Justia Civil Procedure Opinion SummariesArticles Posted in Public Benefits
Edwin R. Banks v. Secretary, Department of Health and Human Services
Plaintiff’s doctors prescribed him Optune, a medical technology that had recently received FDA approval for treating recurrent GBM. The device delivers tumor treating field therapy (TTFT) to inhibit cancer-cell replication. A company called Novocure is the sole supplier of the Optune device, which is rented by patients on a monthly basis. Because Plaintiff is a Medicare Part B beneficiary, he and Novocure asked Medicare to cover his TTFT. Novocure was held liable for the claims. Plaintiff and Novocure submitted 13 claims to Medicare, corresponding to 13 months of TTFT. The district court held that Plaintiff lacked standing because he hadn’t suffered an injury in fact. The Eleventh Circuit was tasked with deciding whether Plaintiff has standing to challenge a denial of Medicare coverage where the costs of his treatment were imposed not on him, but rather on a third-party supplier. The court affirmed the district court’s determination that Plaintiff hadn’t suffered an injury in fact. Here, Plaintiff’s alleged harm will only come to pass due to the challenged action if, at some indefinite point in the future: (1) his condition worsens, (2) he has paid his premiums and stayed on Medicare Part B, (3) he elects to resume TTFT, (4) his doctor prescribes the therapy (5) Plaintiff receives the treatment, (6) he files a claim, (7) which is denied at every level of the Medicare appeals process, (8) the adjudicators determine that Plaintiff’s hypothetical future case presents a “comparable situation,” and (9) they further find that the instant coverage denial and no other source put Plaintiff on notice that he could be held liable. View "Edwin R. Banks v. Secretary, Department of Health and Human Services" on Justia Law
JODY KAUFMANN V. KILOLO KIJAKAZI
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
Arapahoe County v. Velarde & Moore
The Department of Human Services for Arapahoe County (“the Department”) sued Monica Velarde and Michael Moore to enforce a final order it had issued against them to recover Medicaid overpayments. But the Department did so only after undertaking extensive efforts on its own to recoup the fraudulently obtained benefits. The district court dismissed the Department’s suit, finding that section 24-4-106(4), C.R.S. (2021), which was part of the State Administrative Procedure Act (“APA”), required an agency seeking judicial enforcement of one of its final orders to do so within thirty-five days of the order’s effective date. The Colorado Supreme Court determined district court and the court of appeals incorrectly relied on an inapplicable statutory deadline in ruling that the complaint was untimely filed. Each court was called upon to determine whether a thirty-five-day deadline governing proceedings initiated by an adversely affected or aggrieved person seeking judicial review of an agency’s action also applied to proceedings initiated by an agency seeking judicial enforcement of one of its final orders. Both courts answered yes. The Supreme Court, however, answered no. Judgment was reversed and the case remanded for further proceedings. View "Arapahoe County v. Velarde & Moore" on Justia Law
United Healthcare of Mississippi Inc. et al. v. Mississippi’s Community Mental Health Commissions, et al.
