Justia Public Benefits Opinion Summaries

In 2003, following a physical examination, Contreras, 13 years old, received the Tetanus-Diphtheria and Hepatitis B vaccines. About 24 hours later, he was diagnosed with atypical Guillain-Barre Syndrome (GBS), a peripheral nervous system disease that causes descending paralysis. Three months later, Contreras was discharged from the hospital with a diagnosis of Transverse Myelitis (TM), an inflammatory disease of the spinal cord. His petition for compensation under the Vaccine Act, accompanied by an expert report indicating that he developed both conditions as a result of the vaccines, was denied, on the basis that the time interval between the administration of Contreras’s vaccines and the onset of TM was too short to establish causation. Contreras submitted the expert report of pediatric neurologist concerning his rapid adverse immunological response. In 2012, a Special Master concluded that Contreras failed to establish that the TM arose within a “medically appropriate” timeframe. Following a remand from the Claims Court, the government disclosed that the medical license of its expert (Sladsky) was suspended during the time that he had provided witness services in this case. The Special Master again denied compensation, stating that Sladky’s opinion “retain[ed] some value” and that Contreras did not suffer from GBS—a violation of the court’s instruction to refrain from diagnosing Contreras. The Claims Court again remanded, with instructions to address Sladky’s credibility in light of his misrepresentations and to issue an alternative ruling that disregards Sladky’s testimony. The Special Master denied compensation. The Claims Court denied review based on the time interval. The Federal Circuit vacated. The Special Master improperly diagnosed Contreras and failed to consider evidence relevant to his GBS. View "Contreras v. Secretary of Health & Human Services" on Justia Law

Plaintiff filed filed a qui tam action against a corporation and its subsidiary, both of whom manufacture and market medical devices, alleging that Defendants violated the False Claims Act in selling two particular medical devices to hospitals that seek reimbursement from the federal government through, for example, the Center for Medicare and Medicaid Services. Through two subsequent amendments, both with permission of the court, Plaintiff added several defendants and retooled his claims. Plaintiff then requested leave to amend fourth amended complaint. The district court applied the “good cause” standard from Fed. R. Civ. P. 16(b) to that request and struck the amended complaint. The First Circuit originally held that the district court should have evaluated Plaintiff’s fourth amended complaint under the standard set forth in Fed. R. Civ. P. 15(a). On remand, the district court concluded that Plaintiff’s desired amendment failed under that standard. The First Circuit affirmed, holding that Plaintiff’s request for leave to file his fourth amended complaint was properly denied as futile because none of the claims in Plaintiff’s fourth amended complaint was adequately pled. View "D'Agostino v. EV3, Inc." on Justia Law

Brown applied for disability benefits on the ground that her bad back and obesity left her in too much pain to work. The Social Security Administration denied Brown’s application; an administrative law judge upheld the denial, concluding that Brown could perform sedentary work associated with six jobs identified by a vocational expert. The Seventh Circuit vacated and remanded, holding that the ALJ violated the Treating Physician Rule when he rejected certain opinions proffered by Brown’s doctor regarding Brown’s ability to sit and stand for prolonged periods of time. In substituting his own opinions for the doctor’s, the ALJ focused on facts that did not directly pertain to sitting or standing and misrepresented multiple statements Brown made to treatment providers and others. The court rejected arguments that the ALJ insufficiently considered her obesity and improperly relied on the vocational expert’s testimony from the administrative hearing, claiming that the expert failed to provide enough information to justify her departure from the Dictionary of Occupational Titles and failed to verify the source of the data on which her jobs-related opinions were based. View "Brown v. Colvin" on Justia Law

