Justia Public Benefits Opinion Summaries

Groups of hospitals in the Cincinnati area and in rural Iowa, challenged the Secretary of Health and Human Services’ calculation of how much to pay those hospitals for inpatient services under Medicare Part A. The hospitals objected to the agency’s decision to include in the calculation the hours associated with a short-term disability program paid from a hospital’s general funds through its payroll system and a program offering a full-time salary for part-time weekend work. The district court entered summary judgment for the Secretary. The Sixth Circuit affirmed, finding the agency’s interpretation was not arbitrary or capricious and referring to “the most completely impenetrable texts within human experience,” statutes and regulations that “one approaches ... at the level of specificity herein demanded with dread.” View "Atrium Medical Ctr. v. U.S. Dep't of Health & Human Servs." on Justia Law

Young served as an Army combat engineer from 1965-1967, including duty in Vietnam. In 1984, Young applied for benefits with the VA Regional Office, describing “‘anxiety,’ ‘bad nerves,’ and ‘unable to adjust to society.’” The RO interpreted the claim as seeking an award of service connection due to PTSD, but denied it after Young failed to report for a VA medical examination. In 1989, a VA psychiatrist submitted a letter, stating that Young had been under his care since 1989 and was suffering from PTSD. The RO denied Young’s claim in 1989, 1990, and 1991 because the record did not establish exposure to an in-service stressor. The Board’s 1991 denial became final because Young did not appeal. Young sought to have his claim reopened. The RO denied the request in 1992, 1993, 1995, and 1997. In 1998, the RO received service department records documenting Young’s exposure to an in-service stressor for PTSD that had not been previously associated with his file and reopened Young’s claim. The agency granted him service connection with a 100% disability rating, effective to August 1992. Young sought an effective date of September 1984. The Veterans Court concluded that the effective date should be March, 1989. The Federal Circuit affirmed. View "Young v. McDonald" on Justia Law

The Public School Employees Retirement System of Georgia (PSERS) filed suit against Appellant Leroy Ayers to recover three months of benefit payments to his mother that PSERS mistakenly made after Mrs. Ayers had died. A jury ultimately returned a $5,000 verdict in favor of Appellant. PSERS appealed, and the Court of Appeals reversed, holding that the trial court erred in denying PSERS' motion for a directed verdict. The Supreme Court found that the statutes that established Mrs. Ayers' contract for retirement benefits did not authorize the payment of monthly retirement benefits beyond her life and her designated joint annuitant who predeceased her. Accordingly, no benefits were payable to Appellant after his mother's death. The Court of Appeals correctly concluded that the trial court erred in denying PSERS' motion for a directed verdict, but did so based on analysis of retirement forms Mrs. Ayers filled out and correspondence she exchanged with PSERS instead of analysis of the statutory scheme. View "Ayers v. Public School Employees Retirement System of Georgia" on Justia Law

This appeal related to petitioner Linda Hendron's third application for disability benefits. She filed the first in 1999 and was denied on the merits. She applied again in 2001, and was denied on res judicata grounds. This latest application was filed in 2009, claiming a disability onset date of November 1, 1995. After the Social Security Administration denied the claim on res judicata grounds, requested a hearing before an administrative law judge (ALJ). The ALJ heard testimony from petitioner, and considered 19 medical exhibits that had not been submitted in petitioner's previous applications. The ALJ issued a written decision finding that petitioner was not disabled before the expiration of her insured status. The Appeals Council denied review, and petitioner took her appeal to the district court, which concluded the ALJ failed to develop a sufficient record on which to base a disability decision. The Commissioner appealed the district court's decision. Finding ample evidence in the record that the ALJ developed the record on which he denied petitioner's claim, the Tenth Circuit reversed and remanded the case for entry of judgment in favor of the Commissioner. View "Hendron v. Colvin" on Justia Law

Plaintiff, a 25-year-old woman of 25, was denied Supplemental Security Income benefits. She claims to be mentally retarded and to suffer from knee and hip pain in one leg, caused by a defect in the hip joint resulting from a childhood disease. A psychologist administered an IQ test when she was 18. Her IQ was 68. The psychologist thought her more intelligent than her IQ score of 68 implied, and concluded that she could function in “typical work environments.” Three years later two other psychologists evaluated the plaintiff and concluded that despite her serious mental deficiencies she would be able to work, although one referred to work in “sheltered workshops.” She does not use a computer and cannot obtain a driver’s license because she can’t read the test that one must pass to obtain a learner’s permit. Her work history consists of three hand-packager jobs. The Seventh Circuit reversed, with instructions to remand the case to the Social Security Administration, noting multiple errors in the agency’s assessment of the plaintiff’s condition and of employment possibilities. View "Browning v. Colvin" on Justia Law

