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

The Seventh Circuit affirmed the judgment of the district court denying Heart of CarDon, LLC's motion for judgment on the pleadings in this interlocutory appeal concerning section 1557 of the Patient Protection and Affordable Care Act, holding that T.S. was a proper plaintiff against CarDon under section 1557, and his suit may continue on that basis.CarDon was a healthcare provider that was reimbursed by Medicare and Medicaid for its serves. CarDon provided health insurance to its employees and their depends through a self-funded employee benefits plan. T.S., a dependent who had autism, brought this action alleging that the plan's exclusion of coverage for autism treatment violated section 1557. CarDon moved for judgment on the pleadings, arguing that only a recipient of CarDon's healthcare services was a permissible plaintiff under section 1557. The district court denied the motion. The Seventh Circuit affirmed, holding that T.S. plausibly alleged an interest that comes within the zone of interests section 1557 seeks to protect. View "T.S. v. Heart of CarDon, LLC" on Justia Law

Illinois moved its Medicaid program from a fee‐for‐service model, where a state agency pays providers’ medical bills, to one dominated by managed care, where private insurers pay medical bills. Most patients of Saint Anthony Hospital are covered by Medicaid, so Saint Anthony depends on Medicaid payments. Over the last four years, it has lost roughly 98% of its cash reserves, allegedly because managed‐care organizations have repeatedly and systematically delayed and reduced Medicaid payments to it. Saint Anthony sued, arguing that Illinois officials owe it a duty under the Medicaid Act to remedy the late and short payments.The Seventh Circuit reversed the dismissal of the suit, concluding that Saint Anthony has alleged a viable claim for relief under 42 U.S.C. 1396u‐ 2(f) and may seek injunctive relief under 42 U.S.C. 1983 against the state official who administers the Medicaid program in Illinois. Illinois has tools available to remedy systemic slow payment problems—problems alleged to be so serious that they threaten the viability of a major hospital and even of the managed‐care Medicaid program as administered in Illinois. If Saint Anthony can prove its claims, the chief state official could be ordered to use some of those tools to remedy systemic problems that threaten this literally vital health care program. View "Saint Anthony Hospital v. Eagleson" on Justia Law

Albert suffers from epilepsy, Asperger syndrome, ADHD, migraines, and insomnia. Born in 1998, Albert’s parents support her financially, help manage her medications, and assist her with daily living. Albert has never had a driver’s license nor worked. Albert graduated from high school in 2017. Although she struggled in math, her academic performance was otherwise average. She enrolled in an online college course but stopped attending after suffering a grand mal seizure in September 2017. She applied for supplemental security income.The ALJ determined that, although Albert suffered from severe mental and physical impairments, these impairments, taken alone or together, did not amount to a “listed disability"; Albert had the residual functional capacity to perform a full range of work at all exertional levels, subject to a few restrictions; Albert “was likely to have difficulty with social interactions” and had poor concentration and a low frustration tolerance; that Albert can “understand, carry out and remember simple instructions” and “make judgments commensurate with functions of simple, repetitive tasks”; and that there are a significant number of jobs that someone with Albert’s RFC could perform.The district court and Seventh Circuit affirmed the denial of benefit, finding substantial evidence supporting the ALJ’s determination. “Should Albert try to work but find herself unable, nothing will prevent her from applying anew for benefits.” View "Albert v. Kijakazi" on Justia Law

Poole has a degenerative disc disease of the lumbar spine; it causes severe pain in her lower back and leg after she either stands or sits for a brief time. She lost her job as a cashier because her pain made it impossible for her to stand throughout her full shift. Poole also suffers from a learning disability, anxiety, and depression, all of which impair her ability to concentrate, understand, or remember detailed instructions. Now 46 years old, she has only a “marginal education,” meaning sixth grade or less. Poole sought Supplemental Security Income, 42 U.S.C. 423(d). An ALJ denied her application and dismissed her companion application for disability insurance benefits.The Seventh Circuit reversed, concluding that the ALJ’s decision rested on contradictory findings. . Either Poole can stand for four hours a day and should have been put in the “light” exertional level, or the ALJ correctly found that she belonged in the “sedentary” category and could stand (or walk) at most for two hours a day. The ALJ never said that Poole could perform sedentary work if she could sit or stand at will, so the vocational expert never focused on that potential set of jobs. When an agency decision is so ambiguous that it frustrates judicial review, it cannot be upheld. View "Poole v. Kijakazi" on Justia Law

In 2009, Grotts applied for Social Security disability benefits, citing depression and low functional capacity. She had previously worked as a caretaker for a child with disabilities and he cared for her own child. Her case was remanded four times. Five times, an ALJ concluded that Grotts was not disabled. The final ALJ found that she could still perform light work with some restrictions and because a significant number of jobs fitting that description existed in the national economy.The district court agreed. The Seventh Circuit affirmed, rejecting arguments that the ALJ erred in its evaluation of Grotts’s subjective complaints about her symptoms, in its evaluation of the medical opinion evidence, and in its residual functional capacity determination. Substantial evidence supported the ALJ’s weighing of the medical opinion evidence and its RFC determination. The ALJ did not patently err in its evaluation of Grotts’s subjective complaints. View "Grotts v. Kijakazi" on Justia Law

