Justia Public Benefits Opinion Summaries

After years of working as a locomotive engineer, and more briefly as a limousine driver, Duncan applied for a disability annuity (Railroad Retirement Act, 45 U.S.C. 231a(a)(1)(v)) in 2010. His application alleged constant back pain stemming from a 2003 workplace injury in which he slipped on ice, hit his head, and injured his back. The Railroad Retirement Board denied his application and denied it again upon reconsideration in 2011. A hearing officer denied Duncan’s application in 2012. In 2013, a three-member board affirmed. The Seventh Circuit affirmed, concluding that substantial evidence supports the Board’s decision that Duncan retains the capacity to perform a reduced range of work. View "Duncan v. United States R.R. Ret. Bd." on Justia Law

Kentucky Spirit Health Care Plan, Inc. brought a declaratory judgment action seeking a ruling that it had a right to terminate its Medicaid managed care contract with the Finance and Administration Cabinet prior to the expiration of the contract without penalty. The trial court entered partial summary judgment in favor of the Cabinet. Both parties appealed. While the appeals were pending, the circuit court stayed Kentucky Spirit’s pre-trial discovery efforts relating to its rights under the Medicaid contract until resolution of the partial summary judgment appeals. The Court of Appeals granted Kentucky Spirit’s petition for a writ of prohibition against the circuit court judge prohibiting the judge from enforcing the order imposing the stay of discovery. The Supreme Court vacated the writ and remanded for entry of an order denying Kentucky Spirit’s petition for a writ of prohibition, holding that the circuit court did not abuse its discretion by temporarily staying discovery, as a stay of discovery was appropriate pending resolution of the threshold issues currently on appeal. View "Commonwealth v. Hon. Wingate" on Justia Law

The Medocks’ company, MAS, transported patients to kidney dialysis for Medicare reimbursement. Reimbursement of non-emergency ambulance transport is allowed only if medically necessary for bedridden patients; both a driver and an EMT must accompany any such passenger. Certification of medical necessity (CMN) must be signed by a doctor. A “run sheet” is reviewed by a Medicare contractor other than the ambulance company, such as AdvanceMed, to reduce fraud. AdvanceMed identified MAS as a high biller in Tennessee for dialysis ambulance transport and audited MAS. MAS’s records were missing some CMNs. Covert surveillance resulted in videotapes of patients walking, riding in the front seat, being double-loaded, being driven by single-staffed ambulances, or being transported by wheelchair. MAS had billed the transports as single-passenger and “stretcher required.” Executing a search warrant at the Medlocks’ home, agents seized CMNs and run tickets; some had been altered or forged. The Sixth Circuit reversed a conviction for aggravated identity theft, 18 U.S.C. 1028A, agreeing that misrepresentations that certain beneficiaries were transported by stretcher did not constitute a “use” of identification, but affirmed health-care fraud convictions, rejecting arguments that the court should have instructed the jury that Medicare, not merely a prudent person, was the relevant decision-maker; that Medicare would have reimbursed MAS without their misrepresentations; and that refusal to sever a defendant was prejudicial. View "United States v. Medlock" on Justia Law

Robles worked collecting food grease from restaurants until his 2010 termination. Robles’s supervisor cited Robles’s attempt to buy shoes at the Red Wing store, where employees can use an annual $150 shoe allowance. Robles asked the clerk to measure his friend’s foot because he “intended to give it to my friend.” Robles reasoned that he had shoes and his friend needed them. The clerk told Robles “that was not possible.” Robles believes there was a misunderstanding of policy but no misconduct. Robles sought unemployment benefits. The Employment Development Department’s record contained no employer information about the incident. The EDD’notice stated that Robles’s claim was denied because he “broke a reasonable employer rule.” Robles appealed, stating his employer did not cite any specific rule, that he was not aware of any such rule, and that he did not obtain an improper benefit or cause his employer any harm. Despite being twice ordered to do by the trial court, EED continued to refuse to award benefits. The court of appeal affirmed the court’s most recent response to Robles’s motion to enforce writ of administrative mandate,ordering EDD “to pay withheld federal extension benefits, costs and interest in the amount of $45,560.39, within 30 days.” View "Robles v. Emp't Dev. Dept." on Justia Law

Petitioners were active and retired members of the Public Employee Retirement System (PERS) who challenged two legislative amendments aimed at reducing the cost of retirement benefits: Senate Bill (SB) 822 (2013), and SB 861 (2013). Petitioners raised numerous challenges to the amendments but primarily argued that the amendments impaired their contractual rights and therefore violated the state Contract Clause, Article I, section 21, of the Oregon Constitution, and the federal Contract Clause, Article I, section 10, clause 1, of the United States Constitution. "Although there is no doubt that the legislature passed SB 822 and SB 861 to address legitimate public policy concerns and with an appropriate sensitivity to the impact that the amendments would have on retirees, those concerns do not establish a defense to the contractual impairment that the amendments effect. The public purpose defense that respondents ask [the Oregon Supreme Court] to recognize imposes a high bar to justify the state’s impairment of a state contract, like PERS, and the record in this case does not meet that standard. We therefore hold that respondents constitutionally may cease the income tax offset payments to nonresidents as set out in SB 822 and that respondents also constitutionally may apply the COLA amendments as set out in SB 822 and SB 861 prospectively to benefits earned on or after the effective dates of those laws, but not retrospectively to benefits earned before those effective dates." View "Moro v. Oregon" on Justia Law

