Justia Health Law Opinion Summaries

Alicia Rae Pufahl applied for disability insurance benefits from the Social Security Administration in August 2012, citing limitations due to Wegener’s granulomatosis, depression, pulmonary disease, back injury, bipolar disorder, and excessive fatigue. She needed to establish disability between August 8, 2011, and December 31, 2016. Her application was initially denied in November 2012, followed by several unfavorable decisions from Administrative Law Judges (ALJs), appeals, and remands. The most recent ALJ decision concluded that she was not disabled during the relevant period, and the district court affirmed this decision.The United States District Court for the Eastern District of Wisconsin affirmed the ALJ’s decision, finding that substantial evidence supported the agency’s determination. The Appeals Council denied further review, making the ALJ’s decision the final decision of the Commissioner of Social Security.The United States Court of Appeals for the Seventh Circuit reviewed the case and affirmed the district court’s judgment. The court held that the ALJ properly weighed the medical opinion evidence, including the opinions of Ms. Pufahl’s neurologist, primary care provider, and psychiatrist, and found substantial evidence supporting the ALJ’s decision to not give controlling weight to these opinions. The ALJ’s evaluation of Ms. Pufahl’s subjective complaints was not patently wrong, as it was supported by specific reasons and evidence. Additionally, the hypothetical question posed to the vocational expert (VE) sufficiently accounted for Ms. Pufahl’s mental limitations, including her ability to maintain attention and concentration for two-hour segments. The court concluded that the ALJ’s decision was supported by substantial evidence and affirmed the district court’s judgment. View "Pufahl v Bisignano" on Justia Law

Randy Wiertella died in the Lake County Adult Detention Facility on December 10, 2018. Dennis Wiertella, as the Administrator of Randy's estate, filed a lawsuit claiming that Randy's constitutional rights under the Eighth and Fourteenth Amendments were violated by Jail staff Diane Snow, RN, and Christina Watson, LPN. Randy had been booked into the Jail without his essential medications for heart disease, diabetes, high blood pressure, and a psychiatric disorder. Despite multiple requests, he did not receive all necessary medications, leading to his death from hypertensive cardiovascular disease.The United States District Court for the Northern District of Ohio denied Snow and Watson's motion for summary judgment, which sought dismissal based on qualified immunity. The court found that there were genuine disputes of material fact regarding whether Snow and Watson were aware of the substantial risk to Randy's health and whether they failed to respond reasonably.The United States Court of Appeals for the Sixth Circuit reviewed the case. The court held that Snow and Watson were not entitled to qualified immunity. The court found that both nurses were aware of Randy's serious medical conditions and the need for continuous medication. Despite this knowledge, they failed to ensure that Randy received his essential medications in a timely manner. The court concluded that their actions were unreasonable and violated Randy's constitutional rights. The court affirmed the district court's decision and remanded the case for further proceedings on the Estate's § 1983 claim. View "Wiertella v. Lake County" on Justia Law

Dr. Brian Carpenter was involved in a scheme to defraud TRICARE, the Department of Defense’s health insurance program. The scheme was orchestrated by Britt and Matt Hawrylak, who hired sub-reps to obtain medical information about TRICARE beneficiaries and identify doctors willing to write unnecessary prescriptions for compounded medications. These prescriptions were filled by Rxpress Pharmacy, which billed TRICARE at high rates. Carpenter, a podiatrist, was recruited by his co-defendant Jerry Hawrylak to write these prescriptions. Carpenter initially refused but later agreed to write prescriptions without receiving payment, claiming it was to help veterans. However, evidence showed that Carpenter's prescriptions were highly profitable for the Hawrylak brothers and Jerry, who made millions from the scheme.In September 2019, Carpenter and Jerry were indicted on six counts of healthcare fraud and one count of conspiracy to commit healthcare fraud. They were convicted on all counts in April 2023 by the United States District Court for the Northern District of Texas. Carpenter appealed, raising several issues, including the district court’s decision to excuse a juror mid-trial.The United States Court of Appeals for the Fifth Circuit reviewed the case. The court found that the district court abused its discretion by excusing a juror after the first day of trial without a legally relevant reason or factual basis. The juror was excused based on an email from her principal stating that her absence would cause hardship for her school, but there was no indication that the juror was unable to perform her duties. The appellate court held that this error was prejudicial and required vacating Carpenter’s convictions. The court remanded the case for a new trial. View "United States v. Carpenter" on Justia Law

