Justia U.S. 11th Circuit Court of Appeals Opinion Summaries

Of two people injured in a car wreck in April 2012, one was a Medicare beneficiary who received her benefits from an MAO-Florida Healthcare Plus, which later assigned its claims to appellant MSPA Claims 1, LLC. The other party involved in the accident was insured by appellee Kingsway Amigo Insurance. The Medicare beneficiary obtained medical treatment for her accident-related injuries between April 29, 2012 and July 26, 2012, and Florida Healthcare made $21,965 in payments on her behalf. On March 28, 2013, the beneficiary settled a personal-injury claim with Kingsway and received a $6,667 settlement payment. The issue this case presented for the Eleventh Circuit’s review centered on the timeliness requirement with which the government had to comply as a prerequisite to filing suit to seek reimbursements that it made on behalf of the Medicare beneficiary, and whether filing suit beyond a statutory three-year period beginning on the date on which medical services were rendered was fatal to the government’s claim. The district court held that MSPA’s claim was stale because it didn’t comply with what the court (somewhat confusingly) called “the three-year limitation requirement.” The Eleventh Circuit disagreed and reversed. “The Medicare Secondary Payer Act’s private cause of action, and our cases interpreting it lead us to conclude that the Act’s claims-filing provision, doesn’t erect a separate bar that private plaintiffs must overcome in order to sue. A closer look at the claims-filing provision’s text and the Act’s structure confirms that conclusion. Accordingly, the district court erred in granting Kingsway’s motion for judgment on the pleadings.” View "MSPA Claims 1, LLC v. Kingsway Amigo Insurance Company" on Justia Law

Plaintiff appealed the denial of his application for Social Security disability benefits, claiming that he had various physical impairments and that he suffered from bipolar disorder. The Eleventh Circuit held that, although plaintiff's claim of bias was forfeited, the ALJ's conclusion contained errors that must be addressed. In this case, the ALJ failed to articulate good cause for discounting two treating physicians' opinions; substantial evidence does not support the finding that plaintiff's bipolar disorder was non-severe; and the ALJ failed to consider plaintiff's mental impairments when assessing his residual functional capacity. Accordingly, the court affirmed in part, reversed in part, and remanded with instructions. View "Schink v. Commissioner of Social Security" on Justia Law

The materiality standard—asking whether a school has failed to implement substantial or significant provisions of the child's individualized education plan (IEP)—is the appropriate test in a failure-to-implement case. L.J. and his mother filed suit under the Individuals with Disabilities Education Act (IDEA), challenging the implementation of his IEP.The Eleventh Circuit held that the content outlined in a properly designed IEP is a proxy for the IDEA's educational guarantee, and thus a material deviation from that plan violates the statute. In this case, the court held that there was no material deviation from L.J.'s IEP and affirmed the district court's judgment in favor of the school. View "L.J. v. School Board of Broward County" 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

Pursuant to the terms of Social Security Ruling 00-4p, and in light of the overall regulatory scheme that governs disability claims, the ALJs within the SSA have an affirmative duty to identify apparent conflicts between the testimony of a Vocational Expert (VE) and the DOT and resolve them. The Eleventh Circuit held that this duty requires more of the ALJ than simply asking the VE whether his testimony is consistent with the DOT. The court explained that, once the conflict has been identified, the Ruling requires the ALJ to offer a reasonable explanation for the discrepancy, and detail in his decision how he has resolved the conflict. Furthermore, the failure to discharge this duty means that the ALJ's decision, when based on the contradicted VE testimony, is not supported by substantial evidence.In this case, the ALJ failed to meet his obligations to identify, explain, and resolve an apparent conflict between the testimony of the VE and the DOT on a matter of considerable importance. Accordingly, the court reversed and remanded with instructions. View "Washington v. Commissioner of Social Security" on Justia Law

Plaintiff filed a civil rights action under 42 U.S.C. 1983, alleging that the termination of her housing voucher violated the Due Process Clause of the Fourteenth Amendment and regulations promulgated by the United States Department of Housing and Urban Development. The Eleventh Circuit vacated the district court's grant of summary judgment for the Authority, holding that indictments and evidence of an arrest did not constitute sufficient evidence to support the decision of a public housing authority to terminate housing subsidies provided under Section 8 of the Housing and Community Development Act of 1937. View "Yarbrough v. Decatur Housing Authority" on Justia Law

The SSA determined that because plaintiff was also receiving civil service disability retirement payments, his Social Security benefits should be reduced under the windfall elimination provision. At issue was the boundaries of "payment based wholly on service as a member of a uniformed service" for the purpose of social security benefit calculations.The Eleventh Circuit, accounting for the unique nature of the dual status technician position and applying Skidmore deference, held that plaintiff did not perform his dual status technician employment wholly as a member of a uniformed service. Consequently, payments based on that employment did not qualify for the exception. The court did not think the requirements of the dual status technician position were sufficient to place dual status technicians within the sweep of the exception—especially given the provision's use of the word "wholly." Therefore, the uniformed services exception did not apply in plaintiff's case. View "Martin v. Social Security Administration" on Justia Law

The Eleventh Circuit sua sponte vacated its prior decision and substituted the following decision, which again affirmed the district court's denial of plaintiff's application for disability insurance benefits and supplemental security income. This decision added a discussion about the 2015 physical capacities form completed by Dr. Jane Teschner and explained why that form did not warrant a remand to the Social Security Administration. View "Hargress v. Social Security Administration" on Justia Law

The Eleventh Circuit sua sponte vacated its prior decision and substituted the following decision, which again affirmed the district court's denial of plaintiff's application for disability insurance benefits and supplemental security income. This decision added a discussion about the 2015 physical capacities form completed by Dr. Jane Teschner and explained why that form did not warrant a remand to the Social Security Administration. View "Hargress v. Social Security Administration" on Justia Law

The Eleventh Circuit affirmed the denial of disability insurance benefits and supplemental security income (SSI) to plaintiff. The court held that substantial evidence supported the ALJ's decision to give little weight to the treating physician's opinion because it was inconsistent with his own medical records and the records as a whole; the ALJ's finding that plaintiff had the residual functioning capacity (RFC) to perform a full range of unskilled sedentary work was supported by substantial evidence; Social Security Ruling 16-3p applied only prospectively and did not provide a basis for remand; and the Appeals Council was not required to consider new evidence because it was not chronologically relevant. View "Hargress v. Social Security Administration" on Justia Law