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

In 2009 Crespo applied for Supplemental Security Income benefits for his mother, representing that she lived with him in Illinois and that he took care of her. He served as her representative payee. By signing the form, Crespo acknowledged that he could be held liable for any improper overpayments he caused. Crespo’s mother was not entitled to those benefits because she lived in Puerto Rico (20 C.F.R. 416.215), which Crespo hid from the Social Security Administration by falsely representing, in three subsequent reports as representative payee, that she lived with him. Airline records established that she resided in Puerto Rico; his mother was serving as representative payee for her own mother’s retirement benefits, declaring herself a resident of Puerto Rico. An ALJ imposed a $114,956 civil penalty on Crespo for misrepresentation. The Departmental Appeals Board of the Department of Health and Human Services dismissed his appeal as untimely. The Seventh Circuit affirmed. The Board did not abuse its discretion in rejecting Crespo’s untimely appeal and finding good cause lacking. Appeals are due 30 days after the ALJ’s initial decision is deemed served. A copy of the regulation is included when the decision is delivered. Crespo offered no reason why he did not request an extension. View "Crespo v. Colvin" on Justia Law

Garbe, an experienced pharmacist, began working at Kmart pharmacy in Ohio in 2007. When Garbe picked up a personal prescription at a competitor pharmacy, he discovered the competitor pharmacy had charged his Medicare Part D insurer far less than Kmart ordinarily charged it for the same prescription. He inspected Kmart’s pharmacy reimbursement claims and discovered that Kmart routinely charged customers with insurance—whether public or private—higher prices than customers who paid out of pocket, even ignoring “discount programs sales. Garbe shared his discovery with the government and filed a qui tam suit in 2008. The government has not intervened. Garbe asserts that Kmart’s “usual and customary” prices should be based on the prices Kmart charged the majority of its cash customers. The district court granted Garbe partial summary judgment. On interlocutory appeal, the Seventh Circuit, reversed in part, holding that Medicare Part D Pharmacy Benefit Managers and Plan Sponsors are not “officers or employees of the United States” for purposes of the False Claims Act, 31 U.S.C. 3729(a). The court agreed that Garbe has satisfied the materiality requirement under the Act for his Medicare Part D claims; and that Kmart’s “discount” prices were offered to the “general public.” View "Garbe v. Kmart Corp." on Justia Law

The Home and Community‐Based Care Waiver Program allowed states to diverge from the traditional Medicaid structure by providing community‐based services to people who would, under the traditional structure, require institutionalization, 42 U.S.C. 1396n. The Indiana Family and Social Services Administration operates the Aged and Disabled Medicaid Waiver Program (A&D waiver), the Community Integration and Habilitation Medicaid Waiver Program (CIH waiver), and the Family Supports Medicaid Waiver Program (FS waiver). Because Indiana has closed most of its institutional facilities, these waiver programs serve the vast majority of its people with disabilities. Until 2011, the Administration placed many people with developmental disabilities on the A&D waiver, which has no cap on services. The Administration then changed its policies, rendering many developmentally disabled persons ineligible for the A&D waiver. These people were moved to the FS waiver, under which they may receive services capped at $16,545 annually. The CIH waiver is uncapped, but not everyone qualifies for the CIH waiver. Plaintiffs argue that their new assignments violated the integration mandate of the Americans with Disabilities Act, 42 U.S.C. 12101 because it deprives them of community interaction and puts them at risk of institutionalization. The court granted defendants summary judgment on the integration‐mandate claims and denied class certification. The Seventh Circuit reversed, finding that there is a genuine dispute of material fact with respect to the individual claims based on the integration mandate. The court agreed that the proposed class is too vague. View "Steimel v. Wernert" on Justia Law

In 2012, Illinois enacted legislation requiring prior approval for reimbursement for more than four prescriptions for one Medicaid patient within a 30‐day period. 305 ILCS 5/5‐5.12(j). Ciarpaglini is an Illinois Medicaid recipient and suffers from chronic conditions, including bipolar disorder, attention deficit hyperactivity disorder, panic disorder, and generalized anxiety disorder. Doctors have prescribed at least seven medications to manage these conditions. Ciarpaglini alleges that after the prior‐approval requirement took effect, he could not, at least at times, obtain medications he needed and that he has contemplated committing suicide, committing petty crimes so that he would be jailed, or checking himself into hospitals just to get medications. He challenged the requirement under federal Medicaid law, the Americans with Disabilities Act, the Rehabilitation Act, and the Constitution. Illinois subsequently moved Ciarpaglini from the general fee‐for‐service Medicaid program to a new managed care program, under which the requirement does not apply. The district court dismissed the matter as moot. The Seventh Circuit remanded, finding insufficient evidence to determine whether the claims were moot, given Ciarpaglini’s stated desire to move to another county and the lack of information about whether the change in his program was individual or part of a change in policy. View "Ciarpaglini v. Norwood" on Justia Law

Plaintiffs, including many with disabilities, had cases pending in state courts and were represented by an attorney who uses a wheelchair. They claimed that the St. Joseph County Courthouse and the Mishawaka County Services Building did not comply with the Americans with Disabilities Act and the Rehabilitation Act, particularly with respect to restrooms, elevators, witness stands, jury boxes, jury deliberation rooms, attorney podiums, spectator seating, entrance ramps, clerk counters, services for the blind, water fountains, and parking. While the case was pending, defendants remodeled the courthouse restrooms, which are now accessible. Defendants presented evidence that their facilities complied with the statutes. Plaintiffs offered little evidence in rebuttal. The district court granted defendants summary judgment. The court dismissed the claims of non-disabled plaintiffs represented by a disabled lawyer and claims relating to jury facilities, saying that the ADA did not provide for “associational” standing. The court found no evidence that other plaintiffs had suffered past injuries that would support standing for damages, and that the prospect of future injury was too speculative to support an injunction. Some plaintiffs had died; some were no longer in litigation. The Seventh Circuit affirmed, without finding the facilities compliant and without expressing an opinion on possible future claims. View "Hummel v. St. Joseph Cnty. Bd. of Comm'rs" on Justia Law

