Justia Public Benefits Opinion Summaries

Raymond Zaborowski, a U.S. Army veteran suffering from anxiety and PTSD, applied for Social Security disability benefits, claiming his conditions have prevented him from working since 2014. An administrative law judge (ALJ) denied his claim, stating that medical evidence indicated he could still perform light work.Zaborowski appealed to the United States District Court for the Eastern District of Pennsylvania, where he consented to jurisdiction by a magistrate judge. The magistrate judge upheld the ALJ's decision, leading Zaborowski to appeal further.The United States Court of Appeals for the Third Circuit reviewed the case. Zaborowski argued that the regulation requiring ALJs to explain their decisions violated the Social Security Act, that the ALJ failed to properly explain the supportability and consistency of medical opinions, and that the ALJ's findings were not supported by substantial evidence. The Third Circuit reviewed the legal issues de novo and the ALJ's factual findings for substantial evidence.The court held that the regulation complies with the statute, as it requires ALJs to explain the dispositive reasons for their decisions, specifically focusing on supportability and consistency. The court found that the ALJ adequately addressed these factors in her analysis, noting that the opinions of two psychologists were consistent with the record, while the treating psychiatrist's opinion was not. The court also found substantial evidence supporting the ALJ's decision, including the psychologists' opinions and evidence of Zaborowski's ability to live independently and assist his mother.The Third Circuit affirmed the decision, concluding that the ALJ's denial of benefits was supported by substantial evidence and that the regulation did not violate the Social Security Act. View "Zaborowski v. Commissioner Social Security" on Justia Law

Former employees of Alternatives, a for-profit hospice provider, sued under the False Claims Act, 31 U.S.C. 3729, alleging that Alternatives submitted claims for Medicare reimbursement despite inadequate documentation in the patients’ medical records supporting hospice eligibility, under 42 C.F.R. 418.22(b)(2). For a patient to be eligible for Medicare hospice benefits, and for a hospice provider to be entitled to reimbursement, a patient must be certified as “terminally ill.” The district court granted Alternatives summary judgment based on lack of materiality, finding “no evidence” that Alternatives’ insufficiently documented certifications "were material to the Government’s decision to pay.” The court reasoned that “[t]he Government could see what was or was not submitted” yet never refused any of Alternatives’ claims, despite the inadequacy or missing supporting documentation or where compliance was otherwise lacking.The Third Circuit vacated. When a government contractor submits a claim for payment but fails to disclose a statutory, regulatory, or contractual violation, that claim does not automatically trigger liability. The Act requires that the alleged violation be “material” to the government’s decision to pay. The Supreme Court has identified factors to assist courts in evaluating materiality. In this case, the court based its decision principally on the government’s continued payments after being made aware of its deficient documentation, overlooking factors that could have weighed in favor of materiality— and despite an open dispute over the government’s “actual knowledge.” View "Druding v. Care Alternatives" on Justia Law

The hospital, located in Philadelphia, received a reclassification into the New York City area, which would sizably increase the hospital’s Medicare reimbursements due to that area’s higher wage index, 42 U.S.C. 1395ww(d). Although a statute makes such reclassifications effective for three fiscal years, the agency updated the geographical boundaries for the New York City area before the close of that period and reassigned the hospital to an area in New Jersey with an appreciably lower wage index. The hospital successfully sued three agency officials in the Eastern District of Pennsylvania.The Third Circuit vacated and remanded for dismissal. The Medicare Act, 42 U.S.C. 1395oo(f)(1), channels reimbursement disputes through administrative adjudication as a near-absolute prerequisite to judicial review. The hospital did not pursue its claim through administrative adjudication before suing in federal court. By not following the statutory channeling requirement, the hospital has no valid basis for subject-matter jurisdiction. View "Temple University Hospital, Inc. v. Secretary United States Department of Health & Human Services" on Justia Law

