Justia Health Law Opinion Summaries

Gogos, a pipe welder for 45 years, has taken blood pressure medication for more than eight years. He began working for AMS in December 2012 as a welder and pipe-fitter. The next month, his blood pressure spiked and he experienced intermittent vision loss and a red eye. His supervisor agreed that he could leave to seek immediate medical treatment. As Gogos left work, he saw his general foreman and stated that he was going to the hospital because “my health is not very good lately.” The foreman immediately fired him. After pursuing a charge with the Equal Employment Opportunity Commission, Gogos sued. He applied to proceed in forma pauperis and requested that the court recruit counsel, stating that he cannot afford an attorney; that he has only a grammar-school education; and that English is not his primary language. The district court dismissed, reasoning that Gogos’s medical conditions were “transitory” and “suspect.” The Seventh Circuit vacated, reasoning that Gogos stated a claim under the Americans with Disabilities Act, 42 U.S.C. 12112.View "Gogos v. AMS-Mech. Sys., Inc." on Justia Law

In 2005, Indianapolis and Marion County passed an ordinance prohibiting smoking in most buildings frequented by the general public, with exceptions for bars and taverns with liquor licenses that neither served nor employed people under the age of 18, tobacco bars, and bowling alleys. In 2012, the City-County Council expanded the ordinance by eliminating many exceptions. As amended, the ordinance included exceptions for private residences, retail tobacco stores, tobacco specialty bars, and private clubs that voted to permit smoking. Bar owners affected by the ordinance sought declaratory and injunctive relief, asserting due process, equal protection, takings and freedom of association claims under both the federal and Indiana constitutions. The district court upheld the ban. The Seventh Circuit affirmed. View "Goodpaster v. City of Indianapolis" on Justia Law

After discovering that she had lung cancer that had spread to her brain, Killian underwent aggressive treatment on the advice of her doctor. The treatment was unsuccessful and she died. Her husband submitted medical bills for the cost of the treatments to her health insurance company. The company denied coverage on most of the expenses because the provider was not covered by the insurance plan network. The husband filed suit, seeking benefits for incurred medical expenses, relief for breach of fiduciary duty, and statutory damages for failure to produce plan documents. The district court dismissed denial-of-benefits and breach-of-fiduciary-duty claims, but awarded minimal statutory damages against the plan administrator. In 2012, the Seventh Circuit affirmed the dismissals, rejecting an argument that the plan documents were in conflict, but remanded for recalculation of the statutory damages award. On rehearing, en banc, the Seventh Circuit affirmed the denial of benefits and statutory penalties holdings, but reversed on the breach of fiduciary duty claim. The instructions given in plan documents were deficient and a reasonable trier of fact could rule in favor of Killian, based on telephone conversations in which Killian attempt to determine whether the physicians who were about to perform surgery were within the network. View "Killian v. Concert Health Plan" on Justia Law

Orillo, her husband (a doctor), and another owned Chalice, a home health care provider. Chalice was an enrolled provider with Medicare and could seek reimbursement of home health care through that program. Orillo falsified forms by altering the codes and information that had been completed by the Chalice nurses to make the patient’s condition appear worse and the health care needs greater than the actuality. Those alterations caused Medicare software to generate different reimbursement rates Orillo also aided her husband in paying kickbacks to a Chicago doctor in return for referrals of Medicare patients. Orillo pled guilty to healthcare fraud, 18 U.S.C. 1347 and paying kickbacks to physicians for patient referrals under a federal health care program, 42 U.S.C. 1320a-7b and 18 U.S.C. 2, and was sentenced to 20 months’ imprisonment. Orillo conceded that her scheme caused a loss, to Medicare, in excess of $400,000, and agreed to entry of a $500,000 forfeiture judgment.The district court determined that the loss amount for the healthcare fraud count was $744,481 and ordered her to pay that amount in restitution. The Seventh Circuit affirmed, rejecting Orillo’s argument that the loss and restitution amount should be limited to only those stemming from visible alterations. View "United States v. Orillo" on Justia Law

Burris worked in coal mines for 23 years. He twice sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901, abandoning his first claim in 2001, and pursuing a second claim in 2006. After a hearing on the second claim, an Administrative Law Judge determined that Burris was totally disabled by pneumoconiosis arising from his coal mining employment and that he qualified for benefits. The Benefits Review Board affirmed. The Seventh Circuit denied a petition for review, rejecting arguments that the ALJ erred in finding that Burris established a material change in condition following his first, abandoned claim; in concluding that Burris proved 15 years of surface mine employment in conditions substantially similar to those that exist in underground mines; and in rejecting evidence rebutting a presumption of pneumoconiosis. View "Consolidation Coal Co. v. Dir., Office of Workers' Comp. Programs" on Justia Law