In 2012, United Healthcare of Mississippi (United) entered into provider agreements with Mississippi’s fourteen Community Mental Health Centers (CMHCs) to provide Medicaid services under the Division of Medicaid’s (DOM’s) managed care program. From 2012 until 2019, United paid the CMHCs an agreed upon amount for Medicaid services - 100 percent of the medicaid fee schedule rates. In July 2019, United unilaterally imposed a 5 percent rate cut, retroactive to January 1, 2019, and later demanded that the CMHCs refund 5 percent of all payments made from July 1, 2018, through December 31, 2018, all of which totaled more than $1 million. The CMCHs demanded that United immediately cease and desist from the 5 percent rate cut and recoupments. When United refused, the CMHCs filed a Complaint for Damages and Injunctive Relief, specifically requesting, inter alia, a preliminary injunction. United responded with a motion to compel arbitration and to stay the proceedings. After a two-day evidentiary hearing, the circuit court denied United’s motion to compel arbitration, granted the CMHCs’ request for injunctive relief, and issued a preliminary injunction. The limited issues presented to the Mississippi Supreme Court were whether the trial court properly enjoined United from imposing a 5 percent rate cut and whether the trial court erred by denying arbitration. After review, the Supreme Court affirmed the trial court’s decision to grant a preliminary injunction and to deny the motion to compel arbitration. View "United Healthcare of Mississippi Inc. et al. v. Mississippi's Community Mental Health Commissions, et al." on Justia Law
Owens, et al. v. Zumwalt
Plaintiffs-appellees Ronda Owens, Darryl Hubbard, Selena Freymiller, Shanika Crowley, Valerie Killman, Michael Lee Pitts, Ebony Warrior, John Ball, Michelle Bullock, Logan Bellew, Sondia Bell, Tumeeka Baker, and Jay Reid (collectively "Citizens") filed the underlying lawsuit seeking declaratory and injunctive relief. Citizens claimed that Oklahoma Governor J. Kevin Stitt and Defendant-appellant Shelley Zumwalt, in her official capacity as Executive Director of the Oklahoma Employment Security Commission, acted without authority and violated 40 O.S.2011 section 4-313 of the Oklahoma Employment Security Act by terminating agreements with the U.S. Department of Labor to administer COVID-related unemployment programs. The trial court entered a preliminary injunction ordering Zumwalt to immediately reinstate and administer the programs. Zumwalt appealed, and the Oklahoma Supreme Court stayed the trial court's order pending appeal. The Supreme Court found 40 O.S. 4-313 did not create a private right of action and, therefore, the trial court abused its discretion by granting a preliminary injunction. View "Owens, et al. v. Zumwalt" on Justia Law
Tshibaka v. Retired Public Employees of Alaska, Inc.
The State redesigned the dental insurance plan offered to public retirees in 2014, narrowing coverage but also decreasing premiums paid by retirees. The Retired Public Employees of Alaska challenged the redesign. After a bench trial the superior court concluded that the new plan unconstitutionally diminished retirees’ accrued benefits. The State appealed, arguing that the superior court erred by determining the dental plan was a constitutionally protected “accrued benefit” and by refusing to consider premium rates for retirees as relevant to the diminishment analysis. The Alaska Supreme Court agreed with the State on the second point only: "The Alaska Constitution does protect public retirees’ option to purchase dental insurance as an accrued benefit, but both coverage for retirees and price to retirees influence the value of this option." The Court therefore vacated and remanded for the superior court to reevaluate the plan changes and incorporate premium pricing into its analysis. View "Tshibaka v. Retired Public Employees of Alaska, Inc." on Justia Law
Baker, et al. v. Brown, et al.
This case arose from the cancellation of long-term-care Medicaid benefits for two claimants when an Oklahoma agency concluded that the claimants’ resources exceeded the regulatory cap for eligibility. One claimant, Idabelle Schnoebelen died, mooting her claim. The eligibility of the other claimant, Nelta Rose, turned on whether her resources included a 2018 promissory note. In 2017 and 2018, Rose loaned money to her daughter-in-law in exchange for three promissory notes. The daughter-in-law provided the first two promissory notes in 2017 (before Rose applied for Medicaid benefits). The Oklahoma Department of Human Services initially approved Rose for Medicaid, declining to regard the 2017 promissory notes as resources. In 2018, the daughter-in-law provided the third promissory note. But the Department of Human Services concluded that the 2018 promissory note: (1) was a resource because the payment to the daughter-in-law did not constitute a bona fide loan; and (2) was a deferral that turned the 2017 promissory notes into resources. The extra resources put Rose over the eligibility limit for Medicaid, so the Department of Human Services cancelled Rose’s benefits. A district court concluded that the agency’s conclusion did not conflict with federal law. In the Tenth Circuit's view, however, a reasonable factfinder could disagree. Summary judgment was reversed and the matter remanded for further proceedings. View "Baker, et al. v. Brown, et al." on Justia Law
