Justia Health Law Opinion Summaries

Eva Mae Givens applied for Medicaid assistance in Washington, D.C., but the District miscalculated her copay, requiring her to pay an extra $2,000 per month. Givens requested an administrative hearing to contest the miscalculation, but D.C. did not provide a timely hearing as required by federal law. Givens then filed a lawsuit under 42 U.S.C. § 1983, seeking injunctive and declaratory relief for a fair hearing and monetary damages for the overpayments. While the case was pending, D.C. held a hearing, corrected the miscalculation, and sent back-payments to the nursing homes, but not to Givens. Givens passed away shortly after the hearing.The United States District Court for the District of Columbia dismissed the case with prejudice, ruling that the claims were moot because D.C. had provided the hearing and corrected the miscalculation. The court also held that Givens failed to state a claim for relief. Givens' children, who sought to be substituted as plaintiffs, appealed the decision.The United States Court of Appeals for the District of Columbia Circuit reviewed the case. The court affirmed the dismissal of the fair-hearing claims as moot but noted that the dismissal should have been without prejudice. The court found that the calculation claim was not moot because Givens had not received compensation for the overpayments she made. However, the court held that the calculation claim failed to plausibly allege a violation of federal rights under § 1983, as Givens did not identify a specific municipal policy or custom that caused the miscalculation.The appellate court vacated the district court's order dismissing the case with prejudice and remanded the case. The district court was instructed to dismiss the moot fair-hearing claims without prejudice and to either dismiss the calculation claim without prejudice or provide a detailed explanation for a dismissal with prejudice. View "Givens v. Bowser" on Justia Law

Angela Midthun-Hensen and Tony Hensen sought insurance coverage for therapies for their daughter K.H.'s autism from Group Health Cooperative between 2017 and 2019. The insurer denied coverage, citing a lack of evidence supporting the effectiveness of speech therapy for a child K.H.'s age and sensory-integration therapy for autism at any age. The family's employer-sponsored plan only covered "evidence-based" treatments. After several medical reviews and appeals upheld the insurer's decision, the parents sued, alleging violations of the Employee Retirement Income Security Act (ERISA) and state law regarding autism coverage.The United States District Court for the Western District of Wisconsin ruled in favor of the insurer, finding no violations of state law or ERISA. The plaintiffs then focused on their claim that the insurer's actions violated the Mental Health Parity and Addiction Equity Act (MHPAEA), which mandates equal treatment limitations for mental and physical health benefits. They argued that the insurer applied the "evidence-based" requirement more stringently to autism therapies than to chiropractic care, which they claimed lacked scientific support.The United States Court of Appeals for the Seventh Circuit reviewed the case and affirmed the district court's decision. The appellate court found that the insurer's reliance on medical literature, which varied in its recommendations based on patient age, was permissible under the Parity Act. The court also noted that the plaintiffs failed to demonstrate that the insurer's treatment limitations for mental health benefits were more restrictive than those applied to "substantially all" medical and surgical benefits, as required by the statute. The court concluded that the plaintiffs' focus on a single medical benefit was insufficient to prove a violation of the Parity Act. View "Midthun-Hensen v. Group Health Cooperative of South Central, Inc.," on Justia Law

Residents of St. Croix, Virgin Islands, sued Limetree Bay Terminals and Limetree Bay Refining after the companies reopened an oil refinery that released oil mist onto nearby properties, contaminating water supplies. The residents, who rely on cisterns for water, claimed the contamination posed health risks. The companies attempted to clean the cisterns and compensate affected residents, but not all residents had access to clean water. The residents sought a preliminary injunction to require the companies to provide bottled water.The District Court for the Virgin Islands granted the preliminary injunction, finding that both Terminals and Refining were responsible for the contamination under their federal operating permit. The court determined that the residents were likely to succeed on the merits of their case and faced irreparable harm without access to clean water. The court limited the bottled-water program to residents in certain neighborhoods who received need-based government assistance and required the residents to post a $50,000 bond.The United States Court of Appeals for the Third Circuit reviewed the case and affirmed the District Court's decision. The Third Circuit agreed that the residents were likely to succeed on the merits and faced irreparable harm. The court also found that the balance of equities and public interest favored the residents. The Third Circuit upheld the $50,000 bond, noting that the District Court had carefully considered the residents' ability to pay and the relative hardships to each party. The court concluded that the District Court had properly applied the law and exercised its discretion in granting the preliminary injunction and setting the bond amount. View "Boynes v. Limetree Bay Ventures LLC" on Justia Law

