Justia Public Benefits Opinion Summaries

Petitioners sued retail pharmacies under the False Claims Act (FCA), 31 U.S.C. 3729, which permits private parties to bring lawsuits in the name of the United States against those who they believe have defrauded the federal government and imposes liability on anyone who “knowingly” submits a “false” claim to the government. Petitioners claim that the pharmacies defrauded Medicaid and Medicare by offering pharmacy discount programs to their customers while reporting their higher retail prices, rather than their discounted prices, as their “usual and customary” charge for reimbursement. The Seventh Circuit concluded that the pharmacies could not have acted “knowingly” if their actions were consistent with an objectively reasonable interpretation of the phrase “usual and customary.”The Supreme Court vacated. The FCA’s scienter element refers to a defendant’s knowledge and subjective beliefs—not to what an objectively reasonable person may have known or believed. The FCA’s three-part definition of the term “knowingly” largely tracks the traditional common-law scienter requirement for claims of fraud: Actual knowledge, deliberate ignorance, or recklessness will suffice. Even though the phrase “usual and customary” may be ambiguous on its face, such facial ambiguity alone is not sufficient to preclude a finding that the pharmacies knew their claims were false. View "United States ex rel. Schutte v. Supervalu Inc." on Justia Law

Combs suffers from several physical and mental impairments. An ALJ found that she suffers from lumbar spondylosis, asthma, migraines/headaches, chronic pain syndrome, diabetes with diabetic polyneuropathy, obesity, attention deficit hyperactivity disorder, schizoaffective disorder, bipolar type, posttraumatic stress disorder, social anxiety disorder, generalized anxiety disorder, and borderline personality disorder. Combs sought treatment for lower back pain in March 2018 at PPG, where she received various tests, treatments, and prescriptions through 2020.Combs applied for Disability Insurance Benefits in August 2019, alleging an onset of disability on December 24, 2015. The claim was denied initially and upon reconsideration. The district court concluded the ALJ’s determination was supported by substantial evidence. The Seventh Circuit affirmed, rejecting an argument that the ALJ should have concluded that Combs suffered a closed period of disability from June 2019 to July 2020 due to her back impairment, pain, and multiple invasive procedures that would have rendered her off task or absent beyond employer tolerances. The record amply supports the ALJ’s conclusion that Combs was not disabled at any time, including during that period. View "Combs v. Kijakazi" on Justia Law

Relying on the vocational expert (“VE”)’s testimony, the administrative law judge (“ALJ”) found that there were a significant number of jobs in the national economy that Plaintiff could perform, and, therefore, Plaintiff was not disabled. Plaintiff’s attorney sent a letter to the Appeals Council asking it to review the ALJ’s finding that there were a significant number of jobs in the national economy that Plaintiff could perform. The Appeals Council made the attorney’s letter and a six-page attachment part of the record and denied Plaintiff’s request for review of the ALJ’s disability determination because it “found no reason under [the] rules to review the Administrative Law Judge’s decision.” On appeal, Plaintiff challenged only the ALJ’s conclusion that there were a significant number of jobs in the national economy that a person with Plaintiff’s limitations, age, education, and experience could perform.   The Ninth Circuit affirmed the district court’s decision upholding the Commissioner of Social Security’s denial. The panel held that to determine whether the ALJ had a duty to address a conflict in job-number evidence (and failed to discharge that duty), it considers on a case-by-case “meritless or immaterial” or has “significant probative value.” Because Plaintiff did not present his job-number evidence to the ALJ during or after the hearing, the ALJ did not have any occasion to address the purported inconsistency between the VE’s estimates and Plaintiff’s contrary estimates. The panel held that the letter by Plaintiff’s counsel and the six pages of printouts together provided no basis to conclude that these results qualified as significant and probative evidence. View "JAMES WISCHMANN V. KILOLO KIJAKAZI" on Justia Law