LA Alliance for Human Rights v. County of Los Angeles
Alliance alleged that County and City policies and inaction have created a dangerous environment in the Skid Row area, claiming that the County violated its mandatory duty to provide medically necessary care and that the municipalities have facilitated public nuisance violations by failing to clear encampments, violated disability access laws by failing to clear sidewalks of encampments, and violated constitutional rights by providing disparate services to those within the Skid Row area and by enacting policies resulting in a state-created danger to area residents and businesses. The district court issued a preliminary injunction, ordering the escrow of $1 billion to address homelessness, offers of shelter to all unhoused individuals in Skid Row within 180 days, and numerous reports. The court found that structural racism was behind Los Angeles’s homelessness crisis and its disproportionate impact on the Black community.The Ninth Circuit vacated. The plaintiffs lacked standing on all but their ADA claim; no claims were based on racial discrimination. The district court impermissibly resorted to independent research and extra-record evidence. There was no allegation that any individual plaintiff was Black nor that there was a special relationship between the City and unhoused residents nor that any individual plaintiff was deprived of medically necessary care or general assistance. Two plaintiffs who use wheelchairs and cannot traverse Skid Row sidewalks because of homeless encampments had standing to bring ADA claims but had not shown a likelihood of success on the merits. View "LA Alliance for Human Rights v. County of Los Angeles" on Justia Law
Larson v. McDonough
Larson served on active duty for training in the Navy Reserves in 1988 and on active duty in the Navy, 1989-1993. He gained a substantial amount of weight before, during, and after his active service. In 2009, Larson filed a claim for service connection for multiple conditions, including obesity and dysmetabolic syndrome (DMS). The VA denied the claims in 2010. The Board affirmed that denial in 2016, holding that neither DMS nor obesity was a disability because neither condition is ratable under the VA Schedule of Rating Disabilities. The Veterans Court affirmed the denial of service connection for DMS and obesity, holding that it lacked jurisdiction to review a Board determination of what constitutes a disability under 38 U.S.C. 1110 because such inquiry amounted to a review of the rating schedule, prohibited by 38 U.S.C. 7252(b).The Federal Circuit reversed, noting that it has previously held that the Veterans Court has jurisdiction to review a Board determination that a claimed condition did not constitute a disability for purposes of section 1110. Larson seeks only to establish a service connection for his conditions and is not asking the Veterans Court to invalidate or revise any portion of the rating schedule. View "Larson v. McDonough" on Justia Law
Jones v. United States
In 1982, while serving in the Air Force in Germany, Jones was struck in the eye by the door of an armored personnel carrier. He developed intense headaches; it became increasingly difficult for Jones to perform his duties. A 1988 Clinical Resume reflects that Jones had developed “intermittent right cranial nerve 4th palsy associated with chronic right retro-orbital stabbing pain, usually occurring during the late afternoon or night.” Jones described "a nearly constant headache which was relieved only with repetitive doses of intramuscular Demoral.” A Physical Evaluation Board recommended that Jones be discharged with severance pay based on a 10% disability rating for “Post-traumatic pain syndrome manifest[ing] as headaches.”Jones was honorably discharged with severance pay. In 1989, his discharge was amended to reflect that his injury was combat-related. Effective in 2017, the VA awarded Jones a 100% disability rating. Jones petitioned the Air Force Board for Correction of Military Records for changes to his record that would entitle him to a disability retirement dating back to 1988, when he was discharged, 10 U.S.C. 1201. The Board denied Jones’s petition. The Federal Circuit affirmed the Claims Court: the claim for disability retirement pay and benefits was a claim under a money-mandating statute, as required by the Tucker Act, 28 U.S.C. 1491(a)(1), but jurisdiction was lacking because the claim was barred by the six-year statute of limitations, 28 U.S.C. 2501. View "Jones v. United States" on Justia Law