Justia Public Benefits Opinion Summaries

The Public Employees Retirement Law, Government Code section 21156, defines disability as being “incapacitated physically or mentally.” A governmental employee loses the right to claim disability benefits if terminated for cause. The Third Appellate District identified exceptions: under “Haywood,” a terminated-for-cause employee can qualify for disability retirement when the conduct which prompted the termination was the result of the disability; under “Smith,” a terminated employee may qualify for disability retirement if he had a “matured right” to a disability retirement before that conduct; Smith further recognized that “a court, applying principles of equity,” could deem an employee’s right to a disability retirement to be matured to survive a dismissal for cause. The Board of Administration of the California Public Employees Retirement System (CalPERS) adopted a precedential decision (Vandergoot) that an employee settling a pending termination for cause and agreeing not to seek reemployment is “tantamount to a dismissal,” precluding a disability retirement. Martinez, a former state employee, settled the termination for cause action against her and agreed to resign and not re-apply for employment. CalPERS denied her application for disability retirement. The trial court and court of appeal concluded that Haywood and Smith were binding as stare decisis and that “Vandergoot is a reasonable extension.” The courts rejected an argument that a 2008 enactment tacitly “superseded” Haywood and Smith. View "Martinez v. Public Employees' Retirement System" on Justia Law

The 2007 Act, 40 ILCS 5/16-106(10), amended the Pension Code, which governs the Teachers’ Retirement System (TRS): An officer or employee of a statewide teachers’ union was permitted to establish TRS service credit if the individual: was certified as a teacher no later than February 27, 2007, applied to the TRS within six months, and paid into the system both the employee contribution and employer (state) contribution, plus interest, for his prior union service. Plaintiff worked as a union lobbyist from 1997 until his 2012 retirement. In 2006, plaintiff obtained a substitute teaching certificate. In January 2007, he worked one day as a substitute teacher. Within six months, plaintiff became a member of the TRS. Plaintiff then contributed $192,668 to the system for his union service. In 2011, the Chicago Tribune published an article, identifying plaintiff and criticizing the law that allowed him to qualify for a teacher’s pension. In response to the negative media coverage, the 2012 Act repealed the 2007 amendment and provided for a refund of contributions. TRS eliminated plaintiff’s service credits and refunded his contributions. Plaintiff sought a declaratory judgment that the retroactive repeal violated the state constitution’s pension protection clause (Ill. Const. 1970, art. XIII).The Illinois Supreme Court ruled in favor of plaintiff. The 2007 amendment's inclusion of a cutoff date did not render it unconstitutional special legislation (Ill. Const. 1970, art. IV); the amendment applied generally to all eligible employees who met its criteria. Under the pension clause, “once a person commences to work and becomes a member of a public retirement system, any subsequent changes to the Pension Code that would diminish the benefits conferred by membership in the retirement system cannot be applied to that person.” View "Piccioli v. Board of Trustees of the Teachers’ Retirement System" on Justia Law

Biestek, a former construction worker, applied for social security disability benefits, claiming he could no longer work due to physical and mental disabilities. To determine whether Biestek could successfully transition to less physically demanding work, the ALJ heard testimony from a vocational expert regarding the types of jobs Biestek could still perform and the number of such jobs that existed in the national economy. The statistics came from her own market surveys. The expert refused Biestek’s attorney's request to turn over the surveys. The ALJ denied Biestek benefits. An ALJ’s factual findings are “conclusive” if supported by “substantial evidence,” 42 U.S.C. 405(g).The Sixth Circuit and the Supreme Court upheld the ALJ’s determination. A vocational expert’s refusal to provide private market-survey data upon the applicant’s request does not categorically preclude the testimony from counting as “substantial evidence.” In some cases, the refusal to disclose data, considered along with other shortcomings, will undercut an expert’s credibility and prevent a court from finding that “a reasonable mind” could accept the expert’s testimony; the refusal will sometimes interfere with effective cross-examination, which a reviewing court may consider in deciding how to credit an expert’s opinion. In other cases, even without supporting data, an applicant will be able to probe the expert’s testimony on cross-examination. The Court declined to establish a categorical rule, applying to every case in which a vocational expert refuses a request for underlying data. The inquiry remains case-by-case, taking into account all features of the expert’s testimony, with the rest of the record, and defers to the presiding ALJ. View "Biestek v. Berryhill" on Justia Law

