Justia Public Benefits Opinion Summaries

Plaintiffs, teaching hospitals, received Medicare payments to offset the costs associated with training "full-time equivalent" residents and intern physicians (FTEs). In 1997, Congress capped those payments in such a way that the number of FTEs the hospitals trained in 1996 would dictate the maximum reimbursement in all future years. Although the parties agreed that the 1996 data was not accurate, the Secretary believed that this predicate fact could not be corrected outside the three-year reopening window. The court held that the reopening regulation allowed for modification of predicate facts in closed years provided the change would only impact the total reimbursement determination in open years. Alternatively, the court agreed with the district court that the Secretary had acted arbitrarily in treating similarly situated parties differently. The court rejected the Secretary's claim that the Medicare Act, 42 U.S.C. 1395 et seq., would not allow the intermediary to change the 1996 GME resident count without changing the corresponding reimbursement amount, which all parties conceded would constitute a reopening of an "Intermediary determination." Accordingly, the court affirmed the judgment. View "Kaiser Foundation Hospitals v. Sebelius" on Justia Law

Plaintiffs, thirteenth North Carolina residents who lost access to in-home personal care services (PCS) due to a statutory change, brought suit challenging the new PCS program. The district court granted plaintiffs' motions for a preliminary injunction and class certification. Defendants appealed, raising several points of error. The court agreed with the district court's conclusion that a preliminary injunction was appropriate in this case. The court held, however, that the district court's order failed to comply with Federal Rule of Civil Procedure 65 because it lacked specificity and because the district court neglected to address the issue of security. Accordingly, the court remanded the case. View "Pashby v. Delia" on Justia Law

Full Life Hospice participates in the federal Medicare program. It sought reimbursement for hospice services provided to Medicare recipients from the Department of Health and Human Services (HHS). A fiscal intermediary, acting on behalf of HHS, later contested some of these reimbursements and demanded repayment of funds that it claimed were distributed in excess of a spending cap. Full Life unsuccessfully challenged HHS intermediary’s determination through an administrative appeal, which was denied as untimely. On appeal to the district court, the court found no basis to excuse Full Life's untimely challenge. Upon review, the Tenth Circuit agreed with the district court that it lacked subject matter jurisdiction because of Full Life's failure to file a timely administrative appeal. View "Full Life Hospice v. Sebelius" on Justia Law

The State appealed from the district court's order enjoining it from requiring plaintiff to submit to a suspicionless drug test pursuant to Section 414.0652 of the Florida Statutes, as a condition for receipt of government-provided monetary assistance for which he was otherwise qualified. Plaintiff applied for financial assistance benefits for himself and his son through Florida's Temporary Assistance for Needy Families program (TANF). The court held that the district court did not abuse its discretion in granting the preliminary injunction enjoining the State from enforcing the statute because the court concluded that the State had failed to establish a substantial special need to support its mandatory suspicionless drug testing of TANF recipients. View "Lebron v. Secretary, FL Dept. of Children and Families" on Justia Law

Walker served in the U.S. Army Air Force, 1943 to 1945, as a four-engine airplane pilot and flight instructor. The VA Regional Office denied his 2007 disability claim for bilateral hearing loss. Walker appealed to the Board of Veterans Appeals, including sworn statements from his son and wife that his hearing loss began in service and continued throughout his life. Walker was examined by a VA audiologist. Walker’s service medical records were not available due to a fire. The audiologist concluded that the hearing loss was “less likely as not caused primarily by military service as a pilot,” that age could not be excluded as the primary etiology, and that Walker was exposed to recreational noise by hunting game without use of hearing protection. The Board concluded that Walker failed under the three-element test to establish service connection for his hearing loss. The Federal Circuit affirmed. View "Walker v. Shinseki" on Justia Law

Petitioner appealed from the district court's judgment affirming the Commissioner's denial of his application for disability benefits. The court held that the ALJ erred in her treatment of plaintiff's claim that he suffered from fibromyalgia by failing to accord the proper weight to the opinion of plaintiff's treating physician, by misconstruing the record, and by failing to evaluate the claim in light of medically accepted diagnostic criteria. The court also held that the ALJ's determination that plaintiff could perform light work was not supported by substantial evidence, and that the ALJ further erred by not determining whether plaintiff's reaching limitation was non-eligible and would therefore require the testimony of a vocational expert. Accordingly, the court vacated and remanded for further proceedings. View "Selian v. Astrue" on Justia Law