Clark sought attorney fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(2)(A): $6,790.52 in fees for 34.75 attorney hours at an hourly rate of $176.13, plus 6.70 paralegal hours at an hourly rate of $100. The rate exceeded the $125 rate set by the EAJA. Clark argued that her counsel should receive a cost of living adjustment, based on the U.S. Bureau of Labor Statistics Consumer Price Index (CPI) for “Midwest Urban Consumers.” The agency requested that the court award fees at no more than $140, "the current reasonable and customary rate for experienced Social Security practitioners in the Western District of Kentucky." In her reply, Clark attached a declaration from her attorney, stating that he had practiced disability law from his Syracuse, New York, office for several years and provided his firm’s non-contingent hourly rate. Clark cited 2014 Sixth Circuit precedent, concluding that the requested rate of $176.13 was modest and appeared to be reasonable; she argued that other courts have held that the CPI alone was sufficient to justify a rate above the statutory cap. The district court awarded fees at an hourly rate of $140. The Sixth Circuit affirmed; there must be some understanding of the rates charged locally before a court can adjust for cost of living or other factors. View "Clark v. Commissioner of Social Security" on Justia Law

The Centers for Medicare & Medicaid Services (CMS) pays Medicare Advantage organizations fixed monthly amounts for each enrollee. Medicare Advantage organizations have a financial incentive to exaggerate an enrollee’s health risks by reporting diagnosis codes unsupported by the enrollee’s medical records, and therefore, Medicare regulations require a Medicare Advantage organization to certify that the risk adjustment data is submits are accurate and truthful. Qui Tam Relator James Swoben filed a third amended complaint alleging that Medicare Advantage organizations performed biased retrospective medical record reviews, which rendered Defendants’ periodic certifications false, in violation of the False Claims Act. Defendants moved to dismiss Swoben’s claims. In response, Swoben sought to amend his complaint. The district court dismissed the third amended complaint with prejudice, concluding that Swoben failed to allege a claim with particularity as required by Fed. R. Civ. P. 9(b). The court also denied leave to amend, citing both futility of amendment and undue delay. The Ninth Circuit vacated the district court’s judgment, holding that the dismissing Swoben’s third amended complaint without leave to amend based on futility of amendment and undue delay and that leave to amend was proper in this case. View "United States v. United Healthcare Insurance Co." on Justia Law

The Sixth Circuit declined to stay a preliminary injunction requiring the delivery of bottled water households served by the Flint water system that lack properly installed water filters. For many homes without a proper filter, safe drinking water is inaccessible due to the limited hours of the points of distribution and transportation issues. The cost of verifying and maintaining water filters and delivering bottled water to residents that are not part of the allegedly 96% of homes that have a functioning filter is "nowhere near $10.5 million" claimed by the defendants. There is still $100 million left of the $212 million that Michigan allocated to respond to the Flint water crisis. The court rejected an argument that delivering bottled water will slow down the recovery of Flint’s water system by decreasing the amount of water moving through the delivery lines. The defendants did not demonstrate a strong likelihood of success on their arguments, nor have they shown that portions of the preliminary injunction, including the provisions requiring the delivery of bottled water to non-exempt households, are overbroad. A stay would not support the public interest. Flint residents continue to suffer irreparable harm from the lack of reliable access to safe drinking water. View "Concerned Pastors for Social Action v. Khouri" on Justia Law

Under the Department of Housing and Urban Development’s (HUD) Housing Choice Voucher Program, 42 U.S.C. 1437f, housing agencies use HUD funds to issue housing subsidy vouchers based on family size. The Montgomery County, Maryland Housing determined, based on a medical form, that Angelene has a disability and requires a live-in aide. HUD regulations mandate that any approved live-in aide must be counted in determining family size. The Commission issued Angelene a two-bedroom voucher. Angelene’s sister was Angelene’s live-in aide. Angelene decided to move to the District of Columbia. Program vouchers are portable. Angelene obtained a two-bedroom voucher from the D.C. Housing Authority. The sisters moved into a two-bedroom District apartment. Within weeks, they received a letter revoking Angelene’s right to a live-in aide and her legal entitlement to a two-bedroom voucher. They sued, citing the Americans with Disabilities Act, 42 U.S.C. 12132, Rehabilitation Act, 29 U.S.C. 794, and Fair Housing Act, 42 U.S.C. 3604(f)(1). The court denied motions for a temporary restraining order and to seal their complaint, medical records, and “nondispositive materials.” While the case was pending, the Authority sent another letter reaffirming that Angelene’s request for a live-in aide was denied, but stating that the decision did not reverse the two-bedroom voucher. The court dismissed, finding no allegation of injury-in-fact. The D.C. Circuit reversed with respect to the motion to seal and the dismissal. At the pleadings stage, plaintiff’s allegation that the government denied or revoked a benefit suffices to show injury-in-fact. Angelene’s loss of a statutory entitlement traces directly to the Authority’s letter and would be redressed by a court order to approve her aide request. View "Hardaway v. District of Columbia Housing Authority" on Justia Law