Blue Valley Hospital, Inc., (“BVH”) appealed a district court’s dismissal of its action for lack of subject matter jurisdiction. The Department of Health and Human Services (“HHS”) and the Centers for Medicare and Medicaid Services (“CMS”) terminated BVH’s Medicare certification. The next day, BVH sought an administrative appeal before the HHS Departmental Appeals Board and brought this action. In this action, BVH sought an injunction to stay the termination of its Medicare certification and provider contracts pending its administrative appeal. The district court dismissed, holding the Medicare Act required BVH exhaust its administrative appeals before subject matter jurisdiction vested in the district court. BVH acknowledged that it did not exhaust administrative appeals with the Secretary of HHS prior to bringing this action, but argued: (1) the district court had federal question jurisdiction arising from BVH’s constitutional due process claim; (2) BVH’s due process claim presents a colorable and collateral constitutional claim for which jurisdictional exhaustion requirements are waived under Mathews v. Eldridge, 424 U.S. 319 (1976); and (3) the exhaustion requirements foreclosed the possibility of any judicial review and thus cannot deny jurisdiction under Bowen v. Michigan Academy of Family Physicians, 476 U.S. 667 (1986). The Tenth Circuit disagreed and affirmed dismissal. View "Blue Valley Hospital v. Azar" on Justia Law

The Eighth Circuit affirmed the district court's dismissal of plaintiff's action challenging the denial of his application for disability insurance benefits. The court held that plaintiff was not entitled to equitable tolling of the time limit, because no extraordinary circumstance prevented him from timely filing an action in the district court. In this case, plaintiff's failure to file his appeal despite clear, repeated instructions that he should do so, was at best a garden variety claim of excusable neglect for which equitable tolling was unavailable. Therefore, plaintiff's action was time-barred and was properly dismissed by the district court. View "Thompson v. Commissioner of Social Security Administration" on Justia Law

The First Circuit reversed the order of the district court ruling that the automatic stay provision of the Puerto Rico Oversight, Management, and Economic Stability Act (PROMESA) did not apply to proceedings to determine the amount of federal court-ordered payments that the Commonwealth owed to several federally qualified health centers (FQHCs) per a 2010 injunction, holding that the automatic stay applied in this case.In 2003, several FQHCs sought to enjoin the Secretary of the Department of Health of Puerto Rico from failing to reimburse them for their reasonable costs of providing services to Medicaid patients. In 2018, the Commonwealth filed a motion notifying the district court that the Commonwealth had filed for bankruptcy under Title III of PROMESA and, therefore, the litigation was subject to the automatic stay. The district court ruled that the automatic stay did not apply. The First Circuit reversed, holding that certain provisions of PROMESA did not preclude the automatic stay’s application in this case. View "Migrant Health Center, Inc. v. Commonwealth of Puerto Rico" on Justia Law

The Commissioner of Social Security imposed an assessment of $51,410 and a civil monetary penalty of $75,000 on Valent after the Social Security Administration found that Valent failed to disclose that she had engaged in paid work activity while receiving Social Security disability benefits. Valent argued that 42 U.S.C. 421(m)(1)(B) prohibits the Administration from considering her work activity in determining whether she continues to be eligible as a disability-benefits recipient and that her failure to disclose her paid work activity was, therefore, not a material omission, and that even if her failure to disclose her paid work activity was a material omission, she did not have actual or constructive knowledge that her omission was material. The Sixth Circuit affirmed, rejecting Valent’s argument that the Administration can consider “substantial gainful activity” but not “work” or “work activity.” The Administration’s interpretation is a permissible construction of the statute and Valent’s construction “would be impossible to implement.” The Administration would be unable to examine a beneficiary’s substantial gainful activity without considering the beneficiary’s work activity that generates profit or pay. Valent had constructive notice that her failure to report her work activity that generated profit or pay was a material omission that misled the Administration. View "Valent v. Commissioner of Social Security" on Justia Law