In this consolidated appeal, the court examined whether internal reports and documents created after alleged adverse events at nursing and assisted living facilities are discoverable or privileged under the New Jersey Patient Safety Act (PSA). In the first case, the plaintiff, Madeline Keyworth, claimed injuries from two falls at a skilled nursing facility and sought the facility’s internal incident reports. In the second case, the plaintiffs, Suzanne and Jonathan Bender, sought an incident report regarding an alleged attack on Diane Bender by another resident at an assisted living facility. Both facilities argued that the requested materials were privileged under the PSA’s self-critical-analysis privilege.The trial courts in both cases found that the self-critical-analysis privilege did not apply and ordered the defendants to disclose the materials. The Appellate Division reversed these decisions, concluding that the defendants had complied with the PSA’s procedural requirements, thus making the documents privileged and not subject to discovery.The Supreme Court of New Jersey reviewed the cases and held that the facilities did not comply with the PSA’s procedural requirements. Specifically, the court noted that the PSA requires a patient safety committee to operate independently from any other committee within the facility. The defendants’ certifications revealed that their committees did not adhere to this requirement, as they performed dual functions related to both patient safety and quality assurance. Consequently, the court determined that the disputed documents were not privileged under the PSA and were subject to discovery.The court reversed the Appellate Division’s judgment and remanded the cases to the trial courts for further proceedings consistent with its opinion. The main holding was that the facilities’ failure to comply with the PSA’s procedural requirements meant that the self-critical-analysis privilege did not apply to the disputed documents. View "Keyworth v. CareOne at Madison Avenue" on Justia Law

The juvenile in this case was on probation after being adjudicated as a youthful offender for breaking and entering a vehicle with intent to commit a felony. While on probation, he began experiencing severe mental health issues, including hallucinations and delusions, which led him to obtain a firearm illegally. His mother called the police, and he was found in possession of a loaded firearm without a license. This led to new criminal charges and a notice of probation violation for not obeying state laws.The Juvenile Court judge found that the juvenile violated his probation by possessing the firearm and revoked his probation, sentencing him to incarceration. The judge ruled that the defense of lack of criminal responsibility was not available in probation violation hearings but considered the juvenile's mental illness in determining the disposition. The juvenile appealed, arguing that due process requires allowing the defense of lack of criminal responsibility in probation violation hearings.The Supreme Judicial Court of Massachusetts reviewed the case and held that the affirmative defense of lack of criminal responsibility is not required in probation violation hearings. The court reasoned that the primary inquiry in such hearings is whether the probationer violated a condition of probation, not whether the probationer is criminally responsible. However, the court acknowledged that evidence of mental illness is relevant to determining whether a violation was willful and in deciding the appropriate disposition. The court affirmed the lower court's decision, finding no error in the judge's ruling or abuse of discretion in revoking the juvenile's probation and imposing a sentence of incarceration. View "Commonwealth v. Z." on Justia Law

