Justia Public Benefits Opinion Summaries

Appellant Jeffrey Allen, on behalf of his daughter, appealed the Administrative Law Court's (ALC) order affirming the Appeals Committee of the South Carolina Budget and Control Board Employee Insurance Program's (EIP Appeals Committee) decision to deny Appellant's insurance claim for his daughter's diabetes educational training session. Blue Cross's Appeals Review Committee upheld the denial of benefits on the basis that diabetes educational training was excluded under the State Health Plan, and that section 38-71-46 of the South Carolina Code, did not apply to the State Health Plan. Upon review, the Supreme Court reversed the ALC's decision that section 38-71­46 of the South Carolina Code did not apply to this matter. The EIP was mandated to promptly determine and pay the benefits that were due for Appellant's daughter under the State Health Plan. View "Allen v. SC Public Employee Benefit Authority" on Justia Law

The Secretary of the United States Department of Health and Human Services imposed a civil money penalty on Plott Nursing Home in California for Plott’s violations of the Medicare Act’s standards of care for nursing home patients. The Department’s Appeals Board largely affirmed. Plott petitioned for review. The Ninth Circuit affirmed in part and reversed in part, holding (1) sufficient evidence supported the Secretary’s determination that Plott violated the quality of care for bed sores; (2) the Secretary’s finding that Plott violated the quality of care for urinary tract infections was not supported by substantial evidence on the record; and (3) Plott was entitled to administrative review of all cited deficiencies. Remanded with directions to review or dismiss the violations that were not reviewed by the agency. View "Plott Nursing Home v. Burwell" on Justia Law

The named plaintiff in this putative class action and her daughter (together, Plaintiffs) were injured in motor vehicle accidents. Defendant, which administered the Medicaid program for the state and was the designated assignee of the Department of Social Services under Conn. Gen. Stat. 17b-265, paid for the medical care that Plaintiffs received as a result of their injuries. After Plaintiffs brought civil actions against the tortfeasors, Defendant, acting through its agent, sought to recover from Plaintiffs the amounts they recovered from the tortfeasors as reimbursement for the payments made by Defendant for Plaintiffs’ medical care. Plaintiffs brought this action seeking, inter alia, a declaratory judgment that section 17b-265 did not authorize Defendant to seek reimbursement from them but required Defendant to seek recovery directly from the liable third parties. The trial court granted summary judgment for Defendant. The Appellate Court affirmed. The Supreme Court affirmed, holding that the Appellate Court did not err in concluding that section 17b-265 permitted Defendant to seek reimbursement from Plaintiffs and other similarly situated persons for amounts that they recover from liable third parities for medical costs. View "Rathbun v. Health Net of the Northeast, Inc." on Justia Law

Draper, age 18, suffered traumatic brain injury in a 2006 car accident. Draper executed a durable power of attorney, authorizing her parents to collect money; compromise claims; and “fund, transfer assets to, and to instruct and advise the trustee of any trust wherein [Draper is] or may be the trustor, or beneficiary.” Draper began receiving Supplemental Security Income payments. In February 2008, father signed a personal-injury settlement. Draper received $429,259.41. Her parents signed documents creating a Special Needs Trust, intended to qualify under 42 U.S.C. 1396p(d)(4)(A), to provide for Draper’s needs without “displac[ing] or supplant[ing] public assistance or other sources of support that may otherwise be available” and transferred $429,259.41. In September 2008, Draper received notice that she had been overpaid $3,000 in SSI benefits because her trust exceeded the SSI-eligibility limit of $2,000, and that her SSI payments would cease. An ALJ found that for the trust to be exempt from consideration as a personal asset, Draper’s parents had to act as third-party creators when establishing it, but instead acted as agents under the power of attorney. Draper’s parents obtained a state court order modifying the trust, which retroactively listed the state court, rather than Draper’s parents, as the settlor. The Appeals Council denied review, finding that the order did not provide a basis for altering the ALJ’s decision. The district court and Eighth Circuit affirmed. View "Draper v. Colvin" on Justia Law

Debtor, a New York City tenant, filed for Chapter 7 bankruptcy and listed the value of her apartment lease on Schedule B as personal property exempt from the bankruptcy estate as a "local public assistance benefit." At issue was whether the value inherent in debtor's rent-stabilized lease as a consequence of the protections afforded by New York's Rent Stabilization Code, N.Y. Comp. Code R. & Regs. tit. 9, 2520.1, made the lease, or some portion of its value, exempt from debtor's bankruptcy estate as a "local public assistance benefit" within the meaning of New York Debtor and Creditor Law 282(2). The court certified this unsettled issue to the New York Court of Appeals, which held that a rent‐stabilized lease qualified as a local public assistance benefit. Rejecting the Trustee’s argument that “benefits” should be limited to cash payments, the court noted that the rent‐stabilization program had “all of the characteristics of a local 10 public assistance benefit” under the statute and that an exemption was consistent with the purpose of protecting a debtor’s essential needs, including housing. The Second Circuit then reversed and remanded to allow Debtor to claim the exemption from her bankruptcy estate. View "Santiago-Monteverde v. Pereira" on Justia Law

