Justia Public Benefits Opinion Summaries

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While serving on a Navy aircraft carrier in 1969, Francway was hit by wind: “[t]he resulting fall caused him to injure his back.” He “was placed on bedrest for a week and assigned to light duty for three months.” In 2003, Francway filed a VA claim for service connection for his back disability. In 2003-2011, Francway was examined multiple times by an orthopedist and had his medical records separately reviewed by the orthopedist and an internist. They concluded that Francway’s current back disability was not likely connected to his 1969 injury. After multiple appeals and remands, Francway submitted new evidence from his longtime friend, attesting to Francway’s history of back disability. The Board again remanded, with instructions that Francway’s “claims file should be reviewed by an appropriate medical specialist” and that the examiner should reconcile any opinion with the statements from Francway's "buddy statement.” Francway was again examined by the orthopedist, who concluded that Francway’s symptoms were unlikely to be related to his injury but did not address the “buddy statement.” The internist reviewed Francway’s file and the “buddy statement,” and reached a similar conclusion. The Board concluded that there was insufficient evidence of a nexus between Francway’s 1969 injury and his current disability and that the VA had complied with the remand orders. The Veterans Court concluded that Francway had not preserved his claim that the internist who reviewed the “buddy statement” was not an “appropriate medical specialist” under the remand order. Francway had not challenged the examiner’s qualifications before the Board. The Federal Circuit affirmed, noting that the Board and Veterans Court properly apply a presumption of competency in reviewing the opinions of VA medical examiners. View "Francway v. Wilkie" on Justia Law

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The Supreme Court held that the determination of the California Department of Social Services (the Department) that a household member's income that is used to pay child support for a child living in another household counts as income "reasonably anticipated" to be "received" by the paying household within the meaning of Cal. Welf. & Inst. Code 11265.2 for the purposes of determining eligibility for state welfare benefits was reasonable and therefore valid. Plaintiff applied for California Work Opportunity and Responsibility to Kids (CalWORKs) aid to support herself and her family. The Director of the Department denied the claim, concluding that child support payments garnished from Plaintiff's husband's earned income and unemployment insurance benefits was correctly included as nonexempt available income in determining eligibility for CalWORKs benefits. The superior court declared the department's policy of counting court-ordered child support payments as available income of CalWORKs applicants invalid. The court of appeal reversed. The Supreme Court affirmed, holding that the Department’s determination that funds garnished to pay child support for the benefit of a child living in another household are not exempt from the paying household’s income for purposes of determining its eligibility for or amount of CalWORKs aid was a reasonable exercise of its lawmaking authority and was therefore valid. View "Christensen v. Lightbourne" on Justia Law

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The Eighth Circuit affirmed the denial of social security disability insurance benefits and supplemental security income (SSI) benefits to claimant. The court held that substantial evidence supported the ALJ's findings that claimant's physical and mental impairments did not meet or equal the severity of any of the listed impairments. Furthermore, substantial evidence supported the ALJ's residual functioning capacity determination and the mental limitations included in that finding. The court also held that the vocational expert's testimony did not conflict with the Dictionary of Occupational Titles and the ALJ was entitled to rely on the expert's testimony. View "Twyford v. Commissioner" on Justia Law

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Medi–Cal, California’s program under the joint federal-state Medicaid program (Welf. & Inst. Code 14000), provides health care services to certain low-income individuals and families, including the aged, blind, disabled, pregnant women, and others. (42 U.S.C. 1396). Beginning in 2013-2014, there were delays in the determination of applications for Medi-Cal benefits, sometimes with severe consequences for applicants who did not obtain needed medical care. Applicants and an advocacy organization sued the California Department of Health Care Services (DHCS). The court ordered DHCS to make Medi-Cal eligibility determinations within 45 days unless certain exceptions applied. The court of appeal reversed. The trial court did not abuse its discretion by declining to abstain but California law does not impose on DHCS a duty to make all Medi-Cal eligibility determinations within 45 days. There is an obligation to determine Medi-Cal eligibility within 45 days under federal regulation 32 CFR 435.912(c)(3)(ii), but that obligation is subject to exceptions so that the underlying obligation is not sufficiently clear and plain to be enforceable in mandate. It was not clear whether DHCS was out of compliance with an overall performance benchmark of processing 90% of applications within 45 days; absent such evidence, it was error to issue writ relief applicable across-the-board. View "Rivera v. Kent" on Justia Law

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The materiality standard—asking whether a school has failed to implement substantial or significant provisions of the child's individualized education plan (IEP)—is the appropriate test in a failure-to-implement case. L.J. and his mother filed suit under the Individuals with Disabilities Education Act (IDEA), challenging the implementation of his IEP. The Eleventh Circuit held that the content outlined in a properly designed IEP is a proxy for the IDEA's educational guarantee, and thus a material deviation from that plan violates the statute. In this case, the court held that there was no material deviation from L.J.'s IEP and affirmed the district court's judgment in favor of the school. View "L.J. v. School Board of Broward County" on Justia Law

