Justia Public Benefits Opinion Summaries
Alexander v. Saul
Plaintiff, an applicant for Social Security Income benefits, appeals the district court's judgment denying her motion for an extension of time to file an appeal pursuant to Federal Rule of Appellate Procedure 4(a)(5). Plaintiff contends that because of her mental impairments, she established both "good cause" and "excusable neglect" under Rule 4(a)(5) for her failure to file a timely appeal.The Second Circuit concluded that "excusable neglect," rather than "good cause," is the appropriate standard for evaluating plaintiff's claim because her failure timely to appeal was at least in part due to her own inadvertence. The court explained that, in evaluating claims of "excusable neglect" under Rule 4(a)(5), courts consider the four factors set forth by the Supreme Court in Pioneer Investment Services Company v. Brunswick Associates Limited Partnership, 507 U.S. 380 (1993): the risk of prejudice to the non-movant; the length of the movant's delay and its impact on the proceedings; the reason for the delay, including whether it was within the movant's reasonable control; and whether the movant acted in good faith.In this case, the district court did not abuse its discretion in applying these factors to plaintiff's claim and concluding that she failed to demonstrate excusable neglect. The court explained that because plaintiff's untimely appeal was caused by her failure to maintain contact with her attorney—a factor within her reasonable control—she failed to establish excusable neglect under the Pioneer test. While plaintiff attributes her delay to her mental illness, which she argues is beyond her control, the court determined that the record does not compel the conclusion that her impairments as opposed to her neglect caused her failure timely to appeal. Accordingly, the court affirmed the district court's judgment. View "Alexander v. Saul" on Justia Law
Conservatorship of A.B.
A.B., a 40-year-old male diagnosed to suffer from severe schizophrenia, has been subject to conservatorships on and off for 20 years. A.B. has no real property or significant assets; his only income is $973.40 in monthly social security benefits. The public guardian was most recently appointed as A.B.’s conservator in 2016 and reappointed annually until the dismissal of the conservatorship in 2019. In August 2017, the public guardian was awarded $1,025 and county counsel was awarded $365 in compensation for services rendered 2016-2017. In 2018, the court entered an order for compensation for the public guardian and county counsel in the same amounts covering 2017-2018. The public guardian sought compensation for services rendered 2018-2019, $1,569.79 for its services, and $365 for county counsel.The court found that the request for compensation was just, reasonable, and necessary to sustain the support and maintenance of the conservatee, and approved the petition, again ordering the public guardian to defer collection of payment if it determined that collection would impose a financial hardship on the conservatee. The court of appeal reversed. While the court had sufficient information before it to enable consideration of the factors enumerated in Probate Code section 2942(b), the court failed to do so and improperly delegated responsibility to the public guardian to defer collection. View "Conservatorship of A.B." on Justia Law
Kaplarevic v. Saul
Kaplarevic filed for disability insurance benefits in 2012, alleging that he became disabled on August 1, 2012. His “date last insured” was December 31, 2014, meaning that if his disability arose any later than that, he would not be eligible for benefits.The Seventh Circuit affirmed the denial of benefits, rejecting Kaplarevic’s arguments that an ALJ improperly considered his own observations of Kaplarevic’s physical condition and ability to perform certain physical tasks at a 2018 hearing. Kaplarevic sought an open-ended period of disability so he needed to show that he became disabled before his date last insured and that he was still disabled. The court noted the ALJ’s 15-page opinion, which evaluated extensive medical and behavioral evidence. It was Kaplarevic’s burden to show disability, and if he wanted to do so, he should have accepted the ALJ’s invitation “to identify the portions of the medical records that he believed supported various of [his] allegations.” Vague references to the “totality of the evidence” are not helpful. The ALJ’s opinion did not rely on the failure to seek treatment as a factor demonstrating lack of disability; the record showed that Kaplarevic did not comply with prescribed therapy and that his pain complaints were not consistent with objective medical findings. View "Kaplarevic v. Saul" on Justia Law
Taylor v. McDonough
