Justia Public Benefits Opinion Summaries

Appellant Essie Simmons and Respondent Rubin Simmons divorced in 1990. The parties entered into a settlement agreement that was approved by the family court. Central to the agreement was the requirement that Mr. Simmons give Ms. Simmons a half or third of his Social Security benefits, depending on his age when he retired. When he retired, Mr. Simmons did not pay his ex-wife. She sued, but the family court declined to hear the complaint, finding that it could not hear a case that primarily dealt with Social Security benefits. Mr. Simmons appealed the dismissal, and the appellate court reversed. The court voided the division of Mr. Simmons' benefits, holding that the Social Security Act specifically precluded parties from dividing benefits under the settlement agreement. Because the agreement was partly voided by the court, Ms. Simmons sought to reopen the matter entirely. The family court dismissed again, holding that it lacked jurisdiction to revisit the agreement. On appeal, the Supreme Court was presented with the question of whether the family court could revisit the now partially voided agreement. Upon careful review of the arguments and applicable legal authority, the Court held that "basic principles of equity suggest[ed] that all issues should be revisited by the family court." The Court recognized the practical difficulties confronting the family court, but the Court noted, "that challenge pales in comparison to [Mr. Simmons'] suggestion that we simply end this matter with the remnant of the agreement remaining valid." The Court reversed the decision of the lower court and remanded the case to the family court for further proceedings.

The Commonwealth Court declined to issue a writ of mandamus to Appellant Crozer Chester Medical Center (Crozer) in its attempt to force the Department of Labor and Industry (Department) to reimburse it for medical fees. Claimant William Radel suffered a work-related injury while lifting a bundle of rebar for his employer. The claimant underwent surgery at Crozer, and Crozer sent claimant's records and the bill to claimant's insurance company, Zurich North American Insurance (Zurich). Zurich did not pay, nor did it deny the claim. Crozer then turned to the State for reimbursement. The Department rejected the application as "premature," because Zurich's non-payment made an "outstanding issue of liability/compensability for the alleged injury." Crozer then petitioned the Commonwealth Court to force the Department to pay. The Supreme Court agreed that Crozer's application for reimbursement was premature. The Court found that Crozer did not try to resolve Zurich's nonpayment before petitioning the State or the Commonwealth Court. The Court affirmed the decision of the Department and the lower court, and dismissed Crozer's petition for a writ of mandamus.

Appellant Lesia Knowlton appealed the Industrial Commission's determination that she was not entitled to workers' compensation benefits. Appellant was employed as a secretary at Respondent Wood River Medical Center. In 2000, Appellant was working at her assigned station when a drain in a nearby patient's bathroom became clogged. One of the maintenance workers used a chemical cleaner to clear the drain. The chemical produced a foul odor. Workers placed fans at the doorway of the room for ventilation. The air blew past Appellant's station from morning until her shift ended in the afternoon. That night, Appellant developed a cough and body aches. Her symptoms persisted, allegedly from exposure to the chemical drain cleaner. Over the course of five years, Appellant visited multiple doctors and specialists to treat her "bronchitis-like" symptoms. Appellant filed a complaint with the Industrial Commission seeking reimbursement for her medical expenses and for temporary total disability benefits. At a Commission hearing, the referee ultimately concluded that Appellant failed to demonstrate that her medical symptoms were causally related to the chemical exposure. Although the referee determined that Appellant was not entitled to "time loss" benefits or any form of disability benefits, he did find that because the medical treatment Appellant received during the six weeks following the incident was a "reasonable precautionary step" taken in response to the exposure, she was entitled to compensation for those expenses. The Commission adopted the referee's findings of fact and conclusions of law. The Commission denied Appellant's motion for reconsideration. Subsequently Appellant appealed to the Supreme Court. The Supreme Court agreed that Appellant failed to demonstrate her medical symptoms were related to the chemical exposure. Accordingly the Court affirmed the Commission's determination.

Petitioner Hartford Insurance Company (Hartford) appealed orders of the Compensation Appeals Board (CAB) that denied it recovery from the State Special Fund for Second Injuries for injuries to Claire Hamel and John Rygiel. Ms. Hamel worked as an assembly person for a motor manufacturing company. She was temporarily disabled for psychiatric reasons. She continued to work until her second injury for degenerative disc disease. Mr. Rygiel worked as a truck driver for a mobile MRI unit. Mr. Rygiel had Type II diabetes that required medication. Mr. Rygiel sustained an employment-related injury to his wrist. In both Ms. Hamel and Mr. Rygiel's cases, Hartford applied for and was denied reimbursement from the second injury fund. Hartford appealed both the Hamel and Rygiel decisions by CAB. The issue from both cases centered on whether state law allowed the CAB to consider an employee's past job performance as evidence that his or her preexisting impairment would not be a hindrance to obtaining employment if that employee became unemployed. The Supreme Court concluded that the employee's ability to perform his or her existing job is not determinative of whether the preexisting impairment was a hindrance to obtaining employment. The Court found that the CAB erroneously relied on the employee's ability when it denied Hartford's claims for reimbursement. Accordingly, the Court vacated the CAB's decisions in both the Hamel and Rygiel cases and remanded the cases for further proceedings.