Schomas, 54 years old, suffers from scoliosis and degenerative disc disease. Following a hearing, the Social Security Administration denied his application for Disability Insurance Benefits. The district court and the Seventh Circuit upheld the denial, rejecting a challenge to the ALJ’s credibility finding and assessment of his residual functional capacity. The court acknowledged that the ALJ’s decision was “problematic,” but concluded that Schomas waived most of his arguments, and that the rest were unfocused or undeveloped. View "Schomas v. Astrue" on Justia Law

After researching qui tam actions and meeting with an attorney, Dr. Watson placed an ad in a Sheboygan newspaper soliciting minor Medicaid patients who had been prescribed certain psychotropic medications. The ad referred to participation in a possible Medicaid fraud suit and sharing in any recovery. Meyer responded and entered into an agreement with Watson, who never met Meyer’s child, but obtained the child’s records by using an authorization stating that Meyer was requesting the records “[f]or the purpose of providing psychological services and for no other purpose whatsoever….” Watson searched the records for “off‐label” prescriptions written for a purpose that has not been approved by the FDA. Off‐label use is common, but generally not paid for by Medicaid. In the child’s records, Watson identified 49 prescriptions that he alleged constituted false claims to the U.S. government. The district court rejected Watson’s suit under the qui tam provision of the False Claims Act, 31 U.S.C.3729(a)(1)(A), reasoning that expert testimony was necessary to prove essential elements of the case and Watson had not named experts. While characterizing Watson’s tactics as “borderline fraudulent,” the Seventh Circuit reversed, citing the district court’s “overly rigid” view of the causation and knowledge elements of the claim. View "Watson v. King-Vassel" on Justia Law

Okoro was arrested without a warrant on suspicion of a misdemeanor property crime. For unknown reasons, Okoro never received a “Gerstein hearing” to determine probable cause during his two months of incarceration. Okoro, then 23, had Type I diabetes, which he could control by monitoring his blood sugar levels. While he was in college, however, he was diagnosed with schizophrenia, which compromised his ability to care for his diabetes. Immediately after his arrest, Okoro’s relatives began calling to inform correctional employees and medical staff of his conditions. Okoro was detained in his cell, usually in isolation, and was dependent on jail employees and medical staff to monitor his blood sugar level and provide insulin shots. On December 23, 2008, Okoro collapsed in his cell. An autopsy revealed that Okoro’s death was the result of diabetic ketoacidosis, a buildup of acidic ketones in the bloodstream that occurs when the body runs out of insulin. A doctor and a nurse, employed by the healthcare company that contracts with the jail, moved for dismissal of the estate’s suit under 42 U.S.C. 1983. The district court denied their qualified immunity claims. The Seventh Circuit affirmed, stating that the record easily supports a finding of deliberate indifference to Okoro’s serious medical condition. View "Currie v. Chhabra" on Justia Law

Health and Hospital Corporation of Marion County, Indiana is a municipal corporation that operates a major hospital and other facilities, including a health center operated in partnership with Citizens Health to serve the medically under-served population in Indianapolis. The health center was funded in part by a Section 330 Grant, awarded by the federal Health Resources and Services Administration, which is part of the Department of Health and Human Services. Section 330 grants fund qualifying health centers that provide primary health care services to medically under-served populations, 42 U.S.C. 254b. A In 2012, Health and Hospital decided to terminate the partnership with Citizens and relinquish the federal grant, which still had several years of funding remaining. Citizens sued Health and Hospital, HRS, and others in an effort to retain the grant funds. The district court granted defendants summary judgment, concluding that Citizens had no contractual, statutory, or constitutionally cognizable interest in the grant. The Seventh Circuit affirmed, finding that Health and Hospital was the grantee; Citizens had no constitutionally-protected entitlement to the grant; and the terms of the contract between Health and Hospital and Citizens clear; there was no obligation to renew. View "Citizens Health Corp. v. Sebelius" on Justia Law

Plaintiffs, insured under employer health plans, filed a proposed class action alleging that health-insurance companies violated Wisconsin law by requiring copayments for chiropractic care. The insurance code prohibits insurers from excluding coverage for chiropractic services if their policies cover the diagnosis and treatment of the same condition by a physician or osteopath. The policies at issue provide chiropractic coverage, although, like other services, it is subject to copayment requirements. The complaint cited provisions of the Employee Retirement Income Security Act for recovery of benefits due, 29 U.S.C. 1132(a)(1)(B) & 502(a)(3), and for breach of fiduciary duty, sections 1132(a)(3), 1104. The district court dismissed. The Seventh Circuit affirmed. Nothing in ERISA categorically precludes a benefits claim against an insurance company. The complaint alleges that the insurers decide all claims questions and owe the benefits; on these allegations the insurers are proper defendants on the 1132(a)(1)(B) claim. The complaint nonetheless fails to state a claim for breach of fiduciary duty; setting policy terms, including copayments, determines the content of the policy, and decisions about the content of a plan are not themselves fiduciary acts. View "Larson v. United Healthcare Ins. Co." on Justia Law