Prasch worked as a mail carrier for the Postal Service until suffering a work-related injury, compensable under the Federal Employees’ Compensation Act. He received benefits from the Office of Workers’ Compensation Programs from December 2007 until October 2008. Prasch applied for disability retirement. OPM approved his application and deposited $14,640.27, representing retroactive retirement annuity payments from December 2007 through the approval of his application. OPM paid him another $5,869.60 in retirement annuity benefits before determining that Prasch had received FECA disability benefits from OWCP during the period that OPM was paying him retirement annuity benefits. Because governing statutes prohibit dual benefits, OPM adjusted the commencement date of Prasch’s retirement annuity and computed an overpayment of $14,703.62.and sent a proposed repayment schedule. Prasch requested a waiver of the repayment obligation, lower installments, or a compromise payment, but he did not ask for reconsideration of OPM’s decisions as to the existence of the overpayment or its amount. OPM affirmed its initial decision, finding that Prasch should have known that he could not receive dual benefits and rejecting his claim of financial hardship, but extended the time for repayment. The Merit Systems Protection denied an appeal. The Federal Circuit affirmed. View "Prasch v. Office of Pers. Mgmt." on Justia Law

Viegas served in the U.S. Army, 1965-1967. After leaving the service, he was injured in a diving accident, resulting in “incomplete” quadriplegia. In 2004, Viegas participated in a prescribed aquatic therapy session at a VA medical center. He used a restroom in the VA facility. The grab bar he used to lift himself into his wheelchair came loose from the wall and he fell to the ground. As a result of the fall, Viegas sustained injuries to his upper and lower extremities. Viegas’ medical condition deteriorated after his fall. Prior to his fall, Viegas could sometimes walk with a walker, but since the accident he can only stand with assistance. Viegas sought disability benefits under 38 U.S.C. 1151. A VA regional office denied the claim. The board affirmed, stating that such benefits are available only if additional disability results from injury that was part of the natural sequence of cause and effect flowing directly from the actual provision of hospital care, medical or surgical treatment, or examination furnished by the VA and such additional disability was directly caused by that VA activity. The Veterans Court affirmed. The Federal Circuit reversed, holding that the Veterans Court misinterpreted the causation requirement. View "Viegas v. Shinseki" on Justia Law

The court consolidated appeals by veterans claiming that their current disabilities are connected to injuries sustained during military service. In both cases, the veterans’ medical records contained at least one physician’s report opining that the claimed disabilities were service-connected and at least one ambiguous or inconclusive report declining to confirm such a nexus. The Department of Veterans Affairs relied on inconclusive opinions in denying the veterans entitlement to service-connected disability benefits, and the Board of Veterans’ Appeals affirmed. Finding that the medical examination did not comply with the Board’s instructions and that the Board failed to explain its reasons and bases for denying service connection, the U.S. Court of Appeals for Veterans Claims remanded. The Federal Circuit affirmed that remand, rather than reversal, was appropriate. View "Deloach v. Shinseki" on Justia Law

Since enacting a program for black-lung benefits in 1969, known as the Black Lung Benefits Act,83 Stat. 742, Congress has repeatedly amended the claim-filing process, sometimes making it harder for miners and survivors to obtain benefits, sometimes making it easier. The most recent adjustment, part of the 2010 Patient Protection and Affordable Care Act, reinstated a presumption that deceased workers who had worked for at least 15 years in underground coal mines and had developed a totally disabling respiratory or pulmonary impairment were presumed to be totally disabled by pneumoconiosis and to have died from it. The presumption is rebuttable. The Act also reinstated automatic benefits to any survivor of a miner who had been awarded benefits on a claim filed during his lifetime, 124 Stat. at 260. Groves, a miner for 29 years, filed a claim for benefits in 2006 and died four months later. An ALJ denied his widow benefits. The law changed while her appeal was pending. The Benefits Review Board concluded that the new law covered this claim. The Sixth Circuit affirmed. View "Vision Processing, LLC v. Groves" on Justia Law