Justia Public Benefits Opinion Summaries

In this case arising from what the Social Security Administration (SAA) did to Appellants, Marie Pagan-Lisboa and Daniel Justiniano-Ramirez, after Jose Hernandez-Gonzalez and Samuel Torres-Crespo admitted to fraudulently helping people get disability-insurance benefits from the SAA, the First Circuit held that Appellants were entitled to a new redetermination proceeding.With the help of Hernandez-Gonzalez and Torres-Crespo, Pagan-Lisboa applied for and started getting disability benefits from the SAA. An ALJ determined that Pagan-Lisboa did not have sufficient evidence to support her initial benefits claim and terminated her benefits. An ALJ also canceled Justiniano-Ramirez's benefits benefits on the grounds that Hernandez-Gonzalez had provided fraudulent evidence in support of the benefits. Thereafter, Appellants sued a putative class action, arguing that the SAA could not terminate their benefits without letting them contest the existence of fraud in their cases. The court of appeals affirmed the ALJ's decision in Justiniano-Ramírez's case and remanded Pagan-Lisboa's case back to the agency. The First Circuit held (1) the judge erred in not accepting Justiniano-Ramírez's amended complaint, which showed that he had exhausted his administrative remedies; and (2) the judge did not wrongly dismiss Appellants' policy challenges to the redetermination procedure. View "Pagan-Lisboa v. Social Security Administration" on Justia Law

Petitioners, whose applications for disability benefits were denied by the Social Security Administration (SSA) unsuccessfully challenged their adverse determinations before an SSA administrative law judge (ALJ). The SSA Appeals Council denied discretionary review in each case. Thereafter, the Supreme Court decided Lucia v. SEC, holding that the appointment of Securities and Exchange Commission ALJs by lower-level staff violated the Constitution’s Appointments Clause. The SSA ALJs were also appointed by lower-level staff. The Courts of Appeals held that the petitioners could not obtain judicial review of their Appointments Clause claims because they failed to raise those challenges in their administrative proceedings. The Supreme Court reversed. The Courts of Appeals erred in imposing an issue-exhaustion requirement on petitioners’ Appointments Clause claims. Administrative review schemes commonly require parties to give the agency an opportunity to address an issue before seeking judicial review of that question. If no statute or regulation imposes an issue-exhaustion requirement, courts decide whether to require issue exhaustion based on “an analogy to the rule that appellate courts will not consider arguments not raised before trial courts.” In the context of petitioners’ Appointments Clause challenges, two considerations tip the scales against imposing an issue-exhaustion requirement: agency adjudications are generally ill-suited to address structural constitutional challenges, which usually fall outside the adjudicators’ areas of technical expertise, and the Supreme Court has consistently recognized a futility exception to exhaustion requirements. Petitioners assert purely constitutional claims about which SSA ALJs have no special expertise and for which they can provide no relief. View "Carr v. Saul" on Justia Law

MAO-MSO acquired rights to collect conditional payments that Medicare Advantage Organizations (MAOs) made if a primary insurer (such as automobile insurance carriers) has not promptly paid medical expenses. MAO-MSO sued those primary payers. The district court proof of required actual injury. Specifically, MAO-MSO needed to identify an “illustrative beneficiary”— a concrete example of a conditional payment that State Farm, the relevant primary payer, failed to reimburse to the pertinent MAO. MAO-MSO alleged that “O.D.” suffered injuries in a car accident and that State Farm “failed to adequately pay or reimburse” the appropriate MAO. The district court determined that these allegations sufficed for pleading purposes to establish standing.As limited discovery progressed, MAO-MSO struggled to identify evidence supporting the complaint. One dispute centered on whether O.D.’s MAO made payments related to medical care stemming from a car accident before State Farm reached its limit under O.D.’s auto policy so that State Farm should have reimbursed the MAO. The payment in question was to a physical therapist. State Farm argued that the physical therapy services had no connection to O.D.’s car accident and related only to her prior knee surgery.The district court determined no reasonable jury could find that the payment related to O.D.’s car accident, meaning that MAO-MSO lacked standing. The Seventh Circuit affirmed the dismissal. The Medicare Act may authorize the lawsuit but MAO-MSO fail to establish subject matter jurisdiction by establishing an injury in fact. View "MAO-MSO Recovery II, LLC v. State Farm Mutual Automobile Ins. Co." on Justia Law

