was properly referred to arbitration. Upon review of the lower court record, the Tenth Circuit affirmed the district court’s decision, holding judicial estoppel prevented Defendant from raising the arbitration issue on appeal. The Court declined to address issues unrelated to that rationale and dismissed Defendant’s case.