Michael Cannata served as a firefighter for the town of Mashpee for over a decade before leaving in 2004 as a "deferred retiree." During his employment, he was enrolled in the town's group health insurance plan, but his enrollment ended upon his departure. In 2021, after turning fifty-five and beginning to collect retirement benefits, Cannata sought to re-enroll in the town's health insurance plan as a retiree. The town denied his request, citing various reasons, including his lack of "time in-service" and the town's practice of denying coverage to retirees not enrolled in the plan at the time of retirement.Cannata filed an action in the Superior Court, seeking a judgment declaring that the town's denial of benefits violated G. L. c. 32B, § 9. The Superior Court judge granted the town's motion to dismiss for failure to state a claim, concluding that Cannata was required to apply for continued coverage and pay the full premium cost during his deferral period in order to later enroll in the town's group health insurance plan upon retirement. Cannata appealed the decision.The Supreme Judicial Court of Massachusetts reviewed the case. The court held that G. L. c. 32B, § 9, neither requires nor prohibits a municipality from enrolling individuals like Cannata in its group health insurance plan upon retirement. The court concluded that the third paragraph of the statute, which the lower court relied on, did not govern Cannata's case. The court determined that municipalities may, but are not obligated to, allow such individuals to enroll in group health insurance upon retirement. The court affirmed the judgment of dismissal on the alternative ground that Cannata's complaint failed to plausibly allege entitlement to relief beyond a speculative level. The case was remanded with instructions to dismiss the complaint without prejudice, allowing Cannata an opportunity to amend his request for declaratory relief. View "Cannata v. Town of Mashpee" on Justia Law

In 2023, Tennessee enacted Senate Bill 1 (SB1), which prohibits healthcare providers from prescribing, administering, or dispensing puberty blockers or hormones to minors for the purpose of enabling them to identify with a gender different from their biological sex or to treat discomfort from such discordance. However, SB1 allows these treatments for minors with congenital defects, precocious puberty, disease, or physical injury. Three transgender minors, their parents, and a doctor challenged SB1 under the Equal Protection Clause of the Fourteenth Amendment.The District Court partially enjoined SB1, finding that transgender individuals constitute a quasi-suspect class, that SB1 discriminates based on sex and transgender status, and that it was unlikely to survive intermediate scrutiny. The Sixth Circuit reversed, holding that SB1 did not trigger heightened scrutiny and satisfied rational basis review. The court found that SB1 did not classify based on sex or transgender status and that Tennessee had provided considerable evidence regarding the risks associated with the banned treatments.The Supreme Court of the United States reviewed the case and held that SB1 is not subject to heightened scrutiny under the Equal Protection Clause and satisfies rational basis review. The Court determined that SB1 does not classify on any bases that warrant heightened review, such as sex or transgender status. Instead, it classifies based on age and medical use, which are subject to rational basis review. The Court found that Tennessee had a rational basis for enacting SB1, citing concerns about the risks and unknown long-term effects of the treatments, the maturity of minors, and the availability of less invasive approaches. The judgment of the Sixth Circuit was affirmed. View "United States v. Skrmetti" on Justia Law

New York City is legally required to provide health insurance coverage for its retired employees. For over 50 years, the City offered a choice of health insurance plans, including Medicare supplemental plans and Medicare Advantage plans (MAPs). In 2021, to reduce costs, the City decided to discontinue most options, including the popular Senior Care plan, and enroll all retirees in a custom-designed MAP managed by Aetna Life Insurance Company. Petitioners, consisting of nine retirees and one organization, initiated this proceeding to prevent the City from eliminating their existing health insurance plans.The Supreme Court ruled in favor of the petitioners on their promissory estoppel cause of action and their claim under Administrative Code of the City of New York § 12-126 (b) (1). The Appellate Division affirmed the decision, concluding that the City had made a clear and unambiguous promise to provide Medicare supplemental coverage for life and that petitioners reasonably relied on this promise.The Court of Appeals of New York reviewed the case and determined that the petitioners were not entitled to judgment on their promissory estoppel cause of action. The court found that the Summary Program Descriptions (SPDs) provided by the City did not constitute a clear and unambiguous promise of lifetime Medicare supplemental insurance coverage. The court also rejected the petitioners' alternative grounds for relief, including their claim under Administrative Code § 12-126 (b) (1) and the Moratorium Law. Consequently, the Court of Appeals reversed the order of the Appellate Division and remitted the matter to the Supreme Court for further proceedings. View "Matter of Bentkowski v City of New York" on Justia Law

Emergency air medical providers challenged award determinations made under the No Surprises Act (NSA). The NSA, enacted in 2022, protects patients from surprise bills for emergency services from out-of-network providers by creating an Independent Dispute Resolution (IDR) process for billing disputes between providers and insurers. Guardian Flight transported a patient in Nebraska, and a dispute arose with Aetna over the service value. Similarly, Guardian Flight and its affiliates provided emergency services to patients insured by Kaiser, leading to disputes over payment amounts. Both disputes were submitted to Medical Evaluators of Texas (MET) as the IDR entity, which sided with the insurers.The United States District Court for the Southern District of Texas consolidated the cases. The court dismissed Guardian Flight’s claims against Aetna and Kaiser, ruling that the providers failed to plead sufficient facts to trigger vacatur of the awards. However, the court denied MET’s motion to dismiss based on arbitral immunity, leading to MET’s cross-appeal.The United States Court of Appeals for the Fifth Circuit reviewed the case. The court held that the NSA does not provide a general private right of action to challenge IDR awards, incorporating Federal Arbitration Act (FAA) provisions that allow courts to vacate awards only for specific reasons. The court affirmed the district court’s dismissal of the providers’ claims against Aetna and Kaiser, finding that the providers did not allege facts sufficient to show that the awards were procured by fraud or undue means under the FAA.Additionally, the Fifth Circuit addressed MET’s claim of arbitral immunity. The court concluded that MET, functioning as a neutral arbiter in the IDR process, is entitled to the same immunity from suit typically enjoyed by arbitrators. Consequently, the court reversed the district court’s judgment on this point and remanded with instructions to dismiss the providers’ claims against MET. View "Guardian Flight, L.L.C. v. Aetna Health, Inc." on Justia Law