Alma Vidauri was convicted of one count of theft and three counts of forgery in connection with filings she made with the Garfield County, Colorado Department of Human Services (“Department”) between 2009 and 2016 for medical assistance benefits. A division of the court of appeals concluded that the evidence was insufficient because the prosecution had not shown the difference in value between the total amount of certain public benefits Vidauri received and the amount for which she might have been eligible had she accurately reported her household income. Therefore, the division reversed the trial court and entered judgment for the lowest level of theft, a class 1 petty offense. The Colorado Supreme Court reversed the division, finding the applicable theft statute placed no burden on the prosecution to establish that Vidauri would have been ineligible for any of the benefits she received. "Because an applicant is not entitled to, and so has no legally cognizable interest in, any benefits until she has submitted accurate information demonstrating as much, we conclude that all the benefits Vidauri received by submitting false information were obtained by deception. Therefore, the original judgment of conviction for a class 4 felony must be reinstated." View "Colorado v. Vidauri" on Justia Law

Morse served in the Navy, 1970-1972; including six months in Da Nang, Vietnam. In 1999, Morse filed a claim for compensation, listing several disabilities, including PTSD. A VA regional office granted him a nonservice-connected pension in 2001, based on joint disease. He later obtained Social Security disability benefits. In 2002, the regional office denied Morse’s claim of service connection for PTSD, finding "no credible evidence of verification of the claimed stressors.” In 2004, Morse sought to reopen his PTSD claim. The regional office received service department records in 2005, showing that in 1972 a psychiatrist reported that Morse appeared “moderately depressed” about personal problems. An examiner concluded that Morse was unable to provide convincingly relate symptoms to his reported military exposure. The Board of Veterans’ Appeals affirmed.In 2009, Morse sought to reopen his claim. A VA examiner diagnosed Morse as suffering from PTSD. The Joint Services Records Research Center (JSRRC) coordinator's memo noted that the events “reported by the veteran" are "consistent" with the conditions of service "even though we were unable to locate official records of the specific occurrence.” Morse was granted service connection for PTSD, effective in 2009. The Board in 2016 affirmed; because no additional service records had been obtained since the Board’s 2008 decision, the VA was not required to conduct another reconsideration. In 2018, the Board found that the 2010 JSRRC memorandum did not constitute an “official service department record”; Morse was “essentially attacking the merits of" the 2008 Board decision, "which is final.”The Veterans Court and Federal Circuit affirmed; the “VA’s obligation to reconsider the PTSD claim upon receipt of new service department records was exhausted in 2008.” The 2010 JSRRC memorandum did not constitute a service department record that triggered a renewed obligation to reconsider Morse’s claim. View "Morse v. McDonough" on Justia Law

The Seventh Circuit affirmed the ALJ's determination that plaintiff has the capacity to perform light work and is therefore not entitled to disability benefits. Plaintiff claimed that the ALJ committed reversible error when determining her residual functional capacity (RFC) by selectively reviewing evidence of cervical and lumbar degenerative disc disease (back problems); incorrectly discounting plaintiff's credibility regarding her description of the intensity, persistence, and limiting effects of her symptoms; and not including any manipulative limitations in the RFC assessment.The court found plaintiff's arguments unpersuasive and concluded that substantial evidence supports the ALJ's denial of benefits where the ALJ did not ignore a line of evidence contradicting her decision; the ALJ's assessment of plaintiff's symptoms was not patently wrong; and the ALJ did not fail to note any supported manipulative limitations. View "Deborah M. v. Saul" on Justia Law

For decades, the U.S. Virgin Islands Government Employees Retirement System (GERS) experienced annual deficits between its assets and projected liabilities to participants. Its aggregate shortfall is now about three billion dollars. The Government of the Virgin Islands (GVI) has sometimes failed to remit to GERS all the employer contributions it is statutorily mandated to make. GERS sued GVI for these contributions, first in 1981, resulting in a consent judgment, and most recently in 2016, when GERS sought to enforce that judgment. GERS claimed that, as far back as 1991, GVI had contributed tens of millions of dollars less than required by the statutory percentages of employee compensation. GERS also claimed that independent of these fixed-percentage contributions, GVI must fund GERS to the point of actuarial soundness.The district court awarded GERS an amount calculated to reflect GVI’s historical percentage-based under-contributions. The Third Circuit affirmed that award of principal but vacated an enhancement of the award that applied late-arriving interest and penalty statutes, enacted in 2005, retroactively. The consent judgment does not require GVI to fund GERS for the gap between its assets and liabilities. Virgin Islands law apparently fails to obligate anyone to fund GERS when employee-compensation-based contributions and associated investment returns fall short of the assets required, based on actuarial assessments, to meet future pension commitments. The citizens of the Virgin Islands (population 106,4052) simply cannot pay the necessary billions. The cure for GERS’s chronic underfunding is legislative. View "Government Employees Retirement System of the Virgin Islands v. Government of the Virgin Islands" on Justia Law