Plaintiff appealed the denial of his application for Social Security disability and supplemental security income benefits. The court concluded that the ALJ's failure to explicitly refer to SSR 96-9p was an arguable deficiency in opinion writing that had no practical effect on the decision and therefore was not a sufficient reason to set aside the ALJ's decision; the ALJ posed a hypothetical that accurately reflected his residual functioning capacity (RFC) finding, questioned the vocational expert (VE) about any apparent inconsistencies with the relevant DOT job descriptions, explained his decision to credit the VE's testimony, and, therefore, the ALJ complied with SSR 00-4p; and substantial evidence supported the ALJ's finding that a sufficient number of jobs existed in the national and local economies that a person with plaintiff's RFC could perform, based on the VE's testimony. Accordingly, the court affirmed the judgment of the district court. View "Welsh v. Colvin" on Justia Law

Relator filed a qui tam action against Planned Parenthood, alleging that it violated the False Claims Act (FCA), 31 U.S.C. 3729-3733, and the Iowa False Claims Act (IFCA), Iowa Code Ann. 685.1-.7, by submitting false or fraudulent claims for Medicaid reimbursement. The district court dismissed the complaint under Rule 9(b). The court concluded that relator has pled sufficiently particularized facts to support her allegations that Planned Parenthood violated the FCA by filing claims for (1) unnecessary quantities of birth control pills, (2) birth control pills dispensed without examinations or without or prior to a physician's order, (3) abortion-related services, and (4) the full amount of services that had already been paid, in whole or in part. The court affirmed the dismissal of relator's claim that Planned Parenthood violated the FCA by instructing patients who experienced abortion-related complications to give false information to medical professionals at other hospitals, causing those medical professionals to unknowingly file claims for services performed in connection with abortions. Because relator failed to provide a factual basis for her knowledge of these alleged false claims, the court was unable to infer that false claims were submitted. Further, the court affirmed the dismissal of relator's upcoding claim. The court's holding with respect to the Rule 9(b) issue, however, should not be read as in any way expressing a view on Planned Parenthood's Rule 12(b)(6) arguments. View "Thayer v. Planned Parenthood" on Justia Law

Commander Cronin began active duty with the Navy in 1977. In 1978, she had a calcaneal spur in her heel. She had unsuccessful surgeries in 1979, 1993, 1994, and 1995. She was hospitalized for bipolar disorder in 1995. Beginning in 1998, medical professionals disagreed about whether she suffered from bipolar disorder, anxiety disorder, post-traumatic stress disorder (PTSD), or some combination. She was diagnosed with chronic pain. Cronin alleged that during her service, she was subjected to physical and sexual assaults, stalking, and “extreme sexual harassment.” A social worker described these incidents as supporting a PTSD diagnosis. She had periods of limited duty. The Navy had selected Cronin for promotion, but in a 1994 letter, a Navy physician found her not fit for full duty. Her promotion was delayed. The Physical Evaluation Board assigned her a disability rating of 60% and placed her on the Temporary Disability Retired List. The Board for Correction of Naval Records upheld the promotion delay. In 1996, Cronin was formally placed on the TDRL and promoted. She was reevaluated every 18 months to continue receiving benefits. In 2000, the Board declined to find a compensable claim of PTSD or chronic pain disorder, concluded that her conditions had stabilized, and placed her on the Permanent Disability Retired List. Cronin sued in 2006. On remand, the trial court concluded that the 2003 Relief Act tolls the limitations period during time on the TDRL, so that the claims were timely, but affirmed the refusal to increase her disability rating. The Federal Circuit held that most of her claims were time barred. As to claims alleging PTSD, there was no timeliness issue, but they were properly rejected on the merits.View "Cronin v. United States" on Justia Law

Scrogham, then age 53, applied for disability benefits under the Social Security Act, submitting medical conditions including degenerative discs, spinal stenosis, sleep apnea, hypertension, arthritis, atrial fibrillation and restless leg syndrome. An ALJ denied the application and the Appeals Council denied his request for review. The district court affirmed, holding that the ALJ did not err in giving less weight to the opinion of a treating physician than to the opinions of nontreating physicians, that the ALJ permissibly found Scrogham not to be credible and that the ALJ’s decision otherwise was supported by substantial evidence. The Seventh Circuit reversed and remanded. The ALJ impermissibly ignored a line of evidence demonstrating the progressive nature of Scrogham’s degenerative disc disease and arthritis and inappropriately undervalued the opinions of Scrogham’s treating physicians, whose longitudinal view of Scrogham’s ailments should have factored prominently into the ALJ’s assessment of his disability status. Even considering only “the snapshots of evidence that the ALJ considered,” that limited evidence does not build the required logical bridge to her conclusions. The ALJ apparently misunderstood or at least considered only partially some of the evidence about Scrogham’s daily activities, rehabilitation efforts and physicians’ evaluations. View "Scrogham v. Colvin" on Justia Law

Plaintiffs filed suit on behalf of themselves and a class, alleging a miscalculation of their Medicare Part B premium calculations. Plaintiffs conceded that they failed to exhaust administrative remedies. Because this case is not one of the exceptional cases where waiver of exhaustion is appropriate, the court affirmed the district court's determination that it lacked subject matter jurisdiction. The court affirmed the judgment of the district court on this issue and affirmed the district court's denial of mandamus relief where plaintiffs may pursue another avenue of relief, the administrative process. View "Degnan, et al. v. Sebelius, et al." on Justia Law