Hernandez filed a voluntary Chapter 7 bankruptcy petition in December 2016, reporting one sizable asset: a pending workers’ compensation claim valued at $31,000. To place that claim beyond the reach of creditors, she listed it as exempt under section 21 of the Illinois Workers’ Compensation Act, 820 ILCS 305/21, applicable via 11 U.S.C. 522(b). Two days after filing for bankruptcy, Hernandez settled the claim. Hernandez owed significant sums to three healthcare providers who treated her work-related injuries. The providers objected to her claimed exemption, arguing that 2005 amendments to the Illinois Act enable unpaid healthcare providers to reach workers’ compensation awards and settlements. The bankruptcy court denied the exemption and the district judge affirmed. The Seventh Circuit certified to the Illinois Supreme Court the question: Whether the Illinois Workers’ Compensation Act, as amended, allows care-provider creditors to reach the proceeds of workers’ compensation claims. The court noted that Section 21 has been interpreted by bankruptcy courts to create an exemption for these assets; 2005 amendments imposed a new fee schedule and billing procedure for care providers seeking remuneration. The Illinois Supreme Court has not addressed the interplay between these competing components of state workers’ compensation law. View "Hernandez v. Marque Medicos Fullerton, LLC" on Justia Law

MSPA, a firm that obtains Medicare Secondary Payer Act (MSP Act) claims and brings them on behalf of Medicare Advantage Organizations (MAOs), filed suit against Tenet over a delayed reimbursement of $286. The Eleventh Circuit affirmed the district court's grant of Tenet's motion to dismiss. The court held that MSPA had standing to invoke a federal court's jurisdiction because it suffered an injury in fact when it had to wait seven months for appropriate reimbursement and it validly assigned the right to vindicate that injury to La Ley Recovery Systems, who in turn validly assigned it to MSPA.On the merits, the court held that the MSP Act's private cause of action was only available in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement). In this case, MSPA did not sue a primary plan, but instead, it sued two medical services providers. Because private MSP Act plaintiffs could only sue primary plans, and MSPA had not done so, its claim was not plausible on its face. Therefore, the district court correctly dismissed MSPA's complaint for failure to state a claim. View "MSPA Claims 1, LLC v. Tenet Florida, Inc." on Justia Law

Ruel served in the Marine Corps, 1966-1969, including two tours in Vietnam; he was exposed to Agent Orange. He died in 1984. His wife, Teresa, sought benefits. In July 1984, the VA received her Form 21-534, which the VA treats as an application for Dependency and Indemnity Compensation (DIC) a benefit paid to eligible survivors of veterans whose death resulted from a service-related injury or disease, and for a Death Pension, a benefit payable to a low-income, un-remarried surviving spouse of a deceased veteran with wartime service, 38 U.S.C. 5101(b)(1). The claim for pension benefits was denied based on her income; the denial did not mention a DIC claim. In response to Teresa's “Application for Burial Benefits,” the VA authorized payment of $150.00, stating: The evidence does not show that the veteran’s death was due to a service-connected condition. Teresa did not appeal. In 2009, ischemic heart disease was added to the presumptive list of diseases related to herbicide exposure while serving in Vietnam. Teresa submitted a new Form 21-534. Her claim was granted with an effective date of October 2009. Teresa sought an effective date of July 1984 arguing that the VA never adjudicated her 1984 DIC claim, which remained “pending.” The Federal Circuit reversed the Board and Veterans Court; proper notice of an explicit denial of a claim under 38 C.F.R. 3.103 requires an actual statement or otherwise clear indication of the claim being denied. View "Ruel v. Wilkie" on Justia Law