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

Herrmann’s application for Supplemental Security Income for benefits for the period before she turned 55 was rejected by an administrative law judge, but because of the less demanding showing of disability, she was deemed to have become disabled when she reached 55. She appealed the partial denial unsuccessfully. Her treating physicians, with three consultative physicians selected by the Social Security Administration, advised the administrative law judge that she suffers from fibromyalgia, spinal disk disease, abnormal sensitivity to light, and other ailments, and that she walks haltingly, has difficulty gripping objects, experiences difficulty in rising from a sitting position, has trouble concentrating in a bright room or when looking at a computer screen, and as a result of this assemblage of impairments cannot do even light work on a full-time basis. The Seventh Circuit reversed, questioning the testimony of the vocational expert concerning available jobs. View "Herrmann v. Colvin" on Justia Law

Grenadyor is a pharmacist formerly employed by Ukrainian Village Pharmacy, which with pharmacies that serve similar communities in other states (joined as additional defendants in this suit), is alleged to be controlled by individuals of Ukrainian origin, mainly members of the Bogacheck family. Grenadyor claims that the pharmacy defrauded the government by making gifts to customers (such as tins of caviar), or forgiving their copays, to induce them to have their prescriptions filled by it rather than by competing pharmacies. He also alleged that the pharmacy sought government reimbursement for drugs that were not delivered to the buyers. The district court dismissed his complaint under the False Claims Act, 31 U.S.C. 3729, which also claimed retaliation. The Seventh Circuit affirmed as to the kickback claims under the Act, noting that Grenadyor was unable to name any person who had received more than $50 worth of kickbacks in a year, when the court requested that he do so. Allegations about claims for reimbursement for undelivered prescriptions were also inadequate. The court reversed with regard to the retaliation claim. View "Grenadyor v. Ukrainian Vill. Pharmacy" on Justia Law

Thulin was a Shopko pharmacist. During his tenure, Thulin observed what he believed to be a scheme in which Shopko submitted inflated claims for prescription drugs to the Medicaid program. Thulin filed a qui tam complaint, claiming violation of the federal False Claims Act by overbilling Medicaid, alleging that Shopko is a “sophisticated,” “multi-regional” business that developed and programmed the PDX system and should have been aware of federal law governing submission of claims, and bringing claims under the laws of eight states. The district court dismissed the federal claim under FRCP 9(b) and 12(b)(6). The Seventh Circuit affirmed. To be liable under the Act, Shopko must have acted with “actual knowledge,” or “deliberate ignorance” or “reckless disregard” of the possibility that its claims were false. Thulin’s allegations were not sufficient to satisfy that requirement even if Shopko’s practices were contrary to the Federal Assignment Law. Although malice, intent, and other conditions of the mind may be alleged generally, vague allegations that a corporation acted with reckless disregard or with reason to know of facts that would lead a reasonable person to realize that it was submitting false claims, simply because of its size or sophistication do not clear even this lower pleading threshold. View "Thulin v. Shopko Stores Operating Co., LLC" on Justia Law

Plaintiff, a 25-year-old woman of 25, was denied Supplemental Security Income benefits. She claims to be mentally retarded and to suffer from knee and hip pain in one leg, caused by a defect in the hip joint resulting from a childhood disease. A psychologist administered an IQ test when she was 18. Her IQ was 68. The psychologist thought her more intelligent than her IQ score of 68 implied, and concluded that she could function in “typical work environments.” Three years later two other psychologists evaluated the plaintiff and concluded that despite her serious mental deficiencies she would be able to work, although one referred to work in “sheltered workshops.” She does not use a computer and cannot obtain a driver’s license because she can’t read the test that one must pass to obtain a learner’s permit. Her work history consists of three hand-packager jobs. The Seventh Circuit reversed, with instructions to remand the case to the Social Security Administration, noting multiple errors in the agency’s assessment of the plaintiff’s condition and of employment possibilities.View "Browning v. Colvin" on Justia Law

Scrogham, then age 53, applied for disability benefits under the Social Security Act, submitting medical conditions including degenerative discs, spinal stenosis, sleep apnea, hypertension, arthritis, atrial fibrillation and restless leg syndrome. An ALJ denied the application and the Appeals Council denied his request for review. The district court affirmed, holding that the ALJ did not err in giving less weight to the opinion of a treating physician than to the opinions of nontreating physicians, that the ALJ permissibly found Scrogham not to be credible and that the ALJ’s decision otherwise was supported by substantial evidence. The Seventh Circuit reversed and remanded. The ALJ impermissibly ignored a line of evidence demonstrating the progressive nature of Scrogham’s degenerative disc disease and arthritis and inappropriately undervalued the opinions of Scrogham’s treating physicians, whose longitudinal view of Scrogham’s ailments should have factored prominently into the ALJ’s assessment of his disability status. Even considering only “the snapshots of evidence that the ALJ considered,” that limited evidence does not build the required logical bridge to her conclusions. The ALJ apparently misunderstood or at least considered only partially some of the evidence about Scrogham’s daily activities, rehabilitation efforts and physicians’ evaluations.View "Scrogham v. Colvin" on Justia Law