The False Claims Act (FCA) imposes civil liability for fraudulent claims for payment to the United States, 31 U.S.C. 3729(a)(1), and authorizes qui tam suits, in which private parties bring civil actions in the government’s name. A relator must first disclose his claims to the government, which then decides whether to take over the action. Whipple alleged that Erlanger knowingly submitted fraudulent claims to federally funded healthcare programs and that he discovered the fraud while working at Erlanger in 2006, by analyzing past billings, reviewing patient records, and observing operations. He claimed to have direct knowledge of fraudulent practices from supervising patient admissions, planning discharges, and reviewing submission of claims. Unbeknownst to Whipple, the government conducted an audit and investigation; the matter was resolved without a hearing by Erlanger’s 2009 payment of a $477,140.42 refund to the government. Whipple disclosed his qui tam claims to the government in 2010 and filed suit in 2011, and the government declined to intervene. The district court dismissed, finding the claims jurisdictionally barred under the FCA’s public-disclosure bar. The Sixth Circuit reversed. Holding that the government audit was not a “public disclosure” sufficient to trigger the jurisdictional bar, the court did not decide whether the original-source exception to that bar would apply. View "United States v. Chattanooga-Hamilton Cnty. Hosp." on Justia Law

Johnson began working for U.S. Steel in 2004. On May 12 2011, he left work, complaining of a headache, and went to a clinic where a physician’s assistant indicated that he had high blood pressure. The next day he provided a note that was deemed insufficient by his employer. His regular physician later indicated that Johnson's blood pressure was normal. Emails, memoranda, and letters indicate that Johnson was suspended on May 16 and then terminated for altering, falsifying, or forging the work excuse. U.S. Steel never provided him with notice of his FMLA rights and obligations. Nor was such notice included in the employee handbook. Johnson filed suit under the Family and Medical Leave Act (FMLA), 29 U.S.C. 2601-2654, alleging that U.S. Steel retaliated against him for taking protected FMLA leave, failed to reinstate him after a period of protected leave, and otherwise unlawfully interfered with his FMLA rights. The district court entered summary judgment for the employer. The Eighth Circuit affirmed. Johnson did not demonstrate how any alleged technical violations could have prejudiced him if his condition was not a serious health condition and did not qualify him for FMLA leave in the first place. View "Johnson v. Wheeling Mach. Prods." on Justia Law

Plaintiff appealed the district court's affirmance of the Commissioner's denial of Supplemental Security Income (SSI) disability benefits, arguing that the ALJ failed to reconcile an apparent conflict between his residual functional capacity (RFC) and the reasoning requirements of the jobs identified by the ALJ. The ALJ found that plaintiff retains the RFC to perform simple, routine, or repetitive tasks and that plaintiff was not disabled because he is still able to perform two occupations: cashier and surveillance system monitor. These occupations require the ability to perform Level 3 Reasoning on the Department of Labor's General Education Development scale. The court agreed with plaintiff's argument and held that there is an apparent conflict between plaintiff's limitation to simple, routine, or repetitive tasks and the demands of Level 3 Reasoning. The court reversed and remanded for further proceedings because the ALJ failed to reconcile this apparent conflict. View "Zavalin v. Colvin" on Justia Law

Mrs. Dixon was the spouse of a veteran. A 1996 an Order of Support issued by the Juvenile and Domestic Relations District Court of Virginia ordered Mr. Dixon to pay Mrs. Dixon child support of $443.00 per month and spousal support of $1000.00 per month. Mrs. Dixon states that the Order required the Department of Veterans Affairs to garnish these sums from Mr. Dixon’s disability payments. Mr. Dixon did not make these payments. On Mr. Dixon’s death in 2004, Mrs. Dixon filed a claim with the VA Regional Office requesting the payments that she claims should have been paid to her from Mr. Dixon’s VA disability benefits, 1996-2004. The Veterans Court rejected the claim, finding that the VA was never served with legal process instructing garnishment, as required by 42 U.S.C. 659(i)(5); that Mrs. Dixon incorrectly asserted that the VA previously made partial payments pursuant to the Order; and that the $500 monthly payments she received were, instead made pursuant to 38 C.F.R. 3.452 (apportionment of veteran’s benefits if the veteran is not residing with his spouse or children). The Federal Circuit affirmed. View "Dixon v. McDonald" on Justia Law

In 2010, while Kerner was an Evidence Custodian, GS-05, with the Department’s Fish and Wildlife Service, he applied for two vacancies: Wildlife Inspector, GS-09/11, and Wildlife Inspector, GS-11/11. Both positions were merit-promotion vacancies. Each required federal employee applicants to meet a time-in-grade requirement. A federal civil service applicant must have completed at least 52 weeks of experience equivalent to GS-07 to be qualified for the GS- 09 position, and at least 52 weeks of experience equivalent to GS-09 to be qualified for the GS-11 position. The vacancies also required one year of specialized experience in the federal civil service equivalent to GS-07 or GS-09, respectively. Kerner had no federal civil service experience at the GS-07 or GS-09 level and, therefore, did not meet the time-in-grade requirements. The Department determined that he did not qualify for either vacancy. Kerner then filed a Veterans Employment Opportunity Act claim with the Department of Labor, alleging that the Department violated his VEOA rights. The Department of Labor and Merit Systems Protection Board rejected the claim. The Federal Circuit affirmed. The provisions cited by Kerner only apply to preference-eligible veterans not already employed in federal civil service, not to current federal employees seeking merit promotions. View "Kerner v. Dep't of the Interior" on Justia Law