Justia Public Benefits Opinion Summaries

Plaintiff filed a lawsuit alleging state law claims arising from SelectHealth’s administration of her deceased husband’s MA plan and his death. Under Part C of the Medicare Act, beneficiaries can enroll in an MA plan and receive Medicare benefits through private MA organizations instead of the government. SelectHealth removed the action to federal court on the basis of diversity jurisdiction.   The Ninth Circuit affirmed the district court’s summary judgment in favor of SelectHealth, Inc. because the Medicare Act’s express preemption provision, 42 U.S.C. Section 1395w-26(b)(3), barred Plaintiff’s state law claims.   The court held that Section 1872 of Title XVIII of the SSA provides that Section 205(h) is applicable to cases under the Medicare Act to the same extent as in cases under Title II. The court concluded that enrollees in an MA plan must likewise first exhaust their administrative remedies before seeking judicial review of a claim for benefits.   Next, the court concluded that Plaintiff’s claims were not subject to the SSA’s exhaustion requirement because the dispute was not whether Plaintiff’s husband received a favorable outcome from the internal benefits determination process but rather whether he should have received the services earlier.   Further, the court held that Plaintiff’s claim that SelectHealth breached a duty to process timely her husband’s October 7, 2016, appeal was expressly preempted. Because the standards established under Part C supersede any state law duty that would impose obligations of MA plans on the same subject. View "NAOMI AYLWARD V. SELECTHEALTH, INC." on Justia Law

Plaintiff was civilly confined by court order pursuant to California’s Sexually Violent Predator Act (“SVPA”), after a probable cause hearing, but before a full civil commitment trial. While confined by court order in a state hospital, Plaintiff applied for Social Security disability benefits. The Social Security Administration (SSA) approved his application, and he received benefits.   In May 2014, the SSA notified Plaintiff that these benefits had been issued in error, and required him to refund the benefits previously paid. Plaintiff challenged that determination and requested a hearing before an Administrative Law Judge (ALJ). After a hearing, the ALJ determined that Section 402(x)(1)(A)(iii) made Plaintiff ineligible for benefits, and ordered him to repay the benefits to the SSA. Plaintiff sought judicial review of the ALJ’s decision and the district court concluded that Plaintiff was not eligible for disability benefits   The Ninth Circuit affirmed and held that the Commissioner did not err in concluding that Plaintiff was not eligible for benefits. The court reasoned the Social Security Act provides that no monthly benefits shall be paid to individuals who are confined at public expense, including someone who “immediately upon completion of confinement” for a criminal sexual offense “is confined in an institution at public expense pursuant to a finding that the individual is a sexually dangerous person or a sexual predator or a similar finding.”  Here, the state trial court’s confinement order in Plaintiff’s case was pursuant to a finding that he was a sexually dangerous person or a sexual predator or a similar finding. View "GEORGE ALLEN V. KILOLO KIJAKAZI" on Justia Law

Plaintiff appealed a judgment of the district court upholding an agency decision to deny her application for social security disability insurance benefits. Plaintiff argued that the administrative law judge (ALJ) who denied her claim erred by giving “little weight” to the opinion of one of her treating physicians.  The Eighth Circuit concluded that the ALJ permissibly weighed the evidence and affirmed the decision. The court held that the agency’s decision is supported by substantial evidence. On the record as a whole, the ALJ was justified in declining to give controlling weight to the conclusory opinion of Plaintiff’s treating physician.   The court reasoned that the doctor’s opinion was entitled to relatively little evidentiary value on its face because it was rendered on a check-box and fill-in-the-blank form. Further, the doctor’s opinion is also in tension with her own treatment notes. The treatment notes refer only to “evidence of elevated blood pressure levels and occasional skin abnormalities,” while observing “otherwise normal heart, lungs, and extremities.” Additionally, some of Plaintiff’s daily activities also undermined her doctor’s opinion of severe limitations. View "Deborah Swarthout v. Kilolo Kijakazi" on Justia Law