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While Ethan Lomeli's guardian filed suit against medical care providers for his catastrophic birth injuries, Medi-Cal paid for his care before and during the lawsuit. After Lomeli settled with defendants, the Department moved to impose a lien on the settlement and the trial court granted the motion. The Court of Appeal affirmed and held that federal law did not block the Department's lien. The court rejected Lomeli's analysis from the dissent in Tristani ex rel. Karnes v. Richman (3rd Cir. 2011) 652 F.3d 360, 379–387, and adopted the majority's holding that two provisions of the Social Security Act did not bar state Medicare liens. The court also held that collateral estoppel did not bar the lien and the court's lien calculation of $267,159.60 was correct. In this case, substantial evidence supported the trial court's reality-based approach to determine the reasonable value of plaintiff's pretrial claim. View "Lomeli v. State Department of Health Care Services" on Justia Law

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The Court of Appeal affirmed the probate court's order denying plaintiffs' request, following the death of their daughter, that the remainder of their daughter's special needs trust be distributed to them rather than to the Department of Health Care Services as reimbursement for Medi-Cal payments for their daughter's medical care. The court held that the mandatory recovery rules for special needs trusts apply to the trust remainder; plaintiffs' interpretation of Probate Code section 3605 conflicts with federal law; the Centers for Medicare & Medicaid Services' opinion letter supports the Department's position that section 3605 permits the Department to recover for the daughter's Medi-Cal expenses; public policy considerations weigh in favor of permitting reimbursement to the Department; and the trust itself requires reimbursement to the Department. The court also held that plaintiffs failed to show that the Department's claim impermissibly included services under the Individuals with Disabilities Education Act and Lanterman Act. View "Gonzalez v. City National Bank" on Justia Law

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NOVA challenged a 2017 Veterans Administration (VA) amendment to 38 C.F.R. 3.321(b)(1), confining the preexisting regulation (as interpreted by a 2014 Federal Circuit ruling) and authorizing the VA “[t]o accord justice to the exceptional case where the schedular evaluation is inadequate to rate a single service-connected disability,” by adopting “an extra-schedular evaluation commensurate with the average impairment of earning capacity due exclusively to the disability.” The regulation does not permit the VA to award extra-schedular disability compensation by considering the synergistic impact of multiple disabilities together. The Federal Circuit upheld the regulation. The VA’s explanation for the change was adequate; the regulation is not on its face arbitrary and capricious. It does not limit “extraschedular rating to a single service-connected disability” but provides for combining multiple disabilities, but not in the manner opponents prefer. The VA explained that the amendment is consistent with the agency’s historical interpretation of the regulation and its predecessors. The VA reasonably concluded that determination of an extra-schedular rating with respect to a single disability is likely to result in a more logical and consistent system of extra-schedular rating than one in which the decision-maker must determine on an ad hoc basis whether extra-schedular rating is appropriate for the synergistic effect of combined disabilities. View "National Organization of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs" on Justia Law

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The First Circuit affirmed the judgment of the district court concluding that transfers of assets by individuals age sixty-five or older into "pooled special needs trusts" are among those transfers that the Medicaid statute counts against eligibility for long-term care benefits, holding that when a beneficiary who is age sixty-five years or older gives up her assets for less than fair market value to a pooled special needs trust, there has been a transfer that triggers a temporary period of ineligibility. Following Yvonne Richardson's deposit of funds into her Maine Pooled Disability Trust (MPDT) account, the Maine Department of Health and Human Services (MDHHS) issued a notice threatening to suspend Medicaid coverage. Richardson and MPDT filed this lawsuit seeking a declaration that her transfer of assets into a pooled special needs trust was not a transfer that affected Medicaid eligibility. The district court dismissed the complaint, concluding that MDHHS correctly applied the governing statute in reaching its conclusion. The First Circuit affirmed, holding that the district court's judgment granting MDHHS's motion to dismiss rested on a reasonable interpretation of the statute. View "Maine Pooled Disability Trust v. Hamilton" on Justia Law

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Shea began serving in the Air Force in October 2006. Her pre-enlistment examination indicated a normal psychiatric condition. A January 2007 medical examination resulted in a diagnosis of an adjustment disorder with anxiety and depressed mood. Days later, Shea was struck by a truck while on base and sustained multiple physical injuries. Her subsequent medical records report anxiety, depression, and impaired memory. A medical evaluation board recommended that Shea be discharged. Shea was transferred to Dover Air Force Base, where her then-husband was stationed, to continue her treatment. A physical evaluation board determined in May 2007 that Shea’s pelvic fractures and transverse process fracture were unfitting conditions that were compensable and ratable but that her adjustment disorder with depression and anxiety was not separately unfitting nor compensable or ratable. In July 2007, Shea was discharged because of her physical disabilities. She sought benefits in October 2007. The VA granted benefits for her physical and psychiatric conditions, but rejected a request for a 2007 effective date for the psychiatric-disability benefits. The Veterans Court affirmed. The Federal Circuit vacated and remanded to allow the Veterans Court to articulate the correct legal standard in considering Shea’s October 2007 informal application for benefits. While a pro se claimant "must identify the benefit sought,” the identification need not be explicit and should be read in conjunction with other submissions and service treatment records. View "Shea v. Wilkie" on Justia Law