Justia Public Benefits Opinion Summaries

In 2008, Pepper, then 54 years old, applied for Supplemental Security Disability Insurance Benefits, alleging that she became unable to work in November 1998 as a result of numerous physical and mental impairments. The alleged onset date was later amended to October 2002, when Pepper last worked. Extensive medical records show that Pepper sought treatment for numerous health concerns over the years. At various times, Pepper has been assessed as having ongoing neck pain and limited range of motion in her neck, degenerative disc disease in her spine, left knee problems, migraine headaches, problems with her vision, diabetes, asthma, mitral valve prolapse, sciatica, dyslipidemia, hyperglycemia, hypertension, allergic rhinitis, obesity, plantar fasciitis in her left heel, caregiver stress, and depression. An ALJ denied the claim and the district court affirmed. The Seventh Circuit affirmed, rejecting arguments that the ALJ erred when addressing Pepper’s residual function capacity and that the ALJ’s credibility determination was inadequately supported and patently wrong. Substantial evidence supported denial of benefits. View "Pepper v. Astrue" on Justia Law

Theresa was married to Myron when he retired from the federal government in 1989. Myron elected to receive a reduced annuity and named Theresa to receive a survivor annuity. In 1998, they divorced. Myron married Roksoliana. Myron received annual notices from the Office of Personnel Management explaining that if he wanted to provide survivor benefits to a spouse that he married after retirement, he had to send a signed request within two years after the date of marriage. In 2002 Myron sent a letter requesting survivor annuity benefits for Roksoliana. OPM denied Myron’s request as not submitted within two years of his marriage and instructed Myron to send his divorce decree to change or eliminate the survivor election previously made. In 2006 Myron sent the divorce decree and the certificate documenting his marriage to Roksoliana. OPM sent notification that his election to transfer full survivor benefits to his new spouse was effective immediately. Myron died in 2009. OPM granted Roksoliana benefits and denied Theresa’s application. An ALJ reversed; the Merit Systems Protection Board affirmed. The Federal Circuit reversed, finding OPM’s annual notice insufficient to inform Myron of his rights and obligations and that the Board’s award to Theresa was not supported by substantial evidence. View "Dachniwskyj v.Office of Pers. Mgmt." on Justia Law

MedQuest is a diagnostic testing company that operates more than 90 testing facilities in 13 states. In 2006 a former MedQuest employee, brought a qui tam suit against MedQuest alleging violations of the False Claims Act. The United States intervened and obtained summary judgment ($11,110,662.71) that MedQuest used supervising physicians who had not been approved by the Medicare program and the local Medicare carrier to supervise the range of tests offered at the Nashville-area sites, and after acquiring one facility, MedQuest failed to properly re-register the facility to reflect the change in ownership and enroll the facility in the Medicare program, instead using the former owner’s payee ID number. The Sixth Circuit reversed, stating that the Medicare regulatory scheme (42 U.S.C. 1395x) does not support FCA liability for failure to comply with the supervising-physician regulations. MedQuest’s failure to satisfy enrollment regulations and its use of a billing number belonging to a physician’s practice it controlled do not trigger the hefty fines and penalties created by the FCA. View "United States v. MedQuest Assocs, Inc." on Justia Law

In 2004 the U.S. Department of Health and Human Services promulgated 42 C.F.R. § 412.106(b), concerning the amount that certain hospitals are entitled to receive as enhancements to their regular reimbursement payments from the Medicare program. In connection with the Medicare program, Congress created a statutory formula to identify hospitals that serve a disproportionate number of low-income patients and to calculate the increased payments due such hospitals. Metropolitan Hospital challenged the way that the Secretary of HHS interprets this statutory formula to exclude certain patients who are simultaneously eligible for benefits under both Medicare and Medicaid, claiming that exclusion of dual-eligible patients cost it more than $2.1 million in 2005. The district court ruled that the challenged HHS regulation was invalid as violating the statute that it purported to implement. The Sixth Circuit reversed, upholding HHS’s interpretation of 42 U.S.C. 1395. View "Metro. Hosp. v. U.S. Dept of Health & Human Servs." on Justia Law

Rohrer Towers is a housing facility for low-income elderly residents in Haddon Township, Camden County, New Jersey. Haddon leased Rohrer Towers to Housing Authority of the Township of Haddon, which entered into a housing assistance payments contract (HAP) with the U.S. Department of Housing and Urban Development (HUD) under the Housing Act of 1937, 88 Stat. 633, 662–66. Haddon sued in 2007 alleging that HUD breached the HAP Contract from 2001-2006 by requiring rent “comparability studies” to be submitted along with requests for annual rent adjustments and adopting a one-percent reduction of the annual adjustment factors for units occupied by the same tenants from the previous year. The Claims Court agreed and ordered rent adjustments for all years other than 2002. The government claimed that the complaint should have been dismissed on statute of limitations grounds and appealed the decision that regulatory imposition of a mandatory one-percent rent reduction for non-turnover units was arbitrary, and beyond HUD’s authority. The Federal Circuit reversed the holding that the prevention doctrine applied to the circumstances surrounding Haddon’s 2001 and 2003 rent adjustment, but affirmed the holdings with respect to the contract years 2002 and 2004-2006. View "Haddon Housing Assocs. v. United States" on Justia Law