Plaintiff, on behalf of a class of similarly situated plaintiffs who received Medicaid assistance and were subject to a Medicaid lien pursuant to 53-2-612, MCA, sued defendant alleging that defendant had collected a greater amount than it was entitled from plaintiffs' recoveries from other sources. The parties raised several issues on appeal. The court held that Ark. Dept. of Health & Human Servs. v. Ahlborn applied retroactively to all class members' claims and that defendant must raise affirmative defenses with respect to individual class members to avoid Ahlborn's effect. The court held that the applicable statute of limitations to be 27-2-231, MCA, which provided for a five-year limitations period. The court declined to disturb the district court's order requiring defendant to compile data on individual class members' claims. The court reversed the district court's determination as to interest assessed against defendant, and concluded that no interest could be assessed until two years after any judgment had been entered, under 2-9-317, MCA. The court concluded that the term "third party" in the Medicaid reimbursement statutes included all other sources of medical assistance available to Medicaid recipients, including private health or automobile insurance obtained by the Medicaid recipient. The court reversed the district court's grant of summary judgment to the class on its proffered distinction between "first party" and "third party" sources. The court affirmed the district court's conclusion that plaintiffs' "made whole" claim was immaterial in light of Ahlborn.

The Equal Access to Justice Act entitles a prevailing party to fees only if the position of the United States was not substantially justified. The Seventh Circuit affirmed denial of fees for a remand to an administrative law judge for an explanation of the determination of a precise date on which the social security applicant became disabled. The ALJ did not ignore, mischaracterize, selectively cite, or otherwise bungle a significant body of relevant evidence, but committed the sort of articulation error that ordinarily does not taint the commissionerâs position. A reasonable person could conclude that both the ALJâs opinion and the commissionerâs defense of the opinion had a rational basis in fact and law.

The Second Injury Fund appealed the Arkansas Workers' Compensation Commission (Commission) finding that the Fund was not entitled to a statutory offset for Appellee Cleveland Osborn's Veterans Administration (VA) benefits. The Supreme Court found that the Commission made its decision based on the "plain language" of the statute: "the legislature intended for the amount of workers' compensation benefits payable to an injured worker to be reduced 'dollar-for-dollar' by the amount of benefits that the worker has previously received for the same medical services under any of the listed group plans." Veterans Administration benefits are not listed as one of the "group plans" in the statute. The Court found that the Fund was not entitled to the offset.

Samantha A. is a 15-year-old with a wide range of medical maladies. Samantha is unable to perform a many activities necessary for independent living. The Department of Social and Health Services (DSHS) determined that Samantha is eligible for 24-hour institutional care because of the extreme nature of her needs. Because Samantha is cared for by a single mother, Samantha qualified for the Medicaid Home and Community Based Waiver Program so that she can receive benefits at home and not be institutionalized. As part of the in-home benefits, Samantha receives Medicaid Personal Care (MPC). DSHS assessed Samantha as needing 90 hours of MPC per month. In 2005, DSHS adopted changes to its assessment formula pertaining to MPC. Under the new rules, Samantha's MPC hours were reduced. Samantha petitioned the Superior Court for review of the DSHS reassessment. The court invalidated some of the DSHS rule changes. DSHS appealed to the Supreme Court, arguing that the rule changes were valid. The Supreme Court agreed with the lower court, finding the rule changes invalid under the Medicaid laws. The Court affirmed the superior court's decision.

Plaintiffs, a class of indigent children who suffered from severe emotional and mental disabilities, sued Idaho state officials more than three decades ago, alleging that the officials were providing them with inadequate care in violation of their constitutional and statutory rights. The parties reached agreements intended to remedy deficiencies in care and those agreements were embodied in three consent decrees entered and monitored by the district court. Plaintiffs appealed the 2007 order of the district court finding that defendants had substantially complied with the remaining Action Items, which were specified in an Implementation Plan that resulted from the third consent decree, asserting that it was error for the district court to apply the standard for civil contempt in determining whether to vacate the decrees. Plaintiffs further contended that the district court committed errors in fact and law in issuing protective orders barring them from taking supplemental depositions of appellee and two non-parties. The court held that the district court's application of the contempt standard with the imposition of the burden of proof on plaintiffs was error where the district court accepted the Action Items as the entire measure of compliance with the consent decree. Accordingly, the court reversed the order of the district court. The court also held that the district court committed no errors in upholding the assertion of the deliberative process privilege to one non-party and appellee, as well as the legislative privilege to the second non-party. Accordingly, the court did not abuse its discretion in issuing the protective orders.

Appellant Fairfield City Schools (Fairfield) sought reimbursement for a total disability compensation award given to one of its employees. Edward Carpenter, Jr. had hypertension since 1995. In 2002, he injured his back while at work. Mr. Carpenterâs injury resulted in a considerable amount of disability compensation. In 2008, Fairfield requested handicap reimbursement from the Ohio Bureau of Workersâ Compensation for at least part of the disability payments it made to Mr. Carpenter. Fairfieldâs application alleged that Mr. Carpenterâs pre-existing hypertension is a cardiac disease that delayed his recovery from back surgery, contributing to prolonged disability payments. The Bureau rejected Fairfieldâs application as âinsufficient to establish cardiac disease as a pre-existing condition.â Fairfield appealed the Bureauâs decision multiple times. With every appeal, Fairfield added additional doctorâs reports and Bureau datasheets to support its argument that hypertension is a cardiac disease. The court of appeals eventually denied Fairfieldâs appeal and application for a writ of mandamus. The appellate court found that the Bureau had exclusive authority to weigh the evidence Fairfield submitted, and the Bureau could find Fairfieldâs evidence insufficient to prove hypertension was a cardiac disease. Fairfield appealed to the Supreme Court, and the Court agreed with the Bureauâs and appellate courtâs decisions. The Court affirmed the lower courtâs judgment.