For decades, the U.S. Virgin Islands Government Employees Retirement System (GERS) experienced annual deficits between its assets and projected liabilities to participants. Its aggregate shortfall is now about three billion dollars. The Government of the Virgin Islands (GVI) has sometimes failed to remit to GERS all the employer contributions it is statutorily mandated to make. GERS sued GVI for these contributions, first in 1981, resulting in a consent judgment, and most recently in 2016, when GERS sought to enforce that judgment. GERS claimed that, as far back as 1991, GVI had contributed tens of millions of dollars less than required by the statutory percentages of employee compensation. GERS also claimed that independent of these fixed-percentage contributions, GVI must fund GERS to the point of actuarial soundness.The district court awarded GERS an amount calculated to reflect GVI’s historical percentage-based under-contributions. The Third Circuit affirmed that award of principal but vacated an enhancement of the award that applied late-arriving interest and penalty statutes, enacted in 2005, retroactively. The consent judgment does not require GVI to fund GERS for the gap between its assets and liabilities. Virgin Islands law apparently fails to obligate anyone to fund GERS when employee-compensation-based contributions and associated investment returns fall short of the assets required, based on actuarial assessments, to meet future pension commitments. The citizens of the Virgin Islands (population 106,4052) simply cannot pay the necessary billions. The cure for GERS’s chronic underfunding is legislative. View "Government Employees Retirement System of the Virgin Islands v. Government of the Virgin Islands" on Justia Law

Dual-status military technicians are “Federal civilian employees” but must maintain National Guard membership and wear the appropriate military uniform while performing civilian technician duties. They must meet certain military requirements.Newton worked as a National Guard dual-status technician, 1980-2013, also serving as a New Jersey Army National Guard member, receiving separate military pay. In 2013, Newton retired from both. He received a pension from the Defense Finance and Accounting Service for his National Guard service and an annuity paid by the Office of Personnel Management for his dual-status technician service. The Social Security Administration (SSA) notified Newton that he qualified for retirement benefits, subject to a reduction under the Windfall Elimination Provision (WEP), 42 U.S.C. 415(a)(7)(A), because he received a separate pension payment “based in whole or in part upon" earnings not subject to Social Security tax, his civil service annuity. Newton argued that his civil service pension triggered an exception to the WEP for uniformed service.The Third Circuit held that Newton’s benefits are subject to a WEP reduction. Newton has always received two separate salaries and now receives two separate pensions. At most, Newton’s OPM civil service pension is based on service he provided while also serving in the National Guard, but not for “service as a member of a uniformed service.” View "Newton v. Commissioner Social Security" on Justia Law

Ehnert was placed at WPP by Staffmark as a temporary general laborer. It was understood that Ehnert would be considered for hire as a WPP employee. Ehnert suffered from various medical conditions but never requested accommodations. On May 23, 2012—the last day of his work placement—Ehnert was informed that he would not be hired by WPP. Ehnert completed applied for social security disability insurance (SSDI) benefits, representing that he had been unable to work due to a “disabling condition” since May 21, 2012. An ALJ granted Ehnert benefits. Ehnert then sued WPP and Staffmark, alleging discrimination on the basis of disability and age, under the Americans with Disabilities Act, the Pennsylvania Human Relations Act, and the Age Discrimination in Employment Act.The Third Circuit affirmed summary judgment for the defendants. Ehnert was unable to establish a prima facie case of discrimination because a necessary element was lacking for his ADA and PHRA claims--that he was otherwise qualified to perform the essential functions of the job as of the date WPP informed him that he would not be hired. Ehnert’s statements regarding his disability for SSDI purposes preclude his subsequent claim that, for the purposes of the ADA and the PHRA, he was “qualified” for the position; Ehnert failed to advance a reasonable explanation that reconciles those positions. View "Ehnert v. Washington Penn Plastic Co Inc." on Justia Law