The Medicaid statute’s anti-lien provision, 42 U. S. C. 1396p(a)(1), pre-empts state efforts to take any portion of a tort judgment or settlement not “designated as payments for medical care.” A North Carolina statute requires that up to one-third of damages recovered by a beneficiary for a tortious injury be paid to the state to reimburse it for payments made for medical treatment on account of the injury. E. M. A. suffered serious birth injuries that require her to receive 12 to 18 hours of skilled nursing care per day and that will prevent her from working or living independently. North Carolina’s Medicaid program pays part of the cost of her ongoing care. E. M. A. and her parents filed a medical malpractice suit against the physician who delivered her and the hospital where she was born and settled for $2.8 million, due to insurance policy limits. The settlement did not allocate money among medical and nonmedical claims. The state court placed one-third of the recovery into escrow pending a judicial determination of the amount owed by E. M. A. to the state. While that litigation was pending, the North Carolina Supreme Court held in another case that the irrebuttable statutory one-third presumption was a reasonable method for determining the amount due the state for medical expenses. The federal district court, in E.M.A.’s case, agreed. The Fourth Circuit vacated. The Supreme Court affirmed. The federal anti-lien provision pre-empts North Carolina’s irrebuttable statutory presumption that one-third of a tort recovery is attributable to medical expenses. North Carolina’s irrebuttable, one-size-fits-all statutory presumption is incompatible with the Medicaid Act’s clear mandate View "Wos v. E. M. A." on Justia Law

In 1979, Plaintiffs sued under 42 U.S.C. 1983, on behalf of present and future recipients, alleging that Tennessee’s Medicaid program violated federal requirements, 42 U.S.C. 1396, and the Due Process Clause. The decades that followed involved intervenors, consent orders, revisions, and creation of a subclass. In 1994, Tennessee converted to a managed care program, TennCare. In 1995, five class members filed motions alleging that TennCare was being administered inconsistent with a 1992 decree and federal law. In 2009, the district court awarded plaintiffs more than$2.57 million for fees and expenses leading up to a 2005 Revised Consent Decree. Plaintiffs had originally requested a lodestar amount of $3,313,458.00, but the court reduced the award by 20 percent on account of plaintiffs’ “limited” success relative to the breadth of defendants’ requests and the scope of the litigation. The court noted that there was “no dispute that Plaintiffs in this case are the prevailing party, and thus entitled to attorneys’ fees under 42 U.S.C. 1988.” The Sixth Circuit vacated parts of the award, noting that section 1988 “is not for the purpose of aiding lawyers and that the original petition for fees included requests for dry cleaning bills, mini blinds, and health insurance. View "Binta B. v. Gordon" on Justia Law

Tennessee participates in Medicaid through “TennCare,” Tenn. Code 71-5-102. The Medicaid Act requires that TennCare administer an Early and Periodic Screening, Diagnosis, and Treatment program for all enrollees under age 21, 42 U.S.C. 1396a(a)(43), 1396d(r) and must provide outreach to educate its enrollees about these services. In 1998 plaintiffs filed a putative class action under 42 U.S.C. 1983, alleging that TennCare had failed to fulfill these obligations. The district court entered a consent decree that explained in detail the requirements that TennCare had to meet to “achieve and maintain compliance” with the Medicaid Act, based on the assumption that the Act created rights enforceable under section 1983. Eight years later, the Sixth Circuit held that one part of the Medicaid Act was unenforceable under section 1983. Following a remand, the district court vacated paragraphs of the decree that were based on parts of the Act that are not privately enforceable. After a thorough review of TennCare’s efforts, the court then vacated the entire decree, finding that TennCare had fulfilled the terms of the decree’s sunset clause by reaching a screening percentage greater than 80% and by achieving current, substantial compliance with the rest of the decree. The Sixth Circuit affirmed. View "John B. v.Emkes" on Justia Law

Gayheart applied for Social Security disability insurance benefits in 2005 due to manifestations of anxiety, panic disorder, bipolar disorder, and depression. After an initial denial and three separate hearings, an administrative law judge (ALJ) found that the limitations caused by Gayheart’s impairments did not preclude him from performing a significant number of jobs available in the national economy and denied Gayheart’s application. Gayheart’s request for an administrative appeal was denied. The Report and Recommendation issued by the federal court’s assigned magistrate judge concluded that the ALJ’s decision was not supported by substantial evidence and that Gayheart should be awarded benefits. But the district court sustained the Commissioner’s objections and affirmed the ALJ’s decision. The Sixth Circuit reversed and remanded, holding that the ALJ failed to weigh the medical opinions according to 20 C.F.R. 404.1527. View "Gayheart v. Comm'r of Soc. Sec." on Justia Law

While working at a Ford Motor plant, Rudisill was hit in the face by a piece of equipment, was knocked against a wall, fell to the floor, and rolled forward through the floor opening into the hot pit below. He lay there unconscious, being burned, until coworkers pulled him out of the pit. Rudisill had gained consciousness by this time and was screaming in pain. Rudisill sustained a head injury that required several staples to close. He was also burned on his arms and legs, abdomen, and left hand. Rudisill continues to experience pain, dizzy spells, ringing in the ears, and memory problems. He has had numerous surgeries and has undergone physical and occupational therapy. After a safety review immediately following the incident, Ford decided to modify the process so that employees slide metal grates over the pit before removing the guard rails. After receiving workers’ compensation benefits, Rudisill sued Ford, alleging intentional tort; his wife asserted a derivative claim of loss of consortium. The district court granted summary judgment for Ford. The Sixth Circuit affirmed, finding insufficient evidence that Ford acted with deliberate intent to injure Rudisill, as required by Ohio statute. View "Rudisill v. Ford Motor Co." on Justia Law