Justia Public Benefits Opinion Summaries

Articles Posted in US Court of Appeals for the Eleventh Circuit
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MSPA Claims 1 LLC—the assignee of a now-defunct Medicare Advantage Organization—sued Tower Hill Prime Insurance Company to recover a reimbursable payment. The district court granted Tower Hill’s motion for summary judgment because it determined that MSPA Claims 1’s suit was untimely.The Eleventh Circuit affirmed. The court explained that because it is at least “plausible” that the term “accrues” in Section 1658(a) incorporates an occurrence rule—in fact, and setting presumptions aside, the court wrote that it thinks that’s the best interpretation—that is how the court interprets it. Therefore, MSPA Claims 1’s cause of action accrued in 2012 when MSPA Claims 1’s assignor, Florida Healthcare, paid D.L.’s medical bills and became entitled to reimbursement through the Medicare Secondary Payer Act. Because that was more than four years before MSPA Claims 1 filed suit in 2018, its suit is not timely under 28 U.S.C. Section 1658(a). View "MSPA Claims 1, LLC. v. Tower Hill Prime Insurance Co." on Justia Law

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Plaintiff applied for disability benefits, alleging that, as of August 2016, she was unable to work because of degenerative disc disease, bulging and herniated discs, other spine issues, fatigue, migraines, asthma, fatty liver, and food allergies. The district court affirmed the decision of the administrative law judge denying Plaintiff's claims. The district court determined that section 404.1520c, and not the treating-physician rule, applied to Plaintiff’s claim. Plaintiff argued that the court's earlier precedents establishing and applying the treating-physician rule are still good law, notwithstanding the promulgation of section 404.1520c.   The Eleventh Circuit affirmed, finding that the new regulation validly abrogated the treating-physician rule and applied to Plaintiff’s claim. The court found that the new regulation instructs administrative law judges to give a treating physician’s opinion no deference and instead to weigh medical opinions based on their persuasiveness. The Social Security Act (“Act”) conferred “exceptionally broad authority” to the Commissioner “to prescribe standards for applying certain sections of the . . . Act.” The court explained that it has never held that the treating-physician rule is unambiguously required by the Act.   Here, Plaintiff filed her disability claim on April 28, 2017, after the effective date for section 404.1520c. And because section 404.1520 forbids administrative law judges from “defer[ring] or giv[ing] any specific evidentiary weight, including controlling weight, to any medical opinion(s),” 20 C.F.R. Section 404.1520c(a), the administrative law judge did not err by declining to give more weight to the medical opinions of Plaintiff’s treating physicians. View "Zinta Harner v. Social Security Administration, Commissioner" on Justia Law

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Plaintiff’s doctors prescribed him Optune, a medical technology that had recently received FDA approval for treating recurrent GBM. The device delivers tumor treating field therapy (TTFT) to inhibit cancer-cell replication. A company called Novocure is the sole supplier of the Optune device, which is rented by patients on a monthly basis.   Because Plaintiff is a Medicare Part B beneficiary, he and Novocure asked Medicare to cover his TTFT. Novocure was held liable for the claims. Plaintiff and Novocure submitted 13 claims to Medicare, corresponding to 13 months of TTFT. The district court held that Plaintiff lacked standing because he hadn’t suffered an injury in fact.   The Eleventh Circuit was tasked with deciding whether Plaintiff has standing to challenge a denial of Medicare coverage where the costs of his treatment were imposed not on him, but rather on a third-party supplier. The court affirmed the district court’s determination that Plaintiff hadn’t suffered an injury in fact.   Here, Plaintiff’s alleged harm will only come to pass due to the challenged action if, at some indefinite point in the future: (1) his condition worsens, (2) he has paid his premiums and stayed on Medicare Part B, (3) he elects to resume TTFT, (4) his doctor prescribes the therapy (5) Plaintiff receives the treatment, (6) he files a claim, (7) which is denied at every level of the Medicare appeals process, (8) the adjudicators determine that Plaintiff’s hypothetical future case presents a “comparable situation,” and (9) they further find that the instant coverage denial and no other source put Plaintiff on notice that he could be held liable. View "Edwin R. Banks v. Secretary, Department of Health and Human Services" on Justia Law

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In 2008, following a diagnosis of multiple sclerosis (MS), Karantsalis sued the city under the Americans with Disabilities Act (ADA) and the Rehabilitation Act of 1973 by failing to make its facilities and infrastructure accessible to individuals with disabilities. He later voluntarily dismissed the lawsuit, believing that he lacked constitutional standing because his symptoms were mild and did not prevent him from accessing and using the city’s programs or services. By 2019, Karantsalis’s MS and his symptoms had progressed dramatically: he had started falling, developed a limp, and needed a disabled parking permit. His neurologist had prescribed a wheelchair.He again sued the city under the ADA and Rehabilitation Act alleging the sidewalks, municipal gymnasium, and parking at public facilities were inaccessible. The district court dismissed the case with prejudice, holding that it was barred by the four-year statute of limitations, which was triggered before or during 2008 when Karantsalis became aware of his MS diagnosis. The Eleventh Circuit reversed. From the face of his complaint, Karantsalis’s injury did not occur until at least 2017. Karantsalis could not have sued before he lost his mobility and his ready access to and use of the city’s public services. View "Karantsalis v. City of Miami Springs" on Justia Law