In 2009, six-month-old Trystan received vaccines, including DTaP-HepB-IPV. Hours later, Trystan developed a fever and was in pain; he developed a hot lump on his thigh. Trystan’s mother took him to urgent care, where he was diagnosed with a “common cold.” Trystan’s arm contortions continued. At his one-year exam, Trystan could not stand, crawl, grasp, hold his head up while sitting, or attempt to move his lower extremities. Trystan received additional vaccinations. His arm contortions returned. Trystan had muscle spasms, developmental delays, seizures, dystonia, and other neurologic issues. In 2014, Trystan was diagnosed with Leigh’s syndrome, a severe neurological disorder that often presents in the first year of life, is characterized by progressive loss of mental and movement abilities, and typically results in death. Genetic testing showed that Trystan has two associated disease-causing mutations.His parents sought compensation under the Vaccine Act, 42 U.S.C. 300aa–1. The Claims Court upheld determinations that Trystan did not experience neurologic deterioration until many weeks after his 2009 vaccination and that Trystan’s genetic mutations solely caused his Leigh’s syndrome. The Federal Circuit reversed. Because the contortions began within two weeks of his vaccinations, Trystan has shown a logical chain of cause and effect between his vaccination and his neurodegeneration, satisfying his burden. He is entitled to compensation unless the Secretary establishes the injury was due to factors unrelated to the vaccine. There is no evidence that Trystan’s mutations would have resulted in the same progression and severity of his Leigh’s syndrome absent the vaccine. View "T.S. v. Secretary of Health & Human Services" on Justia Law

Albert suffers from epilepsy, Asperger syndrome, ADHD, migraines, and insomnia. Born in 1998, Albert’s parents support her financially, help manage her medications, and assist her with daily living. Albert has never had a driver’s license nor worked. Albert graduated from high school in 2017. Although she struggled in math, her academic performance was otherwise average. She enrolled in an online college course but stopped attending after suffering a grand mal seizure in September 2017. She applied for supplemental security income.The ALJ determined that, although Albert suffered from severe mental and physical impairments, these impairments, taken alone or together, did not amount to a “listed disability"; Albert had the residual functional capacity to perform a full range of work at all exertional levels, subject to a few restrictions; Albert “was likely to have difficulty with social interactions” and had poor concentration and a low frustration tolerance; that Albert can “understand, carry out and remember simple instructions” and “make judgments commensurate with functions of simple, repetitive tasks”; and that there are a significant number of jobs that someone with Albert’s RFC could perform.The district court and Seventh Circuit affirmed the denial of benefit, finding substantial evidence supporting the ALJ’s determination. “Should Albert try to work but find herself unable, nothing will prevent her from applying anew for benefits.” View "Albert v. Kijakazi" on Justia Law

Groves served in the Army on active duty, 1970-1971, including service in Vietnam. In 1990, a VA regional office awarded Groves benefits for PTSD, shell fragment wounds, and a nerve injury. In 1998, Groves sought education benefits through the Vocational Rehabilitation and Employment (VRE) program. Groves never attended the initial VRE evaluation—due at least in part to the isolated nature of his town and his asserted inability to travel—notwithstanding the VA counseling officer’s attempts to accommodate Groves over a period of years. During the ensuing proceedings, Groves twice sent the VA letters in which he stated that he “enjoin[ed]” further action on the claims.“The Board of Appeals ultimately denied Groves entitlement to VRE benefits, finding that his letters did “not constitute[] withdrawal[s] of the appeal, such that there [was] no basis for the Board to not proceed.” The Veterans Court affirmed, finding that the Board lacked authority to adjudicate Groves’s appeal under “Hamilton,” which required an automatic stay when requested by a veteran but that any error was harmless. The Federal Circuit vacated. The Veterans Court legally erred in finding that the Board was compelled to grant an automatic indefinite stay of proceedings; it should have determined whether Groves had established good cause for a stay and, if so, the appropriate duration and conditions of the stay. View "Groves v. McDonough" on Justia Law

On active Army duty in the 1970s, Kennedy fell from a lawnmower and injured his knee. Although no disability was noted at his discharge, Kennedy received service connection for his knee injury in 2000. He later received service connection for depression secondary to his knee injury. In 2005, Kennedy died; his death certificate listed “melanoma, metastatic” as the immediate cause of death and listed “other significant conditions contributing to death,” including diabetes, hypertension, and “depression disorder.” Mrs. Kennedy three times unsuccessfully sought Dependency and Indemnity Compensation (DIC), 38 C.F.R. 3.114. The VA found no evidence that Kennedy’s death was related to military service.In 2013, VA “Fast Letter 13-04, “Simplified Processing of Dependency and Indemnity Compensation (DIC) Claims,” instructed personnel to grant “service connection for the cause of death when the death certificate shows that the service-connected disability is [a] . . . contributory cause of death.” In 2015, the VA granted Mrs. Kennedy DIC, effective July, 2015. The Board of Appeals denied her appeal of the effective date, explaining that Fast Letter 13-04 was a “change[] to VA procedural manuals and guidance provisions,” not a liberalizing law or liberalizing VA issue. The Veterans Court affirmed, reasoning that Fast Letter 13-04 does not constitute a VA issue approved by the Secretary because it does not bind the Agency. The Federal Circuit affirmed. Kennedy forfeited her argument that the Veterans Court erred in its interpretation of “VA issue.” View "Kennedy v. McDonough" on Justia Law

