Justia Public Benefits Opinion Summaries

Medicare Part A reimburses hospitals according to a Prospective Payment System (42 U.S.C. 1395ww(d), which uses a predetermined formula to calculate reimbursement for each patient discharge without regard to the actual cost incurred. The formula includes the average hourly wage of the employees in the geographic region, including paid lunch hours. Hospitals objected to the practice because some hospitals give paid lunch breaks, which depresses the average area hourly wage and, in turn, their Medicare reimbursements. The district court granted summary judgment for the government. The Seventh Circuit affirmed, reasoning that counting all paid hours, for the sake of administrative simplicity, is not arbitrary. View "Adventist GlenOaks Hosp. v. Sebelius" on Justia Law

This case arose when defendant denied plaintiff's application for Medicaid benefits on the grounds that she had transferred property in 2005-2006 valued at $340,000. The district court subsequently dismissed plaintiff's 42 U.S.C. 1983 claim against defendants based on the abstention doctrine set forth in Younger v. Harris. Plaintiff appealed, contending that the district court should not have abstained from hearing her claim. Because, under Alleghany Corp. v. McCartney, abstention was appropriate in administrative proceedings like plaintiff's, the court held that the district court did not err in abstaining. View "Hudson v. Campbell, et al." on Justia Law

Plaintiff Donna Saterlee appealed a district court order that affirmed the Commissioner of Social Security's decision to deny social security disability and supplemental security income benefits. The Administrative Law Judge (ALJ) denied benefits at the last step of the five-step process for determining disability. Plaintiff argued that the ALJ erred by (1) improperly rejecting her hand impairment as medically nondeterminable at step two and consequently not including it in the RFC that formed the basis of the dispositive hypothetical to the Vocational Expert; and (2) failing to perform a proper credibility analysis in determining that complaints of limitations other than, or in excess of, those later included in the RFC were not credible. The Tenth Circuit found that the ALJ was "undeniably wrong" about the lack of documented medical evidence of Plaintiff's condition that gave rise to the alleged numbness, "undercutting the categorical rejection of such an impairment on this threshold basis." The Court remanded the case for an administrative decision that properly accounted for all of the evidence of record. View "Saterlee v. Astrue" on Justia Law

Defendant operated what appeared to be convenience stores, but in fact were fronts that rang up phony sales for food-stamp recipients to exchange their benefits for discounted amounts of cash. When federal investigators discovered the scheme at one location, he obtained government authorization to accept food stamps at a different address and continued the operation. Defendant eventually pleaded guilty to eight counts of wire fraud, 18 U.S.C. 1343, and was sentenced to 60 months' imprisonment and ordered to pay almost $1.7 million in restitution. The Seventh Circuit affirmed. The district court properly imposed a 16-level sentencing increase under 2B1.1(b)(1)(I) for a loss of more than $1 million because. If anything, the court underestimated the loss. The court properly assessed a 4-level increase under 3B1.1(a) for leadership in an "extensive" scam; defendant ran the scam from multiple locations, traded cash for benefits with "probably hundreds" of customers, and supervised employees at his stores. View "United States v. Hussein" on Justia Law

Petitioner Ellen St. Louis appealed the decision of the New Hampshire Department of Employment Security (DES) Appellate Board (board) that denied her claim for unemployment benefits. Early 2009, Petitioner received a disciplinary notice stating that her conduct was not in line with company policy because she appeared to be asleep at work and was argumentative when her trainer instructed her regarding her faulty soldering work. Subsequently, Petitioner informed a human resources representative that she was having difficulties breathing and that she was depressed. The human resources representative recommended she take medical leave. Petitioner claims that when she returned to work she could no longer perform soldering work because the fumes caused headaches, and caused her to shake, cough, and have difficulty breathing. The record indicated that she never provided Insight Technology with any medical records or doctor's instructions regarding her breathing problems or opinions regarding her inability to do soldering work. Petitioner was ultimately terminated for poor work performance. She applied for unemployment benefits but was denied. After an unsuccessful appeal to the Board, Petitioner appealed to the Supreme Court. Upon review, the Court found that the record supported the determination that Petitioner was terminated for misconduct, and that there was no error in the Board's decision. View "Appeal of Ellen St. Louis " on Justia Law

