Justia Public Benefits Opinion Summaries

Johnson worked successively as a firefighter for South San Francisco (CSSF) and Pacifica. He developed nasopharyngeal cancer. Labor Code section 3212.11 establishes a presumption that cancer manifesting during and for a specified period following employment in certain public safety positions, including firefighters, arose out of and in the course of that employment. Section 5500.5(a) limits employer liability for a cumulative injury to the employer who employed the applicant during the one year preceding the earliest of the date of injury or the last date of injurious exposure to the hazards that caused the injury, so either CSSF or Pacifica would be potentially responsible for compensation for the entire injury. CSSF settled Johnson's workers’ compensation claim and sought contribution from Pacifica. An arbitrator denied the petition, ruling that evidence of the latency period for Johnson's cancer showed the injurious exposure occurred during Johnson’s earlier employment with CSSF. The Workers’ Compensation Appeals Board adopted the order. CSSF argued the Board erroneously utilized a more lenient preponderance evidentiary standard in applying section 5500.5(a), rather than the more stringent cancer presumption rebuttal standard of section 3212.1. The court of appeal affirmed; the evidence supports the award. Worker protection policies embodied in section 3212.1 are not implicated in the allocation of liability between employers. View "City of South San Francisco v. Workers' Compensation Appeals Board" on Justia Law

Guzman was operating a soil compactor on a hillside with a 45-degree slope when the compactor hit a rock. The compactor rose in the air, causing Guzman to fall backward, and then fell on top of him. The workers’ compensation judge determined that Guzman sustained an injury to his back and psyche and that the psychiatric injury was caused by a “sudden and extraordinary employment condition,” Lab. Code, 3208.3(d). The workers’ compensation carrier for Guzman’s employer unsuccessfully sought reconsideration by the Workers’ Compensation Appeals Board, arguing that Guzman failed to meet his burden of proving that his psychiatric injury was caused by a “sudden and extraordinary employment condition.” The court of appeal annulled the Board’s order denying reconsideration. Guzman did not provide any evidence establishing that it is “uncommon, unusual, and totally unexpected” for a rock to be in soil, for a compactor to rise when striking a rock, or for an operator to become unbalanced and to fall when the compactor rises on a 45-degree hillside. He did not introduce any evidence regarding what regularly or routinely happens if a compactor hits a rock on a slope. Guzman admitted that he had previously worked on flat surfaces only. View "State Compensation Insurance Fund v. Workers’ Compensation Appeals Board" on Justia Law

Shamrock Psychiatric Clinic, P.A., a Medicaid provider, was entitled to a contested-case hearing on the merits of the State’s claim to recoup alleged overpayments.Texas law directs the Inspector General to recover from a Medicaid provider any “overpayment” identified in a fraud or abuse investigation. Here, Shamrock received a “Notice of Payment Hold." Shamrock requested an expedited administrative hearing. Shamrock later received a “Final Notice of Overpayment.” The parties agreed to consolidate the payment hold and overpayment issues into one proceeding. The administrative law judge (ALJ) dismissed the overpayment and payment-hold cases due to Shamrock’s failure to submit a timely written request for an appeal. Shamrock filed suit. The trial court granted the Inspector General’s plea to the jurisdiction on sovereign immunity grounds. Shamrock appealed, arguing that the ALJ and Inspector General had a ministerial duty to abide by a Rule 11 agreement created by the parties’ communications and the Inspector General’s written representations. The court of appeals affirmed. The Supreme Court reversed, holding (1) the parties agreed that Shamrock would defend itself against the overpayment claims in a contested-cse hearing; (2) the ALJ failed to perform the purely ministerial act of enforcing the Rule 11 agreement; and (3) therefore, the ultra vires exception to sovereign immunity applied to Shamrock’s suit. View "Shamrock Psychiatric Clinic, P.A. v. Texas Department of Health & Human Services" on Justia Law

Shamrock Psychiatric Clinic, P.A., a Medicaid provider, was entitled to a contested-case hearing on the merits of the State’s claim to recoup alleged overpayments.Texas law directs the Inspector General to recover from a Medicaid provider any “overpayment” identified in a fraud or abuse investigation. Here, Shamrock received a “Notice of Payment Hold." Shamrock requested an expedited administrative hearing. Shamrock later received a “Final Notice of Overpayment.” The parties agreed to consolidate the payment hold and overpayment issues into one proceeding. The administrative law judge (ALJ) dismissed the overpayment and payment-hold cases due to Shamrock’s failure to submit a timely written request for an appeal. Shamrock filed suit. The trial court granted the Inspector General’s plea to the jurisdiction on sovereign immunity grounds. Shamrock appealed, arguing that the ALJ and Inspector General had a ministerial duty to abide by a Rule 11 agreement created by the parties’ communications and the Inspector General’s written representations. The court of appeals affirmed. The Supreme Court reversed, holding (1) the parties agreed that Shamrock would defend itself against the overpayment claims in a contested-cse hearing; (2) the ALJ failed to perform the purely ministerial act of enforcing the Rule 11 agreement; and (3) therefore, the ultra vires exception to sovereign immunity applied to Shamrock’s suit. View "Shamrock Psychiatric Clinic, P.A. v. Texas Department of Health & Human Services" on Justia Law