Plaintiff, who receives two government pensions, one from noncovered employment and one from covered employment, alleged that the Government Pension Offset (“GPO”) should not apply to his benefits. During Plaintiff’s administrative proceedings, the Social Security Administration (“SSA” or the “agency”) agreed with Plaintiff and paid him spousal benefits without applying any offset. Ultimately, though, the agency decided that the GPO should apply. The agency then temporarily withheld Plaintiff’s spousal benefits to recoup approximately $15,000 in overpayments to him, and it reduced his spousal benefits going forward. On appeal, the parties disputed whether the GPO applies to Plaintiff’s spousal benefits and if it does apply, whether the agency was entitled to recoup the overpayment.   The Ninth Circuit held that the GPO applies to Plaintiff’s spousal benefits but that a remand to the agency is necessary to determine whether SSA was entitled to recoupment. The court reasoned that under both the old and new version of Social Security regulation 20 C.F.R. Sec 404.408a, the existence of Plaintiff’s pension earned through noncovered employment triggered the GPO’s application to his spousal benefits notwithstanding his later covered employment in a job with a different pension plan.  Further, the court held that the ALJ’s finding of Plaintiff’s fault for the overpayment was not supported by substantial evidence and that on remand the agency could consider whether any evidence in the record beyond that relied on by the ALJ supported the proposition that Plaintiff was at fault for the overpayment and, if so, whether recoupment would be appropriate. View "PAUL MISKEY V. KILOLO KIJAKAZI" on Justia Law

In July 2019, the Appeals Council denied Claimant’s appeal without elaboration. Claimant challenged, among other rulings, the ALJ’s analysis of her testimony. Claimant did not assert any constitutional challenges to the district court. The district court entered a judgment reversing the ALJ’s denial of benefits and remanded the matter to the agency for further proceedings. The Commissioner filed a motion pursuant to Federal Rule of Civil Procedure 59(e) to amend or alter the judgment, arguing that the court had clearly erred by overlooking the ALJ’s explanation for rejecting Claimant’s testimony. The district court agreed with the Commissioner and entered an order granting the Rule 59(e) motion   The Ninth Circuit affirmed the amended judgment in favor of the Commissioner.  The court upheld the Commissioner’s decision denying her application for benefits because claimant did not show that the removal provision caused her any actual harm. Further, Federal Rule of Civil Procedure 59(e) allows a district court to alter or amend a judgment if the court determines that its original judgment was clearly erroneous. Because the district court properly concluded that it had clearly erred in its original ruling in favor of Claimant, the court’s granting of the Commissioner’s Rule 59(e) motion fell within the court’s considerable discretion View "JODY KAUFMANN V. KILOLO KIJAKAZI" on Justia Law

Plaintiff sought benefits under the Social Security Act based on various physical and mental impairments. An administrative law judge (“ALJ”) found that she was not disabled and denied her claim. The district court affirmed.The Ninth Circuit affirmed the district court’s decision affirming the Commissioner of Social Security’s denial of claimant’s application for benefits under the Social Security Act based on various physical and mental impairments.The court decided that recent changes to the Social Security Administration’s regulations displaced case law requiring an administrative law judge (“ALJ”) to provide “specific and legitimate” reasons for rejecting an examining doctor’s opinion. The “relationship factors”, such as length and purpose of the treatment relationship, frequency of visits, and extent of examinations the medical source has performed are still relevant. However, the ALJ no longer needs to make specific findings regarding those factors. Under the new regulations, an ALJ cannot reject an examining or treating doctor’s opinion without providing an explanation supported by substantial evidence.In this case, the ALJ acknowledged the doctor’s opinion that the claimant had marked and extreme limitations in various cognitive areas; but the ALJ found this opinion unpersuasive because it was inconsistent with the overall notes in the record. The court held that substantial evidence supported the ALJ’s finding. View "LESLIE WOODS V. KILOLO KIJAKAZI" on Justia Law