Mandrell, born in 198, pursued her education through one year in college. In 2005-2009, she served in the Coast Guard, which she left with an honorable discharge. While in service she was the victim of a rape by a fellow service member. She developed PTSD and anxiety afterward. The VA found her to be 100% disabled based on a service-related cause and awarded benefits but later revised her level of disability down to 70%. Mandrell’s 2017 application for Social Security disability benefits was denied and the Appeals Council denied her request for review. The district court affirmed.The Seventh Circuit reversed and remanded. The ALJ failed to connect the residual functional capacity he found with the evidence in the record, and he did not adequately account for her deficits in concentration, persistence, and pace. The ALJ apparently accepted that Mandrell suffered from PTSD as a result of the rape, but dismissed most of the symptoms that accompanied that condition. While the Social Security Administration is not bound by the VA’s assessment of Mandrell’s disability, the underlying medical evidence on which the VA relied is just as relevant to the social‐security determination as it was to the VA. View "Mandrell v. Kijakazi" on Justia Law

Reynolds, born in 1992, graduated from high school and previously worked part-time in retail. Reynolds suffers from migraines, vertigo, and “major depressive disorder, recurrent moderate with anxious distress.” She applied for Social Security disability benefits in 2017. Reynolds testified that she suffers from back pain, vertigo, and migraines, and she cannot stand for more than 10 minutes. Her parents handle household chores. She has migraines every day. She stopped taking some prescription medications for her migraines because of the side effects. Reynolds quit her job at Walmart because of her migraines. Reynolds testified has never gone to an emergency room or crisis center for mental health treatment but suffers from anxiety around “more than five people.” She was taking medication for her mental health conditions.The ALJ concluded that Reynolds was not disabled under the Social Security Administration’s five-step method and that Reynolds had the residual functional capacity to perform a full range of work with certain non-exertional limitations. The Seventh Circuit affirmed the denial as supported by substantial evidence. The court rejected an argument that the ALJ erred by failing to include a qualitative interaction limitation in the residual functional capacity determination. No medical evidence called for a qualitative interaction limitation; the ALJ was not required to intuit such a limitation from the administrative record. View "Reynolds v. Kijakazi" on Justia Law

Ruenger applied for Social Security Disability benefits in 2015, alleging that he had limited use of his left arm and mental impairments including anxiety and depression. At a hearing, the ALJ determined that Ruenger had not worked within the claim period, that his mental and physical impairments were severe but did not presumptively establish a disability, and that he had the capacity to perform light work with certain physical and social limitations. At the final step of the inquiry, the ALJ determined—based on a vocational expert’s testimony—that Ruenger could still perform jobs that exist nationwide in significant numbers and denied Ruenger’s application.The Seventh Circuit vacated and remanded. Substantial evidence does not support the ALJ’s decision. ALJs cannot afford complete discretion to vocational experts. When a claimant challenges a vocational expert’s job-number estimate, the ALJ must inquire whether the methodology used by the expert is reliable. In this case, the vocational expert enlisted by the agency to estimate the number of jobs suitable for Ruenger omitted crucial details about her methodology, such as the source of her job numbers and the reason she used the equal distribution method; the ALJ nevertheless relied on the expert’s testimony. View "Ruenger v. Kijakazi" on Justia Law

For almost 30 years, Prill worked for the Eau Claire, Wisconsin County Highway Department performing physically demanding work, including driving a dump truck and maintaining roads. She suffered from pain in her lower back and knees, which was exacerbated by a car accident and multiple work injuries. Prill retired in 2014 and later filed for Social Security disability benefits alleging she could no longer perform heavy or medium work. Several doctors examined Prill or reviewed her medical records but reached different conclusions about her physical limitations.An ALJ found Prill’s testimony only partially credible, concluding that her report about the severity of her symptoms and the extent of her limitations was inconsistent with other record evidence. The ALJ also weighed the competing medical evidence and gave greater weight to the opinions of consulting physicians who reviewed Prill’s medical records than to the opinion of Prill’s treating physician. The ALJ concluded that Prill had not been disabled since August 2014. The Appeals Council of the Social Security Administration denied her request for review. The district court and Seventh Circuit affirmed. Substantial evidence supported the ALJ’s decision. The court rejected arguments the ALJ wrongly discounted Prill’s subjective allegations and improperly weighed the differing medical opinions. View "Prill v. Kijakazi" on Justia Law

Wilder, born in 1970, has a high school education. She previously worked as a motor vehicle quality worker and a sales clerk. She has not worked since October 2015. Wilder applied for Social Security disability benefits in 2016, alleging a disability onset date in October 2015. She alleged hip pain, difficulty walking, lower back pain, and balance issues. Her claim was administratively denied. An ALJ concluded that Wilder’s impairments, while severe, did not meet or equal one of the impairments listed in 20 C.F.R. Part 404, Subpart P, App’x 1, that Wilder had the residual functional capacity to perform sedentary work with limitations, and that suitable jobs existed in significant numbers in the national economy. The Appeals Council denied Wilder’s request for review.The district court and Seventh Circuit held that substantial evidence supported the ALJ’s decision. The court rejected Wilder’s arguments that the ALJ erred by failing to consider whether she met or equaled Listing 11.17(a), even though her attorney did not argue to the ALJ that she met or equaled that Listing (or any Listing) and by failing to request the opinion of a medical expert, and that the ALJ’s evaluation of her subjective symptoms was patently wrong. View "Wilder v. Kijakazi" on Justia Law