Two air ambulance providers, Guardian Flight, LLC, and Med-Trans Corporation, sued Health Care Service Corporation (HCSC) for failing to timely pay dispute resolution awards under the No Surprises Act (NSA). The providers also claimed that HCSC improperly denied benefits under the Employee Retirement Income Security Act (ERISA) and was unjustly enriched under Texas law.The United States District Court for the Northern District of Texas dismissed the providers' complaint. The court found that the NSA does not provide a private right of action for enforcing dispute resolution awards. It also dismissed the ERISA claim for lack of standing, as the providers did not show that the beneficiaries suffered any injury since the NSA shields them from liability. Lastly, the court dismissed the quantum meruit claim, stating that the providers did not perform their services for HCSC's benefit. The court also denied the providers' request for leave to amend their complaint, deeming it futile.The United States Court of Appeals for the Fifth Circuit affirmed the district court's decision. The appellate court agreed that the NSA does not contain a private right of action and that the statute's text and structure support this conclusion. The court also upheld the dismissal of the ERISA claim, reiterating that the beneficiaries did not suffer any concrete injury. Finally, the court affirmed the dismissal of the quantum meruit claim, as the providers did not render services for HCSC's benefit. The appellate court also found no abuse of discretion in the district court's denial of leave to amend the complaint. View "Guardian Flight v. Health Care Service" on Justia Law

UnitedHealthCare Insurance Company and its affiliates (collectively, United) were sued by Fremont Emergency Services and other emergency medical providers (collectively, TeamHealth) for underpaying claims for emergency medical services provided to United’s members. TeamHealth alleged that United failed to adequately reimburse them for services rendered under the Emergency Medical Treatment and Labor Act (EMTALA) after their contract with United expired, leaving them as out-of-network providers. TeamHealth claimed United was unjustly enriched and breached an implied-in-fact contract, also asserting statutory claims under the Prompt Pay and Unfair Claims Practices Acts.The case was initially removed to federal court, which found no ERISA preemption and remanded it to state court. The Eighth Judicial District Court of Nevada ruled in favor of TeamHealth, awarding them compensatory and punitive damages, prejudgment interest, and attorney fees. United appealed the judgment and petitioned to seal certain court documents.The Supreme Court of Nevada reviewed the case and found substantial evidence supporting the jury’s verdict on unjust enrichment but not on the implied-in-fact contract or statutory claims. The court held that ERISA did not preempt TeamHealth’s claims and that United was entitled to judgment as a matter of law on the Unfair Claims Practices Act claim, as the statute did not provide a private right of action for medical providers. The court affirmed the compensatory damages for unjust enrichment but vacated the punitive damages award, remanding for recalculation to a 1:1 ratio of compensatory to punitive damages. The court also reversed the prejudgment interest and attorney fees awards under the Prompt Pay Act and remanded for a new determination of prejudgment interest.Additionally, the court denied United’s petition to seal certain documents, finding that United failed to meet its burden to demonstrate the necessity of sealing. The court concluded that the district court did not abuse its discretion in refusing to seal parts of the record. View "UnitedHealthCare Insurance Company v. Fremont Emergency Services" on Justia Law

West Virginia filed a complaint in state court against CaremarkPCS Health, LLC, a pharmacy benefit manager (PBM), alleging that Caremark unlawfully drove up the cost of insulin, causing financial harm to the state. The complaint included state law claims of civil conspiracy, unjust enrichment, fraud, and breach of contract. Caremark removed the case to federal court under the federal officer removal statute, 28 U.S.C. § 1442(a)(1), arguing that its conduct in negotiating rebates, which is central to the complaint, was performed under the direction of the federal government as part of its work for federal health plans.The United States District Court for the Northern District of West Virginia found that removal was unwarranted and remanded the case to state court. The district court concluded that Caremark failed to meet the requirements for federal officer removal and noted that West Virginia had disclaimed any federal claims in its complaint.The United States Court of Appeals for the Fourth Circuit reviewed the case and reversed the district court's decision. The Fourth Circuit held that Caremark was entitled to remove the case to federal court under § 1442(a)(1). The court found that Caremark acted under a federal officer because it administered health benefits for federal employees under contracts with FEHBA carriers, which are supervised by the Office of Personnel Management (OPM). The court also determined that Caremark had a colorable federal defense, specifically that federal law preempted West Virginia's claims. Finally, the court concluded that the charged conduct was related to Caremark's federal work, as the rebate negotiations for federal and non-federal clients were indivisible. Thus, the Fourth Circuit reversed the district court's remand decision and returned the case to the district court for further proceedings. View "West Virginia ex rel. Hunt v. CaremarkPCS Health, L.L.C." on Justia Law