Justia Public Benefits Opinion Summaries

Medicare pays teaching hospitals for work by residents when a teaching physician supervises. During the 1990s, HHS concluded that many hospitals were billing for unsupervised services and began to audit invoices. There was also a GAO report and private litigation: qui tam suits under the False Claims Act, allowing relators to collect a bounty. Under 31 U.S.C. 3730(e)(4)(A), suits cannot be based upon public disclosure of allegations or transactions in public agencies’ official reports unless the relator is an original source of information. A prior case concluded that the 1998 GAO report and similar public documents disclosed that billing for unsupervised work was common practice. The district court dismissed a suit filed against a teaching hospital in 2004, claiming to describe conduct, such as inadequate supervision, not previously disclosed. The Seventh Circuit vacated. No one who read the GAO report, or followed the progress of the audits, would suspect that Rush University was misrepresenting "immediate availability" of teaching physicians during concurrently scheduled procedures. The complaint alleged a kind of deceit that the GAO report does not attribute to any teaching hospital. View "Goldberg v. Rush Univ. Med. Ctr." on Justia Law

Petitioner, then 45 years old and having previously worked in a factory and as a health aid, applied for disability benefits in 2004, claiming an onset date in 2004. Her conditions include peripheral vascular disease, chronic obstructive pulmonary disease, osteoarthritis, obesity, vascular dementia, depression, panic disorder, and anxiety. The Social Security Appeals Council denied review of the ALJ's adverse decision. The Seventh Circuit reversed and remanded. The ALJ failed to adequately consider petitioner's mental impairments, her obesity, and several of her physical problems. View "Arnett v. Astrue" on Justia Law

Plaintiff first sought treatment in 1988, at age 27, experiencing double vision, eye strain, and facial numbness, and was diagnosed with abducens nerve palsy of the left eye. He continued to work as a welder until 2004, when symptoms forced him to sell his business. In 2007, he applied for disability insurance benefits, alleging onset in 2004. In 2010 an ALJ rejected the claim, concluding that plaintiff; she noted plaintiff’s complaints of headaches, but concluded that they must be non-severe. The district court upheld the denial. The Seventh Circuit remanded to the Social Security Administration, holding that the ALJ’s credibility determination was not supported by substantial evidence. View "Shauger v. Astrue" on Justia Law

For about seven years, defendant aided undocumented immigrants in filing claims for Illinois unemployment benefits, charging a fee of $80 plus one benefit check, and using social security numbers of unsuspecting, law-abiding citizens. She arranged with a state employee to process the applications as though the undocumented aliens were citizens. She was convicted of eight counts of mail fraud and sentenced to 96 months' imprisonment. The Seventh Circuit affirmed application of sentencing guideline enhancements: for being an organizer or leader of a criminal activity that involved five or more participants or was otherwise extensive, for unauthorized use of any means of identification unlawfully to produce or obtain any other means of identification, and for an offense with 50 or more victims. View "United States v. Vasquez" on Justia Law

Plaintiffs brought a putative class action under the Employee Retirement Income Security Act, 29 U.S.C. 1001, to recover benefits under long-term disability benefit plans maintained by their former employers. The plans provide for reduction of benefits if the disabled employee also receives benefits under the Social Security Act, as both plaintiffs do. They dispute calculation of the reduction, claiming that the plans do not authorize inclusion in the offset of benefits paid to dependent children. Both plans require offsets for "loss of time disability" benefits. The district court dismissed. The Seventh Circuit affirmed, holding that children's Social Security disability benefits paid based on a parent's disability are "loss of time disability" benefits under the language of the plans. View "Schultz v. Aviall Inc. Long Term Disability Plan" on Justia Law