Mr. and Ms. Haynes divorced in 1995. Mr. Haynes died in 2000. Ms. Haynes sought Dependency and Indemnity Compensation (DIC) benefits under 38 U.S.C. 1310, as a “surviving spouse.” Because Ms. Haynes was not married to Mr. Haynes at the time of his death, the VA Regional Office denied the claim. Ms. Haynes later requested that the Regional Office reopen her claim on the presentation of new documentation showing a decision by the Army Board of Correction of Military Records to award Ms. Haynes an annuity as a “former spouse” under the Uniformed Services Former Spouse Protection Act , 10 U.S.C. 1447(10), which permits former spouses to receive annuities. The Regional Office denied the request. The Board of Veterans’ Appeals agreed, while acknowledging Ms. Haynes’ argument that because the basis for her divorce was physical abuse, she should not be required to demonstrate marriage at the time of Mr. Haynes’ death in order to receive DIC benefits. The Veterans Court and Federal Circuit affirmed. Although Mr. Haynes’ abusive actions were documented, the statute requires validly married spouses at the time of the veteran’s death. View "Haynes v. McDonald" on Justia Law

In 2013, Emma Reiger entered the Good Samaritan Society's basic care facility. She executed a general durable power of attorney appointing two women "to be my attorneys-in-fact and co-agents in my name and for my benefit." Rieger signed a "Designation of Authorized Representative" authorizing the Society to "(i) initiate an application for Medicaid benefits on my behalf, (ii) participate in all reviews of my eligibility for Medicaid benefits and (iii) take such action as may be necessary to establish my eligibility for Medicaid." On the same date, Rieger signed a separate document titled, "Assignment of Medicaid Benefits," which assigned to the Society her right to obtain Medicaid benefits for services provided to her by the Society, and an "Authorization for Release of Health Information." These documents were provided to the Department of Human Services. The Department oappealed a judgment reversing the Department's dismissal of Rieger's appeal challenging its denial of her Medicaid application and remanding for a fair hearing on the application. Because the law allowed The Evangelical Good Samaritan Society, doing business as the Good Samaritan Society - Mott ("Society"), to act as Rieger's authorized representative for purposes of appealing the Department's denial of her Medicaid application, the Court affirmed the judgment. View "Evangelical Good Samaritan Society v. N.D. Dep't of Human Services" on Justia Law

Miller suffered: a brain injury in a 1998 car accident and had back surgery in 2004. Although his doctor described his brain injury as stable, but Miller complained of memory and balance problems and pan. Miller claims these injuries caused him to become disabled starting in 2007. In 2008, Miller requested disability insurance benefits as well as supplemental security income. He received a hearing before an administrative law judge, who denied his claim, finding that Miller had the residual functional capacity to perform light work, as defined by 20 C.F.R. 404.1567(b) and 416.967(b). The Appeals Council denied Miller’s request for review. The district court and Eighth Circuit affirmed, upholding the ALJ’s decision to give “little weight” to some of Miller’s medical evidence. View "Miller v. Colvin" on Justia Law

An applicant for federal disability benefits applied for state benefits that were intended to provide basic assistance while the federal application was pending. The Division of Public Assistance denied these interim benefits, relying on a subset of the criteria that the Social Security Administration uses to determine eligibility for federal benefits. The superior court reversed this decision, holding that Alaska law required the Department to apply the same federal substantive criteria and procedural requirements to its determination of eligibility for state interim benefits. The Department petitioned the Alaska Supreme Court for review. After review, the Court concluded that, while state law did not require the Department to track the federal analysis exactly when it assessed eligibility for state interim benefits, the Department’s application of the law erroneously excluded a category of applicants who would be found to be disabled for purposes of federal benefits and who therefore should have been entitled to interim assistance. The Court affirmed the superior court’s decision in part, reversed it in part, and remanded for further proceedings. View "Alaska Dept. of Health & Social Services v. Gross" on Justia Law

Toomer served in the Army, 1971 to 1974. He sought benefits for degenerative disc disease, claiming connection to a 1972 in-service back strain from lifting heavy objects. In 2004, a VA Regional Office denied the claim. In 2009, the Board of Veterans’ Appeals affirmed, relying on a 2007 VA examination. Although Toomer was treated for a back strain in 1972, there was no evidence from subsequent clinical visits that his current pain was connected to that injury: a 1972 x-ray was normal; after January 1973, there were no complaints of back pain during service; and there were potential post-service injuries, considering his occupation as a construction worker. The Decision was mailed on June 2, 2009. On July 27, Toomer informed the VA that he had not received it. On August 4, the VA mailed another copy, noting that the veteran has “120 days from the date this decision was mailed to you (as shown on the first page of this decision) to file a Notice of Appeal,” On October 28, more than 120 days from the decision date, but within 120 days of the August letter, Toomer appealed to the Veterans Court, which dismissed. The Federal Circuit affirmed, stating that even if it disagreed with that court’s finding that dates on the correspondence were not misleading, and did not constitute “extraordinary circumstances,” revisiting this finding was beyond its jurisdiction. View "Toomer v. McDonald" on Justia Law