Coursey’s application for Social Security benefits was denied. He sought judicial review. The district court granted a joint motion to reverse the decision. Coursey sought attorney fees. Although the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412, sets the presumptive maximum hourly rate an attorney may recover at $125. Coursey sought $185.18 per hour. Coursey submitted the Bureau of Labor Statistics’ Consumer Price Index (CPI), which documents that the statutory amount would, when adjusted for the cost of living in the Midwest in 2015, be the equivalent of $185.18. The court concluded that the CPI and the attorney's affidavit were insufficient to justify the requested rate and approved an award of $140 per hour, consistent with recent cases in the district awarding that amount for EAJA attorney-fee requests in Social Security cases. The Sixth Circuit affirmed. A plaintiff seeking an attorney’s fee of greater than $125 per hour must show by competent evidence that the cost of living justifies a higher rate and that the fee is “in line with those prevailing in the community for similar services by lawyers of reasonably comparable skill, experience, and reputation.” The court properly relied on evidence, judicial findings in previous cases, that the prevailing market rate for similar services within its venue was $140 per hour. View "Coursey v. Commissioner of Social Security" on Justia Law

In 2006, Congress amended 42 U.S.C. 1396p(c)(1)(F)(i), which permits individuals and married couples to dispose of their assets (to qualify for Medicaid) by purchasing an annuity, under which the state is named as the remainder beneficiary in the first position for the amount of medical assistance paid. The federal law initially contained a drafting error. It was subsequently amended. A corresponding Kentucky regulation, promulgated four months later, mistakenly included the pre-amendment language, stating that the state had to be the beneficiary for the amount of assistance paid on behalf of the annuitant, rather than the institutionalized spouse. The state agency enforced the corrected federal statute. The Singletons sought Medicaid benefits to support Claude’s full-time nursing home care; in purchasing an annuity, Mary wanted to name the state as a beneficiary for the value of care provided to her, rather than Claude, as the Kentucky regulation seemed to permit. Claude obtained Medicaid eligibility after the purchase of an annuity that complied with the federal regulation. The government paid $98,729.01 in medical expenses before Claude's death. Mary later died, leaving $118,238.41 in the annuity. In compliance with the federal rule, the government’s claim left $19,509.40 for the secondary beneficiaries. The Singleton children sued. The Sixth Circuit rejected their argument that the Medicaid statute gave the state discretion to be more generous concerning annuities and the general spend-down rules. The Kentucky regulation departed from the Medicaid statute’s clear instructions and was preempted. View "Singleton v. Commonwealth of Kentucky" on Justia Law

Fleming had a sporadic work history in the coal industry. Between 1970 and 1991, Fleming worked for 25 different employers. In 2010, Fleming sought Black Lung Benefits Act payments. The DOL Office of Workers’ Compensation calculated that Fleming was employed as a miner for nine and one-quarter years and that he had contracted pneumoconiosis as a result of that employment. Aberry was designated as the employer responsible for payment of benefits. On appeal, an ALJ determined that Fleming could show he had worked 273.50 weeks in the industry (about 5.25 years), but that Fleming was credible and established that he had either been paid under the table or without proper records having been kept. Based on that determination, the ALJ found that Fleming engaged in coal-mine employment “for at least 15 years,” which entitled Fleming to the presumption of total disability under 30 U.S.C. 921(c)(4). The Benefits Review Board remanded, stating that the ALJ had neither explained how he resolved the conflict between Fleming’s “not [being] a good historian” and the ALJ’s crediting of Fleming’s testimony, nor resolved the conflicting evidence. The ALJ's second Decision again awarded benefits. finding that Fleming worked more than 15 years in coal-mine employment. The Sixth Circuit vacated. The evidence was insufficient to establish that Fleming had 15 years of employment. View "Aberry Coal, Inc. v. Fleming" on Justia Law