Justia Public Benefits Opinion Summaries

Plaintiff challenged the district court's judgment upholding the decision of the SSA denying his application for disability benefits. The court held that a VA disability determination must be accorded substantial weight in Social Security disability proceedings. The court also held that an ALJ must give retrospective consideration to medical evidence created after a claimant's last insured date when such evidence could be "reflective of a possible earlier and progressive degeneration." After considering all relevant evidence, and upon determining that plaintiff was disabled at any time, an ALJ must consult with a medical advisor if the date of onset of the disability was ambiguous. In this case, the ALJ made two errors of law in conducting his analysis of the evidence concerning whether plaintiff was disabled before his DLI and therefore, the court vacated the district court's judgment. View "Bird v. Commissioner of Soc Sec" on Justia Law

Plaintiff, the Chapter 7 trustee for the bankruptcy estate of BioniCare Medical Technologies, contested determinations of the Medicare Appeals Council (MAC) refusing to provide coverage for the BIO-1000, a device to treat osteoarthritis of the knee. Plaintiff alleged that the Secretary improperly used the adjudicative process to create a policy of denying coverage for the BIO-1000, that the MAC's decisions were not supported by substantial evidence, and that the MAC's decisions were arbitrary and capricious on account of a variety of procedural errors. The court rejected those contentions and affirmed the judgment of the district court. View "Almy v. Sebelius" on Justia Law

This appeal arose from the district court's order granting final judgment to the United States upon equitable claims of payment by mistake of fact and unjust enrichment against Tuomey arising out of alleged violations of the Social Security Act, 42 U.S.C. 1395nn, (the Stark Law), and awarding damages plus pre- and post-judgment interest. Because the court concluded that the district court's judgment violated Tuomey's Seventh Amendment right to a jury trial, the court vacated the judgment and remanded for further proceedings. Because the court was remanding the case, the court also addressed other issues raised on appeal that were likely to recur upon retrial. View "Drakeford v. Tuomey Healthcare System" on Justia Law

Plaintiff appealed the district court's order affirming the Commissioner's denial of her application for supplemental security income (SSI). The court found that substantial evidence supported the ALJ's conclusion that plaintiff was not disabled within the meaning of the Social Security Act, 42 U.S.C. 301 et seq. Accordingly, the court affirmed the district court's grant of judgment on the pleadings in favor of the Commissioner. View "Hancock v. Astrue" on Justia Law

Plaintiff applied for Social Security disability insurance benefits and an ALJ denied the claim, noting that plaintiff failed to provide an opinion from his treating physician. When plaintiff requested review of his claim by the Appeals Council, he submitted a letter from his treating physician detailing the injuries and recommending significant restrictions on plaintiff's activity. The Appeals Council made this letter part of the record but denied plaintiff's request for review. Thus, the ALJ's decision denying benefits became the final decision of the Commissioner of the Social Security Administration. Plaintiff appealed, contending that the Appeals Council erred by failing to articulate specific findings justifying its denial of his request for review. The court rejected the argument and held that the Appeals Council need not explain its reasoning when denying review of an ALJ decision. But because in this case the court could not determine if substantial evidence supported the denial of benefits, the court reversed and remanded. View "Meyer, III v. Astrue" on Justia Law

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.

West Virginia sued pharmaceutical manufacturers, claiming that the defendants artificially inflated the reimbursement values of certain drugs, in violation of the West Virginia Consumer Credit and Protection Act, W. Va. Code 46A-1-101, and a state statute prohibiting fraud and abuse in the Medicaid program. The complaint alleged that the defendants inflated the average wholesale price of certain drugs and caused the state to pay an artificially inflated amount of reimbursement for the drugs. One company agreed to pay West Virginia $850,000. After learning of the settlement in 2007, the federal Centers for Medicare & Medicaid Services notified West Virginia of a disallowance in federal funding for the state’s Medicaid program for failure to credit the federal government its share of the settlement proceeds. The Appeals Board sustained the disallowance. The district court upheld the decision. The Fourth Circuit affirmed, rejecting an argument the Medicaid Act, 42 U.S.C. 1396b(d)(2)(A), authorizes a disallowance only when the state has recovered from a "provider."

The Secretary of the United States Department of Labor ("DOL") petitioned the district court to enforce administrative document subpoenas after a DOL investigation into the management of respondents (collectively, "Funds"), which arose out of a $10.1 million loss of Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. 1134(a)(1), plan assets, as a result of the Funds' investments in entities related to Bernard L. Madoff. At issue was whether the attorney-client and work product privileges protected some of the materials requested by the Secretary from disclosure and whether the district court erred in applying the fiduciary exception to override these privileges. The court affirmed the district court's order granting the Secretary's petition and held that the fiduciary exception applied to the Funds' claims of attorney-client privilege and no good cause showing was required in the ERISA context. The court also held that the Funds have failed to carry their burden to demonstrate the applicability of the work product doctrine.

Appellees, the parents of a child with moderate-to-severe autism, filed due process proceedings against the Sumter County School District #17 ("District") seeking a determination that the District did not provide a free and appropriate public education ("FAPE") to the child as required by the Individuals with Disabilities Education Act ("IDEA"), 20 U.S.C. 1412(a)(1)(A). At issue was whether the district court erred by concluding that the District failed to provide the child with a FAPE and that the program established by the child's parents to educate him at home was appropriate. The court held that that the district court did not err in concluding that the District failed to provide the child with FAPE for the 2005-2006 school year where the district court considered the evidence of the child's small improvements in a few tested areas against the District's conceded failure to provide the hours of therapy required for the child, the evidence that the lead teacher and aides did not understand or use proper techniques, and the evidence that it took one teacher months of working with the child to correct the problems caused by the improper techniques. The court also held that the district court did not err by finding that the District was not capable of providing FAPE to the child where the District's evidence was not compelling enough to establish it's improved capabilities at the time of the due process hearing. The court also held that the evidence was sufficient to support the district court's findings that the home placement was reasonably calculated to enable the child to receive educational benefits.

Plaintiff sued defendant seeking a declaratory judgment that defendant was required to comply with the rules laid out in Title XIX of the Social Security Act, section 1396-1396v, where there was a dispute as to what rate plaintiff must pay defendant when defendant provided emergency transportation services to plaintiff's Medicaid enrollees. At issue was whether the definition of emergency services in section 1396(u)-2(b)(2)(B) applied to section 1396(u)-2(b)(2)(D) and whether section 1396(u)-2(b)(2)(D) covered the services provided by defendants to members of plaintiff's Medicaid program. The court held that the definition of emergency services found in 1396(u)-2(b)(2)(B) applied to section 1396(u)-2(b)(2)(D) where applying different definitions to a single term of art within this one statute would be both cumbersome and illogical. The court also held that the district court erred in granting summary judgment to defendant where the plain meaning of the word outpatient and the structure of the statute supported a finding in favor of plaintiff.