Justia Public Benefits Opinion Summaries

Wolfe, who was enrolled in VA health care, obtained emergency treatment at a non-VA health care facility, incurring expenses of $22,348.25. Her employer-sponsored healthcare contract covered most of the expenses. She was responsible for a copayment of $202.93 and coinsurance of $2,354.41. The VA denied reimbursement of those expenses; 38 U.S.C. 1725(c)(4(D) bars reimbursement for “any copayment or similar payment.” Wolfe filed a Notice of Disagreement; rather than await the outcome of her appeal, Wolfe also filed a mandamus petition. The Veterans Court certified her requested class and granted her petition, invalidating a VA regulation prohibiting the reimbursement of deductibles and coinsurance for being within the category of “similar payments,” and requiring the VA to re-adjudicate claims denied under the invalidated regulation.The Federal Circuit reversed. Deductibles are excluded from reimbursement under the correct interpretation of the statute and other adequate remedies (appeal) were available with respect to coinsurance, so mandamus was inappropriate. Coinsurance is the type of partial coverage that Congress did not wish to exclude from reimbursement. View "Wolfe v. McDonough" on Justia Law

Martinez-Bodon served on active duty in the Army, 1967-1969. In 2016, he sought benefits for diabetes and for anxiety secondary to his diabetes. At his VA psychiatric examination, he reported: “I can’t sleep well, my right eye trembles too much and that bothers me and I get very anxious about it.” He denied having other symptoms. The VA examiner found that these symptoms did not meet the “criteria for a mental condition as per DSM–5” and concluded that she could not establish a relationship between Martinez-Bodon’s diabetes and anxiety.The VA granted him a service connection for diabetes but denied him a service connection for a mental condition. The Board of Veterans’ Appeals affirmed. The Court of Veterans Claims rejected an argument that even without a formal diagnosis, his symptoms constitute a disability for service-connection purposes under Federal Circuit precedent defining “disability.” The Federal Circuit affirmed that 38 C.F.R. 4.125(a) and 4.130, “require a DSM–5 diagnosis as a precondition to compensate mental conditions.” View "Martinez-Bodon v. McDonough" on Justia Law

Poole has a degenerative disc disease of the lumbar spine; it causes severe pain in her lower back and leg after she either stands or sits for a brief time. She lost her job as a cashier because her pain made it impossible for her to stand throughout her full shift. Poole also suffers from a learning disability, anxiety, and depression, all of which impair her ability to concentrate, understand, or remember detailed instructions. Now 46 years old, she has only a “marginal education,” meaning sixth grade or less. Poole sought Supplemental Security Income, 42 U.S.C. 423(d). An ALJ denied her application and dismissed her companion application for disability insurance benefits.The Seventh Circuit reversed, concluding that the ALJ’s decision rested on contradictory findings. . Either Poole can stand for four hours a day and should have been put in the “light” exertional level, or the ALJ correctly found that she belonged in the “sedentary” category and could stand (or walk) at most for two hours a day. The ALJ never said that Poole could perform sedentary work if she could sit or stand at will, so the vocational expert never focused on that potential set of jobs. When an agency decision is so ambiguous that it frustrates judicial review, it cannot be upheld. View "Poole v. Kijakazi" on Justia Law

The Eighth Circuit affirmed the district court's order upholding the Commissioner's denial of social security disability insurance benefits (DIB). The court concluded that substantial evidence supported the determination that plaintiff's impairments did not meet or medically equal Listing 11.09B or 12.02. In this case, plaintiff's mental impairment did not cause at least two marked limitations or one extreme limitation, as required by the paragraph B criteria for Listing 12.02. Furthermore, although plaintiff's medical records revealed several minor deficiencies, such as a subtle tremor in her left hand and mild executive dysfunction, those records did not indicate a marked limitation in physical functioning and one of the four areas of mental functioning as required by Listing 11.09B. View "Schmitt v. Kijakazi" on Justia Law

Three teaching hospitals challenged the denial of Medicare reimbursements. At that time, a teaching hospital could obtain reimbursement only by incurring “substantially all” of a resident’s training costs. Because the teaching hospitals had shared the training costs for each resident, the government denied reimbursement. The denials led the teaching hospitals to file administrative appeals. While they were pending, Congress enacted the Affordable Care Act (ACA), which created a new standard for reimbursement. The parties disagreed on whether the ACA’s new standard applied to proceedings reopened when Congress changed the law. The agency answered no, and the district court granted summary judgment to the agency. Finding no reversible error in that decision, the Tenth Circuit affirmed. View "St. Francis Hospital, et al. v. Becerra" on Justia Law