The plaintiff, now 62 years old, applied in 2011 to the Social Security Administration for disability benefits, citing ailments including asthma, chronic obstructive pulmonary disease (COPD), asbestosis, and a heel spur in his right foot. He had been a sheet metal journeyman for 33 years; the job requires physical strength and he had been given accommodations on the job for several years. The Social Security Appeals Council declined to review the administrative law judge’s denial and the district judge affirmed. The Seventh Circuit reversed and remanded, referring to the ALJ’s “seemingly inconsistent conclusions” and stating that the denial was “not a reasoned analysis of the plaintiff’s claim.” View "Dimmett v. Colvin" on Justia Law

In 2008 plaintiff began having back pain that radiated to his legs due to a herniated disk and mild arthritis in his lumbar spine region; he also suffers from narcolepsy or obstructive sleep apnea, migraine headaches, numbness in his right leg, fibromyalgia, left-knee pain, and fatigue. He has limited mobility Dr. Imlach, his primary treating physician, concluded that the plaintiff’s conditions limited him to standing for a total of no more than half an hour, and sitting for no more than an hour, in an 8-hour workday and that plaintiff’s medications markedly limit the plaintiff’s ability to sustain concentration and pace. Plaintiff lives with his parents; he weighs 280-310 pounds, with a height of 6’2” to 6’3”. An administrative law judge denied his application for Social Security Disability benefits and the district court affirmed. The Seventh Circuit reversed, stating that the ALJ failed to explain why she gave little weight to Imlach’s findings and erred in finding the plaintiff not credible on the ground that he had “not been forthright in his allegations of … inability to perform work related activities.” The court concluded that plaintiff does not appear to be capable of any full-time gainful employment, given his hypersomnia. View "Allensworth v. Colvin" on Justia Law

Stark worked at GM for over 10 years as a yard driver. Her back pain started in 2000, when she underwent her first of three surgeries. She has been diagnosed with degenerative disc disease, nerve root irritation, moderate-to-severe spinal stenosis, and possible radiculopathy. Stark underwent numerous nonsurgical treatments for pain, including epidural spinal injections and a nerve root block, with a regimen of Neurontin, Darvocet, Celebrex, Oxycocone, Avinza, physical exercises, and physical therapy. Stark’s pain control was “fair-to-poor.” She stopped working in 2009. A doctor assessed that Stark could do light physical demand activities based on her full range of motion and ability to squat, kneel, and walk. A medical consultant estimated that Stark occasionally could lift or carry 20 pounds and sit for about 6 hours in an 8-hour day. At a 2012 hearing, Stark testified to a “tremendous amount of pain every day.” She could no longer take narcotic pain relievers because of a hepatitis C diagnosis. An ALJ denied benefits, finding that “the objective evidence does not substantiate the extreme symptoms and limitations to which she testified” and that her testimony regarding daily activities “demonstrates a level of daily function not inconsistent with light work activity.” The Seventh Circuit reversed, finding the credibility analysis flawed. View "Stark v. Colvin" on Justia Law

Plaintiff’s 1998 dislocation of a kneecap required implantation of a steel plate; a year later a shattered femur required implantation of a steel rod from hip to knee. In 2011, he fractured an ankle. A podiatrist inserted a bar with pins in the ankle and later repeated the procedure. Months later, plaintiff’s ankle pain returned and he was prescribed Vicodin and Percocet, providing limited relief. Two treating physicians reported that he could sit, stand, and walk for only 15 minutes at a time and for no more than one hour in an eight-hour work day; that he could lift a weight of 10-20 pounds only occasionally; and that he could not reach up with his right arm at all. One reported that plaintiff was “fully and completely disabled” with constant and worsening pain that caused constipation, drowsiness, and upset stomach, with a “poor” prognosis. An ALJ denied social security disability benefits, noting that the medical records varied from the reports and finding that plaintiff’s injuries were severe, but he could perform unskilled sedentary jobs. The Seventh Circuit reversed. The question was not whether plaintiff was less disabled than he was four years ago, but whether he was sufficiently recovered to hold down a 40-hour-a-week job; the ALJ did not adequately explain what jobs plaintiff might be capable of. View "Forsythe v. Colvin" on Justia Law

Stage slipped two discs while working in a factory in 1985. She continued working. Her pain became more severe. By 2007, she had been diagnosed with arthritis in her back, hips, left leg, and shoulders; spinal degeneration; a tear in a disc joint; and mild degenerative disc disease. Stage is 5’6” tall and weighed over 200 pounds and also suffered from hyperlipidemia, hypertension, and hypothyroidism, which made her obesity difficult to control. Stage applied for benefits, claiming that debilitating back and hip pain rendered her unable to work after October 2009. Her last job was general kitchen work at a residential‐care facility. She had previously worked as a cook, bartender, and factory laborer. The district court upheld denial of her application for supplemental security income, disability insurance benefits, and disabled widow’s benefits. Stage was then 56 years old. The Seventh Circuit reversed, finding that the ALJ discounted significant new evidence submitted after an agency doctor reviewed Stage's medical records, gave little weight to her treating physician’s opinion, discredited her testimony about pain without adequate support, and overstated her residual functional capacity. The ALJ’s evaluation of her medical evidence was unreasonable; substantial evidence did not support his finding that she remained capable of performing light work. View "Stage v. Colvin" on Justia Law