The Supreme Court dismissed this direct appeal brought by the Iowa Department of Human Services (HDS) from a district court ruling requiring Iowa's Medicaid program to pay for sex reassignment surgery for two transgender adults and affirmed the denial of fees on cross-appeal, holding that the appeal was moot.Petitioners, adult transgender Iowans who were denied preauthorization for sex reassignment surgeries through the Medicaid program, appealed their managed care organization's denial of coverage to DHS. DHS affirmed the denials. The district court reversed, concluding that Iowa Code 216.7(3), an amendment to the Iowa Civil Rights Act (ICRA) violated the guarantee of equal protection under the Iowa Constitution. DHS appealed, but, thereafter, agreed to pay for Petitioners' surgeries. The Supreme Court dismissed the direct appeal as moot and affirmed the district court's order denying any fee award, holding that the court erred in denying Petitioners' request for attorney fees. View "Vasquez v. Iowa Dep't of Human Services" on Justia Law

Frazier served in the Navy from 1988-1993. In 2008, Frazier fractured the fourth and fifth fingers of his right hand after being startled by a nightmare--according to Frazier, a frequent occurrence due to PTSD, a disability for which Frazier had been awarded service connection. The VA's examining physician noted that Frazier experienced pain in his right hand and that the injury was secondary to his PTSD but that the pain “does not result in/cause functional loss.” The Board of Veterans Appeals granted Frazier service connection for the injury; the regional office assigned a noncompensable rating for that injury,The Federal Circuit affirmed, rejecting Frazier’s argument that he was entitled to a compensable rating of 10 percent under 38 C.F.R. 4.59. That regulation provides: The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Frazier cited Diagnostic Codes 5219 and 5223, which provide 20 percent and 10 percent ratings, respectively, for unfavorable and favorable ankylosis of the ring and little fingers. The Board properly focused on Diagnostic Code 5230, which provides for a zero percent rating for limitations of motion in the little or ring fingers. Section 4.59 does not “create a freestanding painful motion disability that is always entitled to a 10% disability rating” and Frazier did not have ankylosis. View "Frazier v. McDonough" on Justia Law

The Supreme Court reversed the judgment of the district court concluding that the Iowa Department of Human Services (DHS) was entitled to a detailed accounting and all of the residual funds The Center for Special Needs Trust Administration, Inc. had retained from Steven Muller's trust subaccount, holding that the district court erred.The Center for Special Needs Trust Administration, Inc. acted as trustee over a pooled special needs trust subaccount for the benefit of Muller. After Muller died, the Center retained all residual funds in his trust subaccount. DHS sought judicial intervention to obtain a detailed accounting of the retained funds. The district court decided in favor of DHS and ordered the Center to pay DHS all of the funds it had retained from the subaccount. The Supreme Court reversed, holding that the Center provided an adequate accounting, and therefore, the district court lacked authority to grant the relief it provided to remedy the Center's alleged failure to account for the retained funds. View "In re Medical Assistance Pooled Special Needs Trust of Steven Muller" on Justia Law

The Supreme Court affirmed the judgment of the district court granting summary judgment for the Center for Special Needs Trust Administration, Inc., as trustee of a polled special needs trust held for the benefit of Scott Hewitt, and dismissing this action brought by the Iowa Department of Human Services (DHS) claiming it was entitled to a detailed accounting, holding that the trustee provided an adequate accounting.Title XIX of the Social Security Act required that the funds remaining in Hewitt's trust subaccount when he died must first be used to reimburse the state for its Medicaid expenditures. DHS filed a petition to invoke jurisdiction over the irrevocable trust, claiming that it was entitled to a detailed accounting to ensure that the funds retained by by the pooled special needs trust were used for a proper purpose. The district court granted summary judgment for the Center, concluding that no further accounting was required absent evidence that the Center breached its duties as trustee. The Supreme Court affirmed, holding that DHS was not entitled to relief on its claims of error. View "In re Medical Assistance Pooled Special Needs Trust Of Scott Hewitt" on Justia Law