The Department of Defense's experiments at Edgewood involved “volunteers,” including Taylor, who was on active duty, 1969-1971. Taylor signed a secrecy oath providing that he would not divulge any information related to the program and that any such action would render him liable to punishment and signed a document stating that the experiment had been explained to him and that he volunteered to participate. Taylor was exposed to a nerve agent, a tear gas agent, and more. Taylor experienced hallucinations, nausea, jumpiness, irritability, sleepiness, dizziness, impaired coordination, and difficulty concentrating. He was subsequently deployed to Vietnam, for two combat tours. The secrecy of the project prevented Taylor from obtaining psychiatric help and from showing extenuating circumstances during his court-martial.In 2006, the Edgewood names were declassified. The VA notified participants that they were permitted to disclose to health care providers information about their involvement at Edgewood that affected their health. In 2007, Taylor sought service-connected benefits for PTSD. A VA medical examiner diagnosed Taylor with PTSD and major depressive disorder, “a cumulative response” to his Edgewood experience and “subsequent re-traumatization in Vietnam.” Taylor had previously sought treatment for his PTSD but was rejected because the provider believed he lied about being an experimental subject.The VA granted Taylor’s claim, with a 2007 effective date, citing the absence of an earlier claim. On remand, the VA failed to obtain the language of Taylor’s secrecy oath and again concluded that the earliest assignable effective date was 2007; “nothing prevented [Taylor] from filing a claim.” The Veterans Court affirmed.The Federal Circuit reversed. The Veterans Court erred in concluding it lacked equitable authority absent an express statutory grant and erred in concluding that 38 U.S.C. 5110(a)(1) is not subject to common law equitable doctrines. The government affirmatively and intentionally prevented veterans from seeking medical care and applying for disability benefits to which they are otherwise entitled under threat of criminal prosecution and loss of the very benefits sought. “If equitable estoppel is ever to lie against the Government, it is here—to preserve the ‘interest of citizens in some minimum standard of decency, honor, and reliability in their dealings with their Government.’” View "Taylor v. McDonough" on Justia Law
Estate of Scheidecker v. Montana Department of Public Health & Human Services
The Supreme Court reversed an order of the district court affirming an administrative law judge's proposed order that trust principal consisting of a jointly owned home constituted a countable asset for the purpose of the Medicaid eligibility of Marilyn Scheidecker, holding that there were no circumstances under which payment from the trust's corpus could be made for Marilyn's benefit.The Montana Department of Public Health and Human Services denied Marilyn's application for Medicaid, concluding that Marilyn's one-half interest in the trust's principal was a countable resource placing her over Medicaid's resource limit. The ALJ upheld the denial. The district court affirmed the ALJ's ultimate conclusion that the trust was a countable asset pursuant to 42 U.S.C. 1396p(d)(3), holding that circumstances existed by which payments form the trust's corpus could be made to or for Marilyn's benefit. The Supreme Court reversed, holding that the district court was incorrect in its application of the federal statute. View "Estate of Scheidecker v. Montana Department of Public Health & Human Services" on Justia Law
Rahimi v. Rite Aid Corp.
Rite Aid’s “Rx Savings Program” provides generic prescription drugs at reduced prices. The program is free and widely available but excludes customers whose prescriptions are paid by publicly funded healthcare programs like Medicare or Medicaid. Federal regulations require pharmacies to dispense prescriptions for beneficiaries of those programs at their “usual and customary charge to the general public” (U&C rate). Rahimi alleged that Rite Aid overbilled the government programs because the amounts it charged did not take into account the lower Rx Savings Program prices. Rahimi claimed Rite Aid's submission of bills for those covered by publicly funded health insurance, representing the price to be the U&C rate, violated the False Claims Act, 31 U.S.C. 3729(a).The Sixth Circuit affirmed the dismissal of Rahimi’s claim. The Act’s public disclosure bar precludes qui tam actions that merely feed off prior public disclosures of fraud. From the beginning, communications about the Rx Savings Program have stated that publicly funded health care programs were ineligible for the discounted prices. Before Rahimi’s disclosures, Connecticut investigated membership discount prices; the Department of Health and Human Services announced that it would review Medicaid claims for generic drugs to determine the extent to which large chain pharmacies are billing Medicaid the usual and customary charges for drugs provided under their retail discount generic programs; and a qui tam action was unsealed in California, describing an identical scheme. View "Rahimi v. Rite Aid Corp." on Justia Law
Prosser v. Becerra