In 2006, Moreno fell off scaffolding and landed on his back while working. An orthopedist found a soft tissue injury but no signs of fracture. He continued to feel significant pain. A follow-up test revealed acute lumbar radiculopathy—lower back pain caused by compression, inflammation or injury to a spinal nerve root. Moreno also is diabetic, has high blood pressure, and is obese. Moreno sought treatment from a psychologist, who reported that Moreno manifested depressed mood, irritability, memory difficulties, inability to concentrate, and an ongoing inability to sleep, sometimes for days. Moreno took several medications. In 2007, Moreno sought Supplemental Security Income and Disability Insurance Benefits. An ALJ affirmed the denial of his application. In the district court, the parties agreed to a remand to a different ALJ, who concluded that Moreno was not disabled although he was suffering from severe impairments and could not perform his past work as a drywall taper. The Seventh Circuit reversed. The ALJ improperly relied on an outdated assessment although later evidence containing new, significant medical diagnoses reasonably could have changed the reviewing physician’s opinion. Doctors’ notes set forth problems with Moreno becoming distracted, “spacing out,” and experiencing difficulties concentrating; these limitations were not included in the hypothetical question posed to the vocational expert. View "Moreno v. Berryhill" on Justia Law

In 2006, Moreno fell off scaffolding and landed on his back while working. An orthopedist found a soft tissue injury but no signs of fracture. He continued to feel significant pain. A follow-up test revealed acute lumbar radiculopathy—lower back pain caused by compression, inflammation or injury to a spinal nerve root. Moreno also is diabetic, has high blood pressure, and is obese. Moreno sought treatment from a psychologist, who reported that Moreno manifested depressed mood, irritability, memory difficulties, inability to concentrate, and an ongoing inability to sleep, sometimes for days. Moreno took several medications. In 2007, Moreno sought Supplemental Security Income and Disability Insurance Benefits. An ALJ affirmed the denial of his application. In the district court, the parties agreed to a remand to a different ALJ, who concluded that Moreno was not disabled although he was suffering from severe impairments and could not perform his past work as a drywall taper. The Seventh Circuit reversed. The ALJ improperly relied on an outdated assessment although later evidence containing new, significant medical diagnoses reasonably could have changed the reviewing physician’s opinion. Doctors’ notes set forth problems with Moreno becoming distracted, “spacing out,” and experiencing difficulties concentrating; these limitations were not included in the hypothetical question posed to the vocational expert. View "Moreno v. Berryhill" on Justia Law

Felton, then employed by Hewlett-Packard, sustained a minor injury to his knee while volunteering on a Douglas County search and rescue team. Felton sought insurance benefits from Douglas County and its workers' compensation insurance carrier. The third-party claims adjustor, ASC, notified Felton that it had calculated his average monthly wage (AMW) for the purpose of determining the amount of benefits based upon the statutorily deemed wage of a search and rescue volunteer as set forth in NRS 616A.157, which is $2,000 per month. ASC awarded Felton a one-percent permanent partial disability (PPD) or whole person impairment (WPI). A hearing officer affirmed the award. Felton appealed only the determination that his AMW should be set at the statutorily deemed wage of a search and rescue volunteer. The appeals officer affirmed, holding that Felton was not entitled to an AMW that aggregated his statutorily deemed wage and his earned wage from his private employment. The Nevada Supreme Court reversed. The plain language of the statutes and regulations requires the aggregation of concurrently earned wages. View "Felton v. Douglas County" on Justia Law

Aponte moved into his mother's one-bedroom New York City Housing Authority (NYCHA)-owned apartment and cared for her until she died in 2012. Two requests for Aponte to be granted permanent permission to live with his mother were denied. After she died, Aponte requested to be allowed to lease her apartment as a "remaining family member." NYCHA denied his request, finding that Aponte lacked permanent permission to reside in the apartment; management properly denied such permission because Aponte's presence would have violated occupancy rules for overcrowding. A person lacking permanent permission to reside in an apartment is not eligible for RFM status. The Court of Appeals upheld the denial. Under its rules, NYCHA could not have granted Aponte permanent permission to reside in his mother's apartment, and thus could not have granted his request for RFM status. NYCHA's rules contemplate that a tenant may require a live-in home-care attendant, either for a transient illness or the last stages of life, and expressly allow for such an attendant as a temporary resident, even if that permission will result in "overcrowding," regardless of whether the attendant is related to the tenant. NYCHA's policy is not arbitrary and capricious for not allowing Aponte to bypass the 250,000-household waiting line as a reward for enduring an "overcrowded" living situation while caring for his mother. View "Aponte v Olatoye" on Justia Law

Me. Rev. Stat. 39-A, 221 entitles an employer to a credit for workers’ compensation benefits previously paid for the same liability period when the employee was also receiving Social Security retirement benefits.Plaintiff was paid total incapacity workers’ compensation benefits by his employer, Interstate Brands International, after he sustained injuries in an initial workplace accident. For three years, Plaintiff collected Social Security retirement benefits while receiving the full amount of the workers’ compensation benefits. When Interstate learned that Plaintiff was receiving Social Security benefits, it sought a credit against the ongoing incapacity payments pursuant to section 221. A hearing officer determined that Interstate was entitled to a credit of nearly $25,000. The Workers’ Compensation Appellate Division vacated the decree, concluding that section 221 does not allow a reduction based on incapacity overpayments made in the past. The Supreme Judicial Court vacated the Appellate Division’s decision, holding that Interstate was entitled to a credit for incapacity benefit overpayments made to Plaintiff during the same period when he received Social Security retirement benefits. View "Urrutia v. Interstate Brands International" on Justia Law

The Eighth Circuit vacated the district court's decision affirming the denial of social security disability benefits to plaintiff. The court held that substantial evidence on the record as a whole supported the ALJ's decision to give plaintiff's treating physician's residual functioning capacity (RFC) assessments little weight and to rely more heavily on other opinions in the record. However, a conflict marred the expert's testimony that an individual with plaintiff's RFC could perform the work of a new accounts clerk. Therefore, the court remanded with instructions for the district court to return the case to the Social Security Administration for a new step-five determination. View "Thomas v. Berryhill" on Justia Law