Bean served in the U.S. Army from 1966-1969. In 1997, he sought disability compensation. Bean was diagnosed with major depression and generalized anxiety disorder, but not PTSD. The VA denied him entitlement to service connection for PTSD. In 2006, Bean sought service connection for major depression, generalized anxiety disorder, and PTSD. In response, the VA notified Bean that it was “working on [his] application for service-connected compensation” for major depression and generalized anxiety disorder and his “claim to reopen for” his PTSD-related claim. In 2007, he was diagnosed with PTSD and major depressive disorder. The VA found service connection for PTSD, deemed the PTSD 30% disabling, and assigned an August 2006 effective date. Bean filed a Notice of Disagreement, concerning the disability rating and effective date.In 2012, the Board of Veterans Affairs addressed Bean’s rating. Bean sought reconsideration. In 2019, the Board dismissed Bean’s appeal of the 2013 denial of his claim without addressing the merits.The Federal Circuit reversed the Veterans Court’s dismissal of the appeal for lack of jurisdiction. When a claim is adequately presented to, but is not addressed by the Board, the Board’s disposition of the appeal constitutes the Board's decision on that claim that may be appealed to the Veterans Court. The Veterans Court's jurisdiction is not limited to the Board's affirmative determinations and covers the disposition of an appeal that is challenged as improperly failing to address contentions clearly before the Board. View "Bean v. McDonough" on Justia Law

Crawford served in the U.S. Army and Florida National Guard for two decades. He was discharged in 2011 due to his service-connected PTSD. Crawford’s PTSD began after his second tour of duty in Iraq. The Florida State Surgeons Medical Discharge Review Board (SSMDRB) found Crawford did not meet medical retention standards and that his PTSD was incurred in the line of duty. It recommended a fitness determination by a Physical Evaluation Board (PEB), a prerequisite for medical retirement, 10 U.S.C. 1201. Crawford was not referred to a PEB but was discharged as if his PTSD was not service-related, without medical retirement.Crawford sought correction of his records and retroactive benefits before the Army Board for the Correction of Military Records (ABCMR). Notwithstanding the SSMDRB’s findings and the fact that Crawford was discharged for failure to meet medical retention standards, a doctor opined Crawford met retention standards at the time of his discharge. Crawford filed suit. On the government's motion, the court remanded for a fitness determination and development of the record. On remand, the ABCMR found Crawford was entitled to medical retirement based solely on the evidence available at the time of his separation and granted him complete relief, including the correction of his records and retroactive medical retirement benefits.The Federal Circuit reversed the denial of Crawford’s subsequent motion for attorneys’ fees and expenses under the Equal Access to Justice Act. Crawford was a prevailing party. View "Crawford v. United States" on Justia Law

Pitts, the surviving spouse of an Army veteran, filed for dependency and indemnity compensation from the VA in 2001. The Board of Veterans’ Appeals affirmed. In 2012, Pitts employed attorney Viterna. Their fee agreement was filed with the VA and provided that Viterna was owed 20% of any past-due benefits Pitts recovered, less certain expenses but applied only to claims for which a notice of disagreement was filed after June 20th, 2007; the NOD covering the 2001 claim was filed in 2005. Viterna asserts that this was an “unintentional drafting error.”In 2014, Viterna secured past-due benefits for Pitts, which related back to the 2005 NOD. The agency refused to pay Viterna 20% of those benefits. The Board affirmed. Before the Veterans Court, Viterna argued that Congress only gave the VA the power to assess whether a fee agreement was valid and if its terms were excessive or unreasonable—not whether the agreement covered the claim at issue.The Veterans Court and Federal Circuit disagreed. There was no qualifying agreement between Viterna and Pitts providing for payment of a fee for the claim in question. The court noted that between 1988-2006, attorneys could only charge fees for representing claimants after the Board’s “final decision.” In 2006, Congress amended 38 U.S.C. 5904, effective June 20th, 2007, to allow attorneys to charge for VA representation as soon as a claimant had filed a NOD seeking review of a regional office decision. View "Viterna v. McDonough" on Justia Law