Prosser, a 37-year-old Medicare recipient, suffers from glioblastoma, which causes brain tumors. The five-year survival rate hovers around 5%. Though not curative, Prosser benefits from tumor treating fields therapy (TTF), approved by the FDA in 2011. For most of the day, patients use a device that attaches to the head via adhesive patches that connect to a mobile power supply. The device emits electrical fields to the tumor, which disrupt the division of cancer cells. Early studies show that the device holds promise in prolonging life. TTF therapy is available through a single supplier, Novocure, which rents the device on a monthly basis. The therapy is expensive. Prosser must file a Medicare benefits claim for each period she uses the device. Medicare denied coverage for the treatment period January-April 2018. Though Prosser received the therapy and owed nothing, the denial left Novocure with the bill. Prosser challenged this denial through Medicare’s appeals process before filing suit.The Seventh Circuit affirmed the dismissal of Prosser’s claim for Medicare Part B coverage, holding that she has suffered no injury-in-fact sufficient to satisfy Article III’s standing requirement. Prosser received—and continues to receive—the TTF therapy. She faces no financial liability for the treatment period Medicare denied coverage. Any future financial risk is too attenuated from the denial of the past coverage and far too speculative to establish standing. View "Prosser v. Becerra" on Justia Law
Temple University Hospital, Inc. v. Secretary United States Department of Health & Human Services
The hospital, located in Philadelphia, received a reclassification into the New York City area, which would sizably increase the hospital’s Medicare reimbursements due to that area’s higher wage index, 42 U.S.C. 1395ww(d). Although a statute makes such reclassifications effective for three fiscal years, the agency updated the geographical boundaries for the New York City area before the close of that period and reassigned the hospital to an area in New Jersey with an appreciably lower wage index. The hospital successfully sued three agency officials in the Eastern District of Pennsylvania.The Third Circuit vacated and remanded for dismissal. The Medicare Act, 42 U.S.C. 1395oo(f)(1), channels reimbursement disputes through administrative adjudication as a near-absolute prerequisite to judicial review. The hospital did not pursue its claim through administrative adjudication before suing in federal court. By not following the statutory channeling requirement, the hospital has no valid basis for subject-matter jurisdiction. View "Temple University Hospital, Inc. v. Secretary United States Department of Health & Human Services" on Justia Law
Arellano v. McDonough
The “effective date of an award” of disability compensation to a veteran “shall not be earlier than the date” the veteran’s application for such compensation is received by the VA. 38 U.S.C. 5110(a)(1). Section 5110(b)(1) provides an exception that permits an earlier effective date if the VA receives the application within one year of the veteran’s discharge from military service: under such circumstances, the effective date of the award shall date back to “the day following the date of the veteran’s discharge or release.”Arellano filed his application more than 30 years after he was discharged from the Navy, he argued that section 5110(b)(1)’s one-year period should be equitably tolled to afford his award an earlier effective date reaching back to the day after his discharge. The Veterans Court denied Arellano an effective date earlier than the date his disability benefits application was received by the VA. The Federal Circuit previously held that 5110(b)(1) is not a statute of limitations amenable to equitable tolling but merely establishes an effective date for the payment of benefits, thereby categorically foreclosing equitable tolling. The Federal Circuit affirmed as to Arellano, declining to overrule that precedent, stating that the statutory text evinces clear intent to foreclose equitable tolling of section 5110(b)(1)’s one-year period. View "Arellano v. McDonough" on Justia Law
Colwell v. MCNA Insurance Co.
The Supreme Court affirmed the ruling of the district court against Defendant and in favor of Plaintiff finding breach of contract and breach of implied covenant of good faith and fair dealing, holding that the district court erred.Defendant, a managed care organization, entered into a contract with Plaintiff, a dentist, to deliver dental services to Medicaid participants as a member of Defendant's network. Defendant later sent Plaintiff a "notice of non-renewal" of the provider contract. Plaintiff sued, and the district court ruled that the provider contract did not allow Defendant to terminate Plaintiff through non-renewal of the provider contract. At issue was whether Defendant properly ended a provider contract that automatically renewed for successive one-year terms by sending a notice of non-renewal. The Supreme Court affirmed, holding that the district court correctly determined that Defendant possessed no right to terminate by non-renewal. View "Colwell v. MCNA Insurance Co." on Justia Law