In 2009, Grotts applied for Social Security disability benefits, citing depression and low functional capacity. She had previously worked as a caretaker for a child with disabilities and he cared for her own child. Her case was remanded four times. Five times, an ALJ concluded that Grotts was not disabled. The final ALJ found that she could still perform light work with some restrictions and because a significant number of jobs fitting that description existed in the national economy.The district court agreed. The Seventh Circuit affirmed, rejecting arguments that the ALJ erred in its evaluation of Grotts’s subjective complaints about her symptoms, in its evaluation of the medical opinion evidence, and in its residual functional capacity determination. Substantial evidence supported the ALJ’s weighing of the medical opinion evidence and its RFC determination. The ALJ did not patently err in its evaluation of Grotts’s subjective complaints. View "Grotts v. Kijakazi" on Justia Law

Brooke Rojas was convicted of two counts of theft based on her improper receipt of food stamp benefits. Rojas initially applied for food stamp benefits from the Department of Human Services in August 2012 when she had no income. She received a recertification letter in December, which she submitted in mid-January 2013, indicating that she still had no income. And although she had not yet received a paycheck when she submitted the recertification letter, Rojas had started a new job on January 1. Rojas continued receiving food stamp benefits every month until July, when she inadvertently allowed them to lapse. She reapplied in August 2013. Although still working, Rojas reported that she had no income. The Department checked Rojas’s employment status in connection with the August application and learned that she was making about $55,000 a year (to support a family of seven). The Department determined that Rojas had received $5,632 in benefits to which she was not legally entitled. At trial, Rojas’s defense was that she lacked the requisite culpable mental state—she didn’t knowingly deceive the government; she just misunderstood the forms. Before trial, Rojas objected to the prosecution’s proposed admission of the August 2013 application because it exceeded the time period of the charged offenses and didn’t lead to the receipt of any benefits. The prosecution countered that the application was admissible as res gestae evidence—to show how the investigation began—and as evidence of specific intent. The court found it relevant as circumstantial evidence of Rojas’s mental state. In its opinion issued upon Rojas' appeal, the Colorado Supreme Court concluded it was "time for us to bury res gestae. ... By continuing to rely on res gestae as a standalone basis for admissibility and allowing the vagueness of res gestae to persist next to these more analytically demanding rules of relevancy, we have created a breeding ground for confusion, inconsistency, and unfairness." The Court's decision to abolish the res gestate doctrine in criminal cases prompted it to reverse judgment and remand for a new trial. View "Rojas v. Colorado" on Justia Law

The Supreme Court affirmed the judgment of the circuit court determining what portion of a settlement was subject to the Commonwealth's Medicaid lien, holding that there was no error.Appellant was seriously injured in a car accident. Because the Commonwealth's Medicaid program paid for a portion of Appellant's medical care the Commonwealth was entitled to a lien on the proceeds of an ensuing settlement between Appellant and the driver who caused the accident. At issue was what portion of the settlement was subject to the Medicaid lien. The Supreme Court affirmed, holding that the circuit court's judgment was proper under the deferential standard. View "Farah v. Commonwealth" on Justia Law

After working underground in coal mines for three decades, Casey developed pneumoconiosis (black-lung disease). His widow, Mabel, sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901–44. It took the Department of Labor 17 years to deny her claims. During this time, the claims bounced back and forth between an ALJ and the Benefits Review Board. In the last appeal, the Board also rejected one of Mabel’s main arguments, citing “law-of-the-case,” without reaching the merits. The Department of Labor then delayed things further by filing an incomplete and disorganized administrative record in the Sixth Circuit.The Sixth Circuit affirmed. While the government’s actions “perhaps could be described as poor customer service, they do not show any reversible legal error.” The Board could lawfully invoke the discretionary law-of-the-case doctrine to avoid reexamining an issue on which it had affirmed the ALJ years before. The credibility findings concerning the conflicting medical opinions concerning whether Casey was totally disabled or had only “moderate impairment” pass muster under the deferential “substantial evidence” test. View "Samons v. National Mines Corp." on Justia Law

Mandrell, born in 198, pursued her education through one year in college. In 2005-2009, she served in the Coast Guard, which she left with an honorable discharge. While in service she was the victim of a rape by a fellow service member. She developed PTSD and anxiety afterward. The VA found her to be 100% disabled based on a service-related cause and awarded benefits but later revised her level of disability down to 70%. Mandrell’s 2017 application for Social Security disability benefits was denied and the Appeals Council denied her request for review. The district court affirmed.The Seventh Circuit reversed and remanded. The ALJ failed to connect the residual functional capacity he found with the evidence in the record, and he did not adequately account for her deficits in concentration, persistence, and pace. The ALJ apparently accepted that Mandrell suffered from PTSD as a result of the rape, but dismissed most of the symptoms that accompanied that condition. While the Social Security Administration is not bound by the VA’s assessment of Mandrell’s disability, the underlying medical evidence on which the VA relied is just as relevant to the social‐security determination as it was to the VA. View "Mandrell v. Kijakazi" on Justia Law