Justia Public Benefits Opinion Summaries

The plaintiff, Afaf Beshay Malak, applied for disability insurance benefits (DIB) in 2021, citing several disabilities including pinched nerves, osteoarthritis, fibromyalgia, and chronic headaches. Her application was denied initially and upon reconsideration by disability examiners. Malak then had a hearing before an Administrative Law Judge (ALJ), who followed the five-step evaluation process for disability claims. The ALJ determined that Malak had severe impairments but did not meet the criteria for a listed impairment. The ALJ assessed Malak’s Residual Functional Capacity (RFC) and found she could perform sedentary work with certain limitations. The ALJ concluded that Malak could perform her past work as a financial institution manager and other jobs in the national economy, thus finding her not disabled.Malak appealed the ALJ’s decision to the Appeals Council, which denied her request for review, making the ALJ’s decision the final decision of the Commissioner of Social Security. Malak then appealed to the district court, which affirmed the ALJ’s denial of her DIB claim. Malak subsequently appealed to the United States Court of Appeals for the Eleventh Circuit.The Eleventh Circuit reviewed the case to determine if the ALJ’s decision was supported by substantial evidence. Malak argued that the ALJ failed to consider her medically related absences and the side effects of her treatments. The court held that the ALJ is not required to consider the time needed for medical appointments when determining RFC, as RFC assessments focus on functional limitations caused by medically determinable impairments. The court also found that the ALJ properly considered the effectiveness and side effects of Malak’s treatments, noting that the medical evidence showed positive responses to treatments without significant side effects. The Eleventh Circuit affirmed the district court’s decision, upholding the denial of Malak’s DIB claim. View "Malak v. Commissioner of Social Security" on Justia Law

The seven consolidated cases in this appeal all involve attempts by assignees of a health maintenance organization (HMO) to recover conditional payments via the Medicare Secondary Payer Act's (MSP Act), 42 U.S.C. 1395y(b)(2)(B)(ii), (b)(3)(A), private cause of action. At issue is whether a contractual obligation, without more (specifically, without a judgment or settlement agreement from a separate proceeding), can satisfy the “demonstrated responsibility” requirement of the private cause of action provided for by the MSP Act. The court held that a plaintiff suing a primary plan under the private cause of action in the MSP Act may satisfy the demonstrated responsibility prerequisite by alleging the existence of a contractual obligation to pay. A judgment or settlement from a separate proceeding is not necessary. Therefore, the court vacated the district courts' judgments and remanded for further proceedings. View "MSP Recovery LLC v. AllState Ins. Co." on Justia Law

The Secretary determined that Bayou Shores was not in substantial compliance with the Medicare program participation requirements, and that conditions in its facility constituted an immediate jeopardy to residents’ health and safety. The bankruptcy court assumed authority over Medicare and Medicaid provider agreements as part of the debtor’s estate, enjoined the Secretary from terminating the provider agreements, determined for itself that Bayou Shores was qualified to participate in the provider agreements, required the Secretary to maintain the stream of monetary benefit under the agreements, reorganized the debtor’s estate, and finally issued its Confirmation Order. The district court upheld the Secretary’s jurisdictional challenge and reversed the Confirmation Order with respect to the assumption of the debtor’s Medicare and Medicaid provider agreements. The court concluded that the statutory revision in this case does not demonstrate Congress's clear intention to vest the bankruptcy courts with jurisdiction over Medicare claims. Therefore, the court agreed with the district court that the bankruptcy court erred as a matter of law when it exercised subject matter jurisdiction over the provider agreements in this case. The bankruptcy court was without 28 U.S.C. 1334 jurisdiction under the 42 U.S.C. 405(h) bar to issue orders enjoining the termination of the provider agreements and to further order the assumption of the provider agreements. Accordingly, the court affirmed the judgment. View "Florida Agency for Health Care Admin. v. Bayou Shores" on Justia Law

VRC filed suit against HHS and the Secretary, seeking the recoupment of payments VRC returned to Medicare after it was issued notice of an overpayment. At issue is the reimbursement rate of the intravitreal injection of Lucentis. VRC did not follow the Lucentis label’s instructions limiting dosage to one per vial. Instead, VRC treated up to three patients from a single vial. Because VRC was extracting up to three doses from a single vial, it was reimbursed for three times the average cost of the vial and three times the amount it would have received had it administered the drug according to the label. The court affirmed the denial of recoupment, concluding that VRC's charge to Medicare did not reflect its expense and was not medically reasonable; the Secretary's decision was supported by substantial evidence; and VRC is liable for the overpayment. View "Vitreo Retinal Consultants v. U.S. Dep't of Health & Human Servs." on Justia Law

Plaintiff appealed the denial of her application for disability insurance benefits, contending in part that the district court should have remanded the case to the Commissioner for further proceedings to consider new evidence. The court agreed with the Sixth Circuit's rejection of the notion that the mere existence of a subsequent decision in the claimant's favor, standing alone, warranted reconsideration of the first application. In this case, the only “new evidence” plaintiff cites in support of her request for remand is the later favorable decision. The court concluded that the later decision is not evidence for purposes of 42 U.S.C. 405(g). Because plaintiff does not offer any other new evidence, she has not established that remand is warranted. The court also concluded that the ALJ's conclusion that plaintiff was able to perform light work was supported by substantial evidence and that the ALJ gave adequate weight to the opinion of her treating physician, finding it inconsistent with the medical records and other evidence. Accordingly, the court affirmed the judgment. View "Hunter v. SSA" on Justia Law

Plaintiff appealed the denial of his application for disability insurance benefits and supplemental security income. The court held that the Appeals Council committed legal error when it failed to consider materials from a psychologist who examined plaintiff. Accordingly, the court reversed and remanded with instructions. View "Washington v. SSA" on Justia Law