Justia U.S. 7th Circuit Court of Appeals Opinion Summaries

After being diagnosed with fibromyalgia, chronic pain, anxiety, and depression, plaintiff was awarded long-term disability benefits under an employee benefit plan issued and administered by defendant. Benefits were discontinued about 24 months later, when defendant determined that plaintiff had received all to which she was entitled under the planâs self-reported symptoms limitation. Because plaintiff had retroactively received social security benefits, defendant also sought to recoup equivalent overpayments as provided by the plan. The district court dismissed. The Seventh Circuit reversed in part and remanded for reinstatement. The self-reported symptom limitation violates ERISA, 29 U.S.C., 1022; the policy sets out that long-term benefits will be discontinued after 24 months if disability is due to mental illness or substance abuse, but does not mention that the time limitation applies if a participantâs disability is based primarily on self-reported symptoms. The Social Security Act does not bar recovery of overpayments occasioned by receipt of social security benefits.

The employee developed bilateral cubital tunnel syndrome while working at a supermarket, then worked as a greeter until she was laid off in 2003 because she was unable to perform the job. She subsequently started and left a dental hygiene, radiology technology, and electroencephalography training programs because of problems related to her hands and vision. At age 45 she had an extensive medical history, including fibromyalgia, degenerative disc disease, bilateral mild ulnar neuropathy, and multiple eye surgeries with dry eye syndrome. In 2008 an ALJ rejected her claim for social security disability benefits. The appeals council denied review and the district court affirmed. The Seventh Circuit affirmed, noting that the ALJ failed to acknowledge a physician report contrary to her conclusion and to explain the weight she gave that opinion, but stating that remand would serve no purpose in light of the overwhelming evidence supporting the denial.

The wife of a deceased coal miner argued that her claim for black lung benefits should be remanded to the administrative law judge (ALJ) because sect. 1556 of the Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148 (2010) revived a presumption under the Black Lung Benefits Act (BLBA), 30 U.S.C. 901, that was not available when the ALJ denied benefits. The presumption states that if a miner was employed for 15 years or more in underground coal mines and other evidence demonstrates the existence of a totally disabling respiratory or pulmonary impairment, there is a rebuttable presumption that such miner is totally disabled due to pneumoconiosis, that his death was due to pneumoconiosis, or that at the time of his death he was totally disabled by pneumoconiosis. The presumption did not apply to the miner's claim, filed in 2001. The Seventh Circuit remanded, rejecting the coal company's arguments concerning due, process, retroactive application and unconstitutional taking.

The doctor was convicted of conspiring to defraud the government and Medicare fraud (42 U.S.C. 1320a) for accepting a salary from the hospital in return for referring patients and sentenced to 72 months imprisonment followed by two years of supervision and to payment of $497,204 in restitution. The Seventh Circuit affirmed. The court did not err in refusing to admit substantive reports from meetings or the minutes of the meetings, although it allowed the government to use the minutes to establish the doctor's non-attendance at meetings. The doctor was allowed to argue that certain reports concerning his services were made and tendered during the meetings. Upholding a jury instruction, the court stated that nothing in the Medicare fraud statute implies that only the primary motivation for remuneration is to be considered and that the conviction is valid even if the payments were, in part, compensation for services. Findings concerning the level of loss supported the sentence.