Plaintiff contracted for satellite TV service. Equipment costs are amortized in monthly payments; a customer who discontinues service owes a fee to cover the unpaid portion of equipment cost. Plaintiff authorized a charge to her debit card should that occur. Plaintiff stopped paying the monthly charge. Defendant collected the termination fee via the debit card. Plaintiff argued that the Social Security Act, 42 U.S.C. 407(a), provides that benefits may not be assigned or subject to attachment or garnishment at the behest of creditors, and that, unbeknownst to defendant, all funds in her account came from Social Security benefits. The district court ruled in favor of defendant. The Seventh Circuit affirmed. Plaintiff's arrangement was consensual, unlike "legal process." The statute does not authorize private parties to sue for damages based on assignments of Social Security benefits. View "Townsel v. DISH Network L.L.C." on Justia Law

ESBC, billing agent for the Fire Department, determined that each of the individual defendants owned a vehicle involved in a collision to which the Fire Department responded and each had insurance coverage, and billed response costs incurred for each collision. The defendants refused to pay and ESBC sought a declaration that defendants were liable under the Comprehensive Environmental Response, Compensation, and Liability Act, 42 U.S.C. 9601. Under CERCLA, the owner of a “facility” from which hazardous substances have been released is responsible for response costs that result from the release. Insurer-defendants counterclaimed for injunctive relief from ESBC’s billing practices and alleging violation of the Fair Debt Collection Practices Act, 15 U.S.C. 1692, unjust enrichment, unlawful fee collection, fraud, constructive fraud, and insurance fraud. The district court granted defendants judgment on the pleadings and dismissed counterclaims without prejudice. The Seventh Circuit affirmed. Motor vehicles for personal use fall under the "consumer product in consumer use” exception to CERCLA’s definition of facilityView "Emergency Serv. Billing Corp., Inc. v. Allstate Ins. Co." on Justia Law

After a 1999 auto accident, plaintiff had severe back pains and was diagnosed with a Chiari malformation, a protrusion of brain tissue into the spinal canal. After three operations on her brain and spine, her vision and speech problems lessened, but she developed hydrocephalus, a buildup of cerebrospinal fluid in the brain that required installation of a shunt in her brain. She has not worked since the auto accident and was last insured for social security disability benefits in June 2005 (when she was 34 years old), so only if she was disabled from full-time work by that date is she eligible for benefits. An administrative law judge found her capable of sedentary work. The Seventh Circuit reversed, finding that the ALJ failed to bridge the gap between medical testimony and plaintiff's testimony and his conclusion. View "Bjornson v. Astrue" on Justia Law

Medicare Part A reimburses hospitals according to a Prospective Payment System (42 U.S.C. 1395ww(d), which uses a predetermined formula to calculate reimbursement for each patient discharge without regard to the actual cost incurred. The formula includes the average hourly wage of the employees in the geographic region, including paid lunch hours. Hospitals objected to the practice because some hospitals give paid lunch breaks, which depresses the average area hourly wage and, in turn, their Medicare reimbursements. The district court granted summary judgment for the government. The Seventh Circuit affirmed, reasoning that counting all paid hours, for the sake of administrative simplicity, is not arbitrary. View "Adventist GlenOaks Hosp. v. Sebelius" on Justia Law

Defendant operated what appeared to be convenience stores, but in fact were fronts that rang up phony sales for food-stamp recipients to exchange their benefits for discounted amounts of cash. When federal investigators discovered the scheme at one location, he obtained government authorization to accept food stamps at a different address and continued the operation. Defendant eventually pleaded guilty to eight counts of wire fraud, 18 U.S.C. 1343, and was sentenced to 60 months' imprisonment and ordered to pay almost $1.7 million in restitution. The Seventh Circuit affirmed. The district court properly imposed a 16-level sentencing increase under 2B1.1(b)(1)(I) for a loss of more than $1 million because. If anything, the court underestimated the loss. The court properly assessed a 4-level increase under 3B1.1(a) for leadership in an "extensive" scam; defendant ran the scam from multiple locations, traded cash for benefits with "probably hundreds" of customers, and supervised employees at his stores. View "United States v. Hussein" on Justia Law