Justia Health Law Opinion Summaries

Plaintiff, a pipefitter, worked with asbestos-containing gaskets made by defendant from 1962 until 1970. From 1962 until 1975, he also sustained significant exposure to asbestos insulation. He died in 2008, of mesothelioma, a cancer of the lining of the lung. Before his death, plaintiff sued under theories including strict liability and negligence. Defendant does not dispute that asbestos-containing products likely caused the mesothelioma, but argues that the mesothelioma was caused by exposure to asbestos insulation, and that its own gaskets were not a substantial factor. A jury awarded plaintiff $516,094. The Sixth Circuit reversed. Given that plaintiff failed to quantify the exposure to asbestos from defendant's gaskets and concedes that plaintiff sustained massive exposure to asbestos from non-defendant sources, there was insufficient evidence to infer that defendant's gaskets probably, as opposed to possibly, were a substantial cause of plaintiff's mesothelioma.

Following a 2007 train derailment and three-day fire that allegedly exposed a small Ohio town to cancer-causing agents, plaintiffs sought damages on behalf of a putative class. Plaintiffs' expert testified that the normal background level of dioxin is four parts per trillion and that the range within area homes was from 11.7 to 274 ppt. A doctor testified about increased risk of cancer. The district court granted summary judgment for the train company, finding that plaintiffs had not established general or specific causation and, as a matter of law, any increased risk of cancer or other diseases was too insignificant to warrant the court's ordering a lengthy period of medical monitoring. The Sixth Circuit affirmed, noting the absence of conclusive medical evidence that plaintiffs faced even a one-in-a-million increased risk of cancer.

Patient, insured by defendant, diagnosed with end-stage renal disease, and received dialysis at plaintiff's center. Three months after diagnosis, she became entitled to Medicare benefits (42 U.S.C. 426-1). Her plan provided that coverage ceased at that time, because of her entitlement to Medicare, but the insurer continued to pay for two months. Under the 1980 Medicare Secondary Payer Act, a group health plan may not take into account that an individual is entitled to Medicare benefits due to end-stage renal disease during the first 30 months (42 U.S.C. 1395y(b)(1)(C)(i)), but the insurer terminated coverage. Plaintiff continued to treat and bill. The insurer declared that termination was retroactive and attempted to offset "overpayment" against amounts due on other patients' accounts. The outstanding balance after patient's death was $210,000. Medicare paid less than would have been received from the insurer. The center brought an ERISA claim, 29 U.S.C. 1132(a)(1)(B), and a claim for double damages under the 1980 Act. The district court granted plaintiff summary judgment on its ERISA claim but dismissed the other. The Sixth Circuit affirmed on the ERISA claim and reversed dismissal. A healthcare provider need not previously "demonstrate" a private insurer's responsibility to pay before bringing a lawsuit under the 1980 Act's private cause of action.

A 66-year -old arrived at petitioner's center with complex ailments, but oriented, able to feed herself and able to speak. During her 18 days at the center, she was sent to the hospital twice with serious medical complications. Upon investigation, the center was found to have failed to maintain substantial compliance with federal regulations for facilities that participate in Medicare and Medicaid (42 U.S.C. § 1395) in its treatment of the resident and appealed the resulting civil money penalty. An administrative law judge, the Departmental Appeals Board, and the Sixth Circuit affirmed. The ALJ acted properly in requiring submission of written testimony, properly weighed the evidence, and found violation of the federal hydration standard, laboratory services requirement, and mandate of a care plan, resulting in "immediate jeopardy."

Doctors filed suit, alleging violations of the False Claims Act, 31 U.S.C. 3279 and the Michigan Medicaid False Claim Act, as qui tam relators on behalf of the United States/ The claimed that the business defrauded the government by submitting Medicare and Medicaid billings for defective radiology studies, and that the billings were also fraudulent because the business was an invalid corporation. The federal government declined to intervene. The district court dismissed. Sixth Circuit affirmed. The doctors failed to identify any specific fraudulent claim submitted to the government, as is required to plead an FCA violation with the particularity mandated by the FRCP. A relator cannot merely allege that a defendant violated a standard (in this case, with respect to radiology studies), but must allege that compliance with the standard was required to obtain payment. The doctors had no personal knowledge that claims for nondiagnostic tests were presented to the government, nor do they allege facts that strongly support an inference that such billings were submitted.

The Medicare program pays teaching hospitals to cover "direct" and "indirect costs of medical education," 42 U.S.C. 1395ww(d)(5)(B), (h). Direct costs include expenses such as residents' salaries. Indirect costs are incurred due to "general inefficiencies" and "extra demands placed on other staff." Congress created a formula for calculating indirect expenses based on full-time equivalency interns; an HHS regulation referred to time residents spend in the "portion of the hospital subject to the prospective payment system or in the outpatient department of the hospital." In reimbursing plaintiff, HHS excluded from the FTE count time residents spent on pure research, unrelated to treatment of a patient. While appeal of a decision favoring the hospital was pending, Congress enacted the Patient Protection and Affordable Care Act, 124 Stat. 119, 660–61. For the years at issue, HHS must include in FTE: "all the time spent by an intern or resident in an approved medical residency training program in non-patient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary." HHS promulgated a regulation specifying that eligible non-patient care activities do not include time residents spend conducting pure research. The Sixth Circuit upheld the regulation as within the Secretary's authority and applicable to the years at issue.

In 2006 the claimant sought disability benefits, alleging injury in a construction accident. An ALJ denied the claim and the appeals council denied review. The district court upheld the denial. The Sixth Circuit vacated. The ALJ's decision was incomplete and improperly gave greatest weight to the opinion of a non-treating state agency physician, rather than to the opinion of a treating physician. The ALJ mischaracterized the treating physician's treatment notes.

Plaintiff filed several suits against healthcare groups on behalf of the United States, claiming violation of the Medicare Secondary Payer Act, 42 U.S.C. 1395y(b). No court has ever found that the MSP is a qui tam statute, permitting private attorneys general to sue on behalf of the United States. The Sixth Circuit found plaintiff was on notice of the frivolous nature of his filings from their inception in the Tennessee district courts and remanded for a show-cause hearing on why sanctions should not issue. The district court awarded sanctions to two defendants in amounts of $131,158.50 and $145,431.19. The Sixth Circuit affirmed, but denied an award for the appeal.

After being fired from his position as operations manager for a regional passenger airline, plaintiff sued, alleging "association discrimination" under the Americans with Disabilities Act, 42 U.S.C. 12112(b)(4). Plaintiff is not disabled; his wife suffers from Polyarteritis Nodosa, a rare and debilitating autoimmune disorder. The district court entered summary judgment in favor of the employer. The Sixth Circuit affirmed. While his wife's condition may have precipitated plaintiff's poor performance, plaintiff did not present evidence that he was fired because of her condition, rather than his performance.

The district court upheld the constitutionality of the Patient Protection and Affordable Care Act, 26 U.S.C. 5000 A, which, among other things, the minimum coverage provision of the Act requires all applicable individuals to maintain minimum essential health insurance coverage or to pay a penalty. The Sixth Circuit affirmed, first holding that the plaintiffs had standing, that the case was not barred by the Anti-Injunction Act, 26 U.S.C. 7421(a), and that the matter was ripe for judicial review. The provision is a valid exercise of the legislative power under the Commerce Clause; it regulates economic activity with a substantial impact on interstate commerce. The court rejected an argument that it regulates inactivity.