After his employment with the town was terminated, the plaintiff sought benefits under the Illinois Unemployment Insurance Act. The town opposed his claim, arguing that he was ineligible for unemployment benefits because he had constructively resigned “without good cause” by failing to obtain a commercial driver’s license within one year of starting work, a condition of his employment. The department agreed with the town. The plaintiff unsuccessfully appealed. He then sued in federal court under 42 U.S.C. 1983, claiming that he was fired in violation of his rights to due process of law and freedom of speech. The district court dismissed the claim as barred by collateral estoppel. The Seventh Circuit reversed, reasoning that the Illinois statute, 820 ILCS 405/1900(B), denies collateral estoppel effect to rulings in unemployment insurance proceedings. View "Council v. Village of Dolton" on Justia Law

Two nurses, formerly employed by Momence, alleged that, during their employment at Momence, they uncovered evidence that Momence knowingly submitted "thousands of false claims to the Medicare and Medicaid programs” in violation of the False Claims Act (FCA) and Illinois Whistleblower Reward and Protection Act. They filed a qui tam action on behalf of the government and alleged that Momence retaliated against them for reporting its fraud. A jury awarded the government more than $3 million in compensatory damages and imposed about $19 million in fines for the qui tam claims. Pursuant to the FCA, the compensatory damages were trebled to more than $9 million. The district court set aside the fines as violating the Excessive Fines Clause of the Eighth Amendment. The jury also awarded the nurses $150,000 and $262,320, respectively, on their retaliation claims. The Seventh Circuit vacated. Both claims failed as a matter of law. Rejecting claims of “worthless services” and false certification, the court stated that, at best, a reasonable jury might be able to say that some of Momence’s claims were false, but that is not enough to satisfy the burden of proof. The employment of one nurse was not terminated, the other’s employment was terminated for an unrelated matter.View "Absher v. Momence Meadows Nursing Ctr., Inc." on Justia Law

An MRI had revealed plaintiff’s herniated disc in 1998. The medical record is blank from then until 2007, when she complained to an emergency room physician that she had been suffering from lower-back pain. She mentioned the herniated disc, and was prescribed Vicodin. Almost a year later she was examined by an anesthesiologist who specializes in pain management, who prescribed Lyrica. The plaintiff subsequently sought disability benefits and testified that her pain, combined with the drowsiness induced by the pain medication, limited her daily activities to eating, caring for her dogs, taking naps, and watching television. The anesthesiologist opined that the plaintiff was “unable to work” because of “lumbar disc protrusion.” Another anesthesiologist reviewed her records, and concluded that she was able to work full time despite the diagnoses of lumber disk herniation, lumbar radiculopathy, and myofascial pain, and a Social Security field officer’s observation that “she had a hard time sitting in the chair during the interview.” He did not identify evidence supporting his conclusion. The district court affirmed the agency’s denial of benefits. The Seventh Circuit remanded, stating that the plaintiff deserves a more careful evaluation than she has received to date. The ALJ’s critical error was failure to obtain a medical report on the results of a 2010 MRI.View "Goins v. Colvin" on Justia Law

To compensate teaching hospitals for the extra financial burden of providing training, the Medicare program provides additional reimbursement for expenses beyond the immediate costs of patient care, including for “indirect medical education” (IME) costs to account for the time medical interns and residents spend in ways that enhance their ability to provide patient care but that are not connected to the treatment of any particular patient, 42 U.S.C. 1395ww(d)(5)(B)(ii). The district court held that time spent by interns and residents in research activities wholly unrelated to the diagnosis or treatment of patients could be counted as part of this indirect-education time and that Rush University Medical Center, was entitled to Medicare reimbursements for these activities between the years 1983 and 2001. The Seventh Circuit reversed and remanded, noting that the Secretary of Health and Human Services has interpreted the Medicare Act consistently since 1983 to exclude pure research activities from compensable IME costs. Congress codified this exclusion for Fiscal Years 2001 onward in the Patient Protection and Affordable Care Act of 2010, but explicitly declined to lay down a rule for the years 1983 to 2001. The Secretary has now promulgated a regulation excluding pure research from the IME cost calculation for all years since 1983. View "Rush Univ. Med. Ctr v. Sebelius" on Justia Law

Moon was a 26-year-old mother who had worked as a cashier, bank teller, and certified nursing assistant. She suffered from documented back and joint problems, mild sleep apnea, depression, and migraine headaches. Most of these problems are related to exceptional obesity: at a height of 5’5”, she weighs more than 400 pounds. In support of her application for disability benefits, Moon submitted extensive medical records. Her migraine headaches were diagnosed as early as 2005 and she saw doctors about her headaches many times. She was taking Imitrex and Motrin at the time of her May 2010 hearing. In his written decision denying benefits, the ALJ went through the standard five-step analysis and found that Moon was no longer engaged in substantial gainful activity and that her combination of impairments qualified as “severe,” but that she was still capable of doing sedentary work if she would be permitted to sit or stand at will. The ALJ relied on the opinions of two doctors who had reviewed medical records but had not examined Moon. The ALJ referred to “alleged headaches” dismissively. The Appeals Council and the district court upheld the denial. The Seventh Circuit reversed. The ALJ improperly discounted evidence of chronic migraine headaches. Because Moon is receiving disability benefits based on a later application, the only issue on remand will be whether she was disabled between August 2008 and the later date from which benefits have been paid.View "Moon v. Colvin" on Justia Law