Care Alternatives provides hospice care to New Jersey patients, employing “interdisciplinary teams” of registered nurses, chaplains, social workers, home health aides, and therapists working alongside independent physicians who serve as hospice medical directors. Former Alternatives employees filed suit under the False Claims Act, 31 U.S.C. 3729–3733 alleging that Alternatives admitted patients who were ineligible for hospice care and directed its employees to improperly alter those patients’ Medicare certifications to reflect eligibility. They retained an expert, who opined in his report that, based on the records of the 47 patients he examined, the patients were inappropriately certified for hospice care 35 percent of the time. Alternatives’ expert testified that a reasonable physician would have found all of those patients hospice-eligible. The district court determined that a mere difference of opinion between experts regarding the accuracy of the prognosis was insufficient to create a triable dispute of fact as to the element of falsity and required that the plaintiffs provide evidence of an objective falsehood. Upon finding they had not adduced such evidence, the court granted Alternatives summary judgment. The Third Circuit vacated, rejecting the objective falsehood requirement for FCA falsity. The plaintiffs’ expert testimony created a genuine dispute of material fact as to falsity. View "Druding v. Care Alternatives" on Justia Law

After the plaintiffs’ disability claims were denied by ALJs employed by the Social Security Administration (SSA), the Supreme Court held in Lucia v. SEC (2018), that ALJs in the Securities and Exchange Commission (SEC) exercised “significant discretion” in carrying out “important functions” and were required, under the Appointments Clause, to be appointed by the President, a court of law, or the head of a department. Because the SEC ALJs were not so appointed, the petitioner there was entitled to a new hearing. When Lucia was decided, the plaintiffs were already in the process of challenging the SSA’s denial of their claims in the district court and demanded new hearings on the ground that the SSA ALJs were unconstitutionally appointed. The Acting Commissioner of SSA quickly reappointed the administrative judges but argued that the plaintiffs were not entitled to relief because they had not previously presented their Appointments Clause challenges to their ALJs or the Appeals Council and had not exhausted those claims before the agency. The district court declined to require exhaustion, vacated the agency’s decisions, and remanded for new hearings. The Third Circuit affirmed. Both the characteristics of the SSA review process and the rights protected by the Appointments Clause favor resolution of these claims on the merits, so exhaustion is not required in this context. View "Cirko v. Commissioner Social Security" on Justia Law

Chang filed a qui tam action against the Center, asserting claims on behalf of the United States and the state under the False Claims Act (FCA). and the Delaware False Claims Act. Chang alleged that the Center had sought and received funding from the state and federal governments by misrepresenting material information. Both governments declined to intervene as plaintiffs. Chang filed an amended complaint and the Center answered. Nearly three years after Chang filed his original complaint, the U.S. and Delaware moved to dismiss the case, asserting that they had investigated Chang’s allegations and discovered them to be “factually incorrect and legally insufficient.” The court granted the motions without conducting an in-person hearing or issuing a supporting opinion. The Third Circuit affirmed. If the government chooses not to intervene, the relator may still “conduct the action” but the government may still “dismiss the action notwithstanding the objections of the person initiating the action if the person has been notified by the Government of the filing of the motion and the court has provided the person with an opportunity for a hearing on the motion,” 31 U.S.C. 3730(c)(2)(A). Chang never requested a hearing; the FCA does not guarantee an automatic in-person hearing to relators before their cases may be dismissed. View "Chang v. Children's Advocacy Center of Delaware" on Justia Law

The ALJ who ruled on Hess’s application for social security disability benefits concluded that Hess had “moderate difficulties” in “concentration, persistence or pace,” but offered a detailed explanation for why she believed those difficulties were not serious and why Hess was capable of performing simple tasks. She found that Hess was “limited to jobs requiring understanding, remembering, and carrying out only simple instructions and making only simple work-related decisions[.]” In a series of hypothetical questions meant to include Hess’s limitations, she asked a vocational expert whether there were jobs in the national economy available to someone with those limitations. The expert said there were. The ALJ decided that Hess was not disabled and rejected his claim. The district court determined that the ALJ had erred because, in her hypothetical questions to the vocational expert, she failed to include or account for her finding that Hess had “moderate” difficulties in “concentration, persistence, or pace.” The Third Circuit reversed, refusing to elevate “form over substance.” An ALJ’s statement of a limitation confining a person to “simple tasks” is permissible after a finding of “moderate” difficulties in “concentration, persistence, or pace,” if the ALJ offers a “valid explanation” for it. The explanation given by the ALJ was “valid.” View "Hess v. Commissioner of Social Security" on Justia Law