Claimant-Appellant Dennis Current appealed the Idaho Industrial Commission's denial of his unemployment benefits. Claimant argued that the Commission erred in finding he willfully made a false statement, and in failing to call one of his witnesses. The Department of Labor argued the Commission's findings were supported by substantial and competent evidence. The Supreme Court found that there was indeed substantial and competent evidence to support the Commission's findings that Claimant willfully made a false statement. The Court also found that the hearing officer did not abuse her discretion in finding that one of Claimant's witnesses would not provide relevant testimony. Accordingly, the Court affirmed the Commission's decision. View "Current v. Haddons Fencing, Inc. " on Justia Law

Plaintiff-Appellant Amby Elkins was denied social security benefits, and appealed the Commissioner's rejection of her claims. She said she suffered from degenerative disc disease, rheumatoid arthritis, tendinitis, and depression. The combination of these conditions, she argued rendered her essentially incapable of performing any work. An administrative law judge, however, rejected Plaintiff's petition. On the basis of medical evaluations by independent physicians, he concluded that Plaintiff's testimony regarding the severity of her impairments was not credible. She appealed to the district court, which affirmed the ALJ's decision. Upon review, the Tenth Circuit declined to overturn the ALJ's findings of fact, and affirmed the district court's judgment. View "Elkins v. Astrue" on Justia Law

Pro se Plaintiff-Appellant Terry Gibbs appealed a district court's order that reversed the administrative decision of the Commissioner of the Social Security Administration and remanded the case to the agency under sentence four of 42 U.S.C. 405(g). Plaintiff argued that the district court abused its discretion by remanding for further proceedings when it should have simply granted his "Motion for Judgment as a Matter of Law" and awarded him benefits. Upon review, the Tenth Circuit found that the remand was appropriate. Accordingly, the Court affirmed the district court's decision. View "Gibbs v. Astrue" on Justia Law

Plaintiff applied for Social Security disability insurance benefits and an ALJ denied the claim, noting that plaintiff failed to provide an opinion from his treating physician. When plaintiff requested review of his claim by the Appeals Council, he submitted a letter from his treating physician detailing the injuries and recommending significant restrictions on plaintiff's activity. The Appeals Council made this letter part of the record but denied plaintiff's request for review. Thus, the ALJ's decision denying benefits became the final decision of the Commissioner of the Social Security Administration. Plaintiff appealed, contending that the Appeals Council erred by failing to articulate specific findings justifying its denial of his request for review. The court rejected the argument and held that the Appeals Council need not explain its reasoning when denying review of an ALJ decision. But because in this case the court could not determine if substantial evidence supported the denial of benefits, the court reversed and remanded. View "Meyer, III v. Astrue" on Justia Law

For 12 months following his injury, plaintiff, a police officer injured on duty, received salary under the Public Employee Disability Act. For a short time thereafter, he received salary through a combination of accrued sick and vacation time, light duty, and temporary total disability payments under the Workers’ Compensation Act. While plaintiff received salary under PEDA, the city deducted 20 percent of his health insurance premiums from his paycheck, in accordance with the collective bargaining agreement. After PEDA benefits expired, plaintiff continued to pay 20 percent of the premiums. When he was awarded a line-of-duty disability pension under the Illinois Pension Code, the city began paying 100 percent of the premiums, as required by the Public Safety Employee Benefits Act, 820 ILCS 320/10(a). Plaintiff's request for reimbursement for premiums paid since the date of injury was refused. The circuit court entered summary judgment for the city. The appellate court reversed. The Illinois Supreme Court reversed the appellate court. Under PSEBA, an employer's obligation to pay the entire health insurance premium for an injured officer and his family attaches on the date that it is determined that the injury is "catastrophic," the date it is determined that the injured officer is permanently disabled and eligible for a line-of-duty disability pension. View "Nowak v. City of Country Club Hills" on Justia Law