Pavlicek, age 49. applied for Disability and Supplemental Security Income benefits. He suffers from anxiety, depression, severe tremors, and pseudoseizures that resemble epileptic seizures but stem from psychological causes. A truck driver, he has a high-school education. Two non-examining agency consultants determined that he could function with some limitations. Pavlicek testified that he had constant tremors and had seven pseudoseizures in the past 16 months when he lost consciousness; in seven other episodes, he remained conscious. A vocational expert testified about employers’ tolerance for absenteeism and about a hypothetical employee with various restrictions. The treating psychiatrist reported that Pavlicek could not work.The ALJ determined that Pavlicek retained the residual functional capacity to perform medium work with exceptions and could perform work that existed in significant numbers in the national economy. The ALJ largely dismissed the report by the treating psychiatrist, who had not justified how his findings could apply “as far back as 2013,” having not treated Pavlicek until 2015 and who relied heavily on Pavlicek’s subjective reporting. The ALJ noted the “infrequent” nature of the treatment relationship and that the report’s assessment of severe functional limitations was unsupported by the clinical records. The Seventh Circuit affirmed. The decision was supported by substantial evidence. The court rejected claims that the ALJ gave inadequate reasons for rejecting the treating psychiatrist's opinion, afforded too much weight to the opinions of non-examining agency physicians, and posed hypothetical questions to the vocational expert that failed to account for his limitations. View "Pavlicek v. Saul" on Justia Law

Vollono served on active duty in the Navy, 1996-1997 and 2001-2005. Vollono’s second stint was compulsory as a condition of his Naval Academy education. Vollono used chapter 30 Montgomery G.I. Bill educational benefits to pursue post-graduate education, 38 U.S.C. 3001, 3011. In 2009, the VA notified Vollono that he might be eligible for chapter 33 Post-9/11 G.I. Bill educational assistance. Vollono was mistakenly found eligible and elected to receive Post-9/11 benefits in lieu of Montgomery benefits to complete post-graduate education. In 2011, the VA regional office (RO) notified Vollono that he had erroneously received $60,507.08 in benefits, because his post-9/11 service was obligatory, precluding his eligibility for such benefits. The VA did not recoup the benefits. The Board of Veterans’ Appeals and Veterans Court affirmed the decision.The Board found that Vollono did not waive entitlement to Montgomery benefits; the RO found Vollono eligible for $29,107 in Montgomery benefits for completing his studies but found that it could not release payment of these funds that would be duplicative of his previous receipt of Post-9/11 benefits. The Board agreed, reasoning that 38 C.F.R. 21.7143(a) and 38 U.S.C. 3033 preclude the payment of duplicative educational benefits regardless of current eligibility. The Veterans Court and Federal Circuit affirmed. Awarding Montgomery benefits to Vollono would “lead to an absurd result of placing the appellant in a better position than that of those worthy veterans who were actually eligible for Post-9/11 GI Bill benefits.” View "Vollono v. McDonough" on Justia Law

Rush retired in 2012. The California State Teachers Retirement System (CalSTRS) calculated his pension as 92.58 percent of his final compensation. Rush disputed the determination of his “final compensation,” defined as “the highest average annual compensation earnable by a member during any period of 12 consecutive months” For 12 consecutive months over portions of two school years, Rush served as an associate dean at a salary significantly higher than his salary during the other portions of those years.CalSTRS applied Education Code section 22115(d): If a member worked at least 90 percent of a school year at the higher pay rate, compensation earnable was to be calculated as if the member earned all service credit for the year at the higher rate. If the member worked less than 90 percent of the year at the higher rate, as Rush did, compensation earnable “shall be the quotient obtained when creditable compensation paid in that year is divided by the service credit for that year.” The court of appeal upheld CalSTRS’s calculation as within the range of reasonable statutory construction. View "Rush v. State Teachers' Retirement System" on Justia Law