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Pupo first applied for supplemental security income (SSI) in June 2011, alleging that she was unable to work due to depression, body tremors, and high blood pressure. Her initial application was denied, but, in 2015, her case was remanded for further proceedings pursuant to sentence four of 42 U.S.C. 405(g). The district court affirmed the subsequent denial of Pupo’s application.The Fifth Circuit reversed and remanded. The decision is not supported by substantial evidence; the ALJ erred by not addressing one of Pupo’s medical diagnoses, her incontinence when assessing her residual functional capacity and the Appeals Council erred by not considering the new medical evidence submitted by Pupo following the ALJ’s denial of her SSI claim. Pupo submitted medical records showing that she had surgery because of her stress urinary incontinence nine days before the ALJ issued his decision. The ALJ did not err in failing to consider Pupo’s borderline age situation because he did not apply the grids mechanically but instead relied on testimony due to Pupo’s non-exertional limitations. View "Pupo v. Commissioner, Social Security Administration" on Justia Law

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Plaintiff appeals the district court's order affirming the ALJ's denial of his application for supplemental security income (SSI) benefits, pursuant to 42 U.S.C. 1383(c). Plaintiff contends that the ALJ erred by ruling that he could perform a job with level 3 reasoning after finding that his residual functional capacity limited him to simple, routine, and repetitive tasks, and by basing the number of available jobs on unreliable vocational expert testimony.The Eleventh Circuit joined the Fourth, Ninth, and Tenth Circuits and held that there is an apparent conflict between a limitation to simple, routine, and repetitive tasks and the demands of level 3 reasoning. Because the ALJ did not address that apparent conflict—as required by precedent—and because the court cannot say that the error was harmless, the court reversed and remanded for further proceedings. View "Viverette v. Commissioner of Social Security" on Justia Law

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Compensatory education is not an automatic remedy for a child-find violation under the Individuals with Disabilities Education Act (IDEA). Compensatory educational services are designed to counteract whatever educational setbacks a child encounters because of IDEA violations—to bring her back where she would have been but for those violations. At minimum, a parent must offer evidence that a procedural violation—like the child-find violation asserted here—caused a substantive educational harm, and that compensatory educational services can remedy that past harm.The Eleventh Circuit concluded that the district court was well within its "broad discretion and equitable authority" when it concluded that plaintiff had not shown that the school board's child-find violation resulted in educational deficits for the child that could be remediated with prospective compensatory relief. Furthermore, because the school began its special education referral process before plaintiff filed suit, she cannot show that she is entitled to attorney's fees. Accordingly, the court affirmed the district court's judgment. View "J.N. v. Jefferson County Board of Education" on Justia Law

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The Eleventh Circuit granted the petition for panel rehearing, withdrew its prior opinion, and issued the following opinion.The court concluded that the ALJ gave little or no weight to three pieces of evidence in the record indicating that plaintiff's mental illness prevents him from maintaining a job: (1) the opinions of plaintiff's treating psychiatrist, (2) the opinions of a consulting psychologist who examined plaintiff at the request of the SSA, and (3) plaintiff's own testimony as to the severity of his symptoms. In this case, the ALJ did not articulate adequate reasons for discounting this evidence, which provided support for a finding of disability. Accordingly, the court reversed and remanded to the agency for further proceedings. View "Simon v. Commissioner, Social Security Administration" on Justia Law

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The Eleventh Circuit vacated its prior opinion and substituted the following opinion.The court affirmed the district court's decision affirming the agency's finding that plaintiff was ineligible for disability insurance benefits. The court held that there is no apparent conflict between one's limitation to following simple instructions and positions that require the ability to follow "detailed but uninvolved" instructions. The court concluded that the agency's decision was otherwise supported by substantial evidence. View "Buckwalter v. Acting Commissioner of Social Security" on Justia Law

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The Eleventh Circuit reversed and remanded the denial of social security disability benefits to plaintiff, who stated that he was no longer able to work due to various psychiatric conditions, which included chronic depression, anxiety, and bipolar disorder. The court held that the SSA's denial of plaintiff's application for disability benefits was not supported by substantial evidence where the ALJ did not articulate adequate reasons for discounting evidence of plaintiff's mental illness, which provided support for a finding of disability. In this case, the ALJ gave little or no weight to three pieces of evidence in the record indicating that plaintiff's mental illness prevents him from maintaining a job: (1) the opinions of plaintiff's treating psychiatrist, (2) the opinions of a consulting psychologist who examined plaintiff at the request of the SSA, and (3) plaintiff's own testimony as to the severity of his symptoms. View "Simon v. Commissioner, Social Security Administration" on Justia Law