Justia Public Benefits Opinion Summaries

Plaintiff Diane Stayton suffered serious burns while a resident at Harbor Healthcare and Rehabilitation Center ("Harbor Healthcare"), a skilled nursing center in Lewes. She sued alleging medical negligence against those responsible for her care. In addition to general damages, Stayton sought special damages for the cost of her medical care after she was burned. Absent Medicare coverage, the burn hospital and other providers who treated her for her injuries would have billed Stayton $3,683,797.11. Because Stayton qualified for Medicare, the Centers for Medicare and Medicaid Services ("CMS") paid Stayton's healthcare providers $262,550.17 in full satisfaction of the expense of Stayton's hospital stay and other care. Medicare regulations required the write-off of $3,421,246.94, and Stayton's healthcare providers could not "balance bill" her for the amount written off. Defendants moved for judgment on the pleadings seeking judgment as a matter of law that Stayton's medical expense damages were limited to the amount actually paid by CMS, rather than the amount Stayton might have been billed for her care. Stayton opposed the motion, relying on the collateral source rule. The Superior Court granted defendants' motion, and limited Stayton's medical expense claim to the amount paid by CMS. The court decided that the collateral source rule did not apply to amounts required by federal law to be written off by healthcare providers. On appeal to the Supreme Court, Stayton argued that the Superior Court should have applied the collateral source rule to the Medicare write-offs. The Supreme Court concluded the collateral source rule did not apply to amounts required to be written off by Medicare. "Where a healthcare provider has treated a plaintiff covered by Medicare, the amount paid for medical services is the amount recoverable by the plaintiff as medical expense damages." View "Stayton v. Delaware Health Corporation, et al." on Justia Law

Wright, a 50-year-old man, suffers from back and knee pain. Wright suffered a shoulder injury and complained of low back pain after being involved in a severe car accident in 2000. Wright suffered from another severe automobile accident in 1987. Wright has not reported earning any income in the years 2006–11. When he has earned income, it was seldom over $10,000 for the year. In his applications for disability insurance benefits and supplemental security income benefits Wright testified that his average day consists principally of laying on his back trying to get comfortable and spending around 30 minutes cooking basic meals for himself. His physician noted that Wright had "type 2 diabetes, vitamin D deficiency, tobacco abuse, obesity, [and] bilateral knee arthritis." The district court upheld the Social Security Commissioner's denial of benefits. The Eighth Circuit affirmed, rejecting arguments that the administrative law judge erred by discrediting the opinions of two examining physicians, discrediting Wright's testimony, not considering Wright's mental condition as a severe impairment, and not considering the record as a whole. View "Wright v. Colvin" on Justia Law

From 1977-2009, Kennard worked as a blaster on strip mines, sometimes directly for a coal company and sometimes for contractors. In 2009, Kennard filed for black lung benefits, 30 U.S.C. 901. Kennard has a significant history of smoking, which gave him cancer in his right lung. The lung was removed. He experiences shortness of breath, coughing, and sleep apnea. His treating physician diagnosed Chronic Obstructive Pulmonary Disorder (COPD). His breathing is extremely limited. After the claims examiner initially recommended that his claim, an ALJ concluded that Kennard was entitled to a rebuttable presumption that he had pneumoconiosis and that the disease caused his total disability because he had worked in conditions that were substantially similar to those in an underground mine. The ALJ held that the employer had successfully rebutted the presumption that Kennard had clinical pneumoconiosis, but had failed to rebut the presumption of legal pneumoconiosis or the presumption that Kennardʼs disability was caused by his employment in a coal mine. The employer appealed, arguing that the 15-year presumption should not apply, and, if it did apply, the company had successfully rebutted it. The Sixth Circuit denied a petition for review, finding the award supported by substantial evidence. View "Brandywine Explosives & Supply v. Office of Workers' Comp. Programs" on Justia Law

Johnson has severe impairments, including chronic asthma, morbid obesity, borderline intellectual functioning, depression, anxiety, and post-traumatic stress disorder. She has never worked, has a ninth grade education, and does not have a drivers’ license. At the request of the Social Security Administration, a Ph.D conducted cognitive tests and reported Johnson was not “functioning within or near the mentally retarded range” and could “sustain concentration and persistence in completing tasks,” and Johnson’s “[m]ental impairments d[id] not significantly interfere with her day to day adaptive functioning.” To determine Johnson’s eligibility for Vocational Rehabilitation Services, another Ph.D., conducted a psychological evaluation o and concluded Johnson had a full scale IQ of 67, found that “a Mild Mental Retardation diagnosis [wa]s warranted,” and suggested Johnson “be encouraged to find employment … that is mechanical in nature, as she showed strength on tasks that require ability to analyze and synthesize abstract stimuli.”, Johnson occasionally attended counseling. Johnson’s counselors estimated she was of “low average” intelligence and education. Johnson was denied supplemental security income benefits, 42 U.S.C. 1381; an ALJ denied benefits, finding that Johnson had “residual functional - capacity to perform light work” with some restrictions. The district court and Eighth Circuit affirmed the denial as supported by substantial evidence. View "Johnson v. Colvin" on Justia Law

The Department appealed the district court’s order expanding a preliminary injunction forbidding the Department from decreasing the individual budgets of a class of participants in and applicants to Idaho’s Developmental Disabilities Waiver program (DD Waiver program) without adequate notice. The court rejected the Department's ripeness argument and concluded that the dispute is ripe for adjudication where plaintiffs alleged that they have already felt the effects of the Department's actions in a concrete way; the district court reasonably found that participants’ services are capped by their individual budgets under Idaho law; the district court also did not abuse its discretion in holding that plaintiffs were likely to show that the 2011 Budget Notices did not comply with the notice requirements of the Medicaid regulations; the district court did not abuse its discretion in holding that plaintiffs were likely to prevail on their claim that they were denied adequate notice under the Due Process Clause; the Department waived its argument that plaintiffs failed to show that the proposed class was likely to suffer irreparable harm; the court joined a number of its sister circuits in rejecting Eleventh Amendment challenges directed at orders reinstating social assistance benefits prospectively; and the court declined to exercise jurisdiction to review the district court’s order denying the motion to approve the 2013 Proposed Notice. Accordingly, the court affirmed the district court's judgment. View "K.W. v. Armstrong" on Justia Law

Plaintiffs, parents of a disabled student, filed suit under the Individuals with Disabilities Education Act (“IDEA”), 20 U.S.C. 1400 et seq., seeking reimbursement by the DOE for the costs of attending a private program. The hearing officer denied the request for reimbursement, concluding that it was untimely under Haw. Rev. Stat. 302A-443(a). The district court held, however, that the student's placement by the parents was “bilateral,” not “unilateral,” so that the parents’ request was not untimely, and concluded that the parents were entitled to reimbursement. The court agreed and concluded that the student's family is entitled to reimbursement for the 2010–11 school year because the DOE tacitly consented to his enrollment at the private school program by failing to provide an alternative. The court also affirmed the district court's fee award. View "Sam K. v. Hawaii Dept. of Educ." on Justia Law

Engstrand, a former dairy farmer, applied for Disability Insurance Benefits and Supplemental Security Insurance because of pain caused by diabetic neuropathy and osteoarthritis, in July 2010, when he was 47. He alleged an onset of disability in July 2007, more than a year before his date last insured in September 2008. The ALJ concluded that his account of his limitations was not credible, that the opinion of his treating physician was not entitled to deference, and that Engstrand was not disabled. The Seventh Circuit reversed and remanded, stating that the ALJ wrongly evaluated the significance of his daily activities and did not explain his rejection of the doctor's testimony. View "Engstrand v. Colvin" on Justia Law

Plaintiff appealed the denial of her Social Security Disability Insurance benefits. The court concluded that there was substantial evidence in the record to support the ALJ’s determination that plaintiff was not eligible for disability benefits. In this case, the court concluded that the ALJ could have reasonably accorded little weight to the medical expert's opinion that plaintiff's condition equals the listing of fibromyalgia; the ALJ discounted the vocational expert's testimony for good reasons; the ALJ did not improperly weigh the testimony of the medical expert and the vocational expert about plaintiff's fibromyalgia; and substantial evidence did not support including migraines in the examination of the vocational expert. Accordingly, the court affirmed the judgment. View "Britton v. Colvin" on Justia Law

Papesh had a GED and worked as a bakery helper. She reported long-term, low-back pain, which radiated to her hips and legs. She said the pain “is worse with working” because the bakery has concrete floors. She began treatment in 2009 (the year she turned 50) with Dr. Cash, who observed “tenderness throughout the lumbar spine to palpation, as well as pain with some spasm in the low back.” Papesh was also caring for her mother, who had severe dementia and suffered “worsened depression and anxiety” after her mother’s death. Papesh applied for disability and for supplemental security income in early 2010, alleging she was disabled due to degenerative disc disease, fibromyalgia, depression, anxiety, and other impairments. The Eighth Circuit reversed and remanded the denial of benefits because the record contained two substantially similar residual function capacity opinions from a treating physician and neutral medical expert plus a consistent opinion from a second treating physician—all consistent with Papesh’s descriptions of her daily functioning. The ALJ’s determination that Papesh can perform light work was outside the available zone of choice. The substantial evidence on the record as a whole supports a finding that Papesh is capable of sedentary work only. View "Papesh v. Colvin" on Justia Law

K.P. , born in 2004, exhibited no apparent signs of disability for several months, but was then referred to an infant development service. Extensive testing revealed that K.P. suffered significant delays in motor skills. His cognitive skills were within normal limits. K.P. experienced rashes, later identified as a symptom of erythema multiforme, and ear infections. At his one-year well baby visit, K.P. received the measles-mumps-rubella, pneumococcal, and varicella vaccines. He then had a fever and did not nap or eat well. After visits to multiple medical specialists, K.P. was diagnosed with an unspecified mitochondrial disorder, likely present at birth. He now lives in a state of severe neurological disability. He has “no purposeful movements” and breathes with a ventilator. Seeking benefits under the National Childhood Vaccine Injury Act, 42 U.S.C. 300aa, his parents alleged that K.P. sustained a permanent brain injury as a result of the vaccines. Their expert testified that K.P.’s underlying mitochondrial disorder prevented him from coping with the oxidative stress from the vaccines. On remand, the special master accepted that the expert had presented a plausible medical theory, but found that K.P.’s condition did not deteriorate as predicted by that theory. The Claims Court disagreed and awarded compensation. The Federal Circuit affirmed. The parents’ burden was to show that K.P.’s mitochondrial disorder was significantly aggravated by the vaccines, not to rule out every other potential cause. View "Paluck v. Sec'y of Health & Human Servs." on Justia Law