The case involves healthcare providers and air ambulance services challenging regulations established by the Departments of Health and Human Services, Labor, and the Treasury. These regulations were designed to guide independent arbitrators in resolving insurance reimbursement disputes under the No Surprises Act, which aims to protect patients from unexpected medical bills by limiting their out-of-pocket costs for emergency and certain non-emergency services provided by out-of-network providers.The United States District Court for the Eastern District of Texas reviewed the case and vacated the regulations, finding that they improperly favored the qualifying payment amount (QPA) over other statutory factors that arbitrators are required to consider. The court held that the regulations conflicted with the No Surprises Act and violated the Administrative Procedure Act (APA) by imposing additional requirements not found in the statute. The court also found that the plaintiffs had standing to sue based on procedural and financial injuries.The United States Court of Appeals for the Fifth Circuit reviewed the case and affirmed the district court's decision. The Fifth Circuit held that the regulations exceeded the Departments' authority by imposing a sequence in which arbitrators must consider the QPA first, disregarding information deemed not credible or unrelated, and requiring arbitrators to explain why they deviated from the QPA. The court found that these provisions placed undue emphasis on the QPA, contrary to the statute's requirement that all factors be considered equally. The court also upheld the district court's universal vacatur of the challenged provisions, rejecting the Departments' arguments for more limited relief. View "Texas Medical Association v. Health and Human Services" on Justia Law

Pearl Ray and Andrew Ray, Sr. sued medical providers in Illinois state court for medical malpractice, which allegedly injured Pearl and caused Andrew to suffer a loss of consortium. They settled with all but one defendant. Pearl was enrolled in a federal health benefits plan, and Blue Cross and Blue Shield Association (BCBSA) was the plan’s carrier. Under the plan, BCBSA sought reimbursement from the settlement for benefits paid to Pearl. The plaintiffs filed a motion to reduce BCBSA’s reimbursement by their attorney’s fees and costs under Illinois’s common fund doctrine.The case was removed to federal court by BCBSA, arguing federal question jurisdiction and federal officer removal. The United States District Court for the Northern District of Illinois initially denied the remand motion but later reconsidered and remanded the entire case, concluding it lacked federal question jurisdiction. BCBSA appealed, asserting federal question jurisdiction and federal officer removal.The United States Court of Appeals for the Seventh Circuit reviewed the district court’s decision de novo. The court held that federal question jurisdiction was not present, as federal common law did not govern the reimbursement dispute, following the precedent set by Empire Healthchoice Assurance, Inc. v. McVeigh and Blue Cross Blue Shield of Illinois v. Cruz. However, the court found that BCBSA met the requirements for federal officer removal under 28 U.S.C. § 1442, as it was acting under a federal agency (OPM) and had a colorable federal defense.The Seventh Circuit affirmed the district court’s decision in part, reversed in part, and remanded, instructing the district court to exercise jurisdiction over the motion for adjudication while remanding the rest of the case to state court. View "Ray v. Tabriz" on Justia Law

Carol Lewis and Douglas Sargent, both diabetics and Medicare beneficiaries, sought reimbursement for continuous glucose monitors and related supplies from 2015 to 2017. After the Department of Health and Human Services (HHS) denied their claims, they pursued judicial review and sought to represent a class of individuals with similar claims. The district court denied their motion for class certification, noting that most putative class members had unexhausted or untimely claims. The court concluded that neither waiver of the exhaustion requirement nor equitable tolling of the limitations period was appropriate, reducing the putative class to seventeen individuals, which was too small to meet the numerosity requirement for class certification. After the Centers for Medicare & Medicaid Services (CMS) issued new guidance in 2022, the district court granted partial judgment in favor of Lewis and Sargent, setting aside the denials of their claims and declaring that continuous glucose monitors are durable medical equipment.Lewis and Sargent appealed the denial of class certification to the United States Court of Appeals for the District of Columbia Circuit. They did not challenge the favorable merits judgment but focused solely on the class certification issue. The Court of Appeals, however, dismissed their appeal for lack of constitutional standing. The court held that their desire to serve as class representatives did not create a cognizable Article III interest, as they did not allege any concrete individual injury resulting from the denial of class certification. The court emphasized that an abstract interest in representing a class is insufficient to satisfy the requirements of Article III standing. Consequently, the appeal was dismissed for lack of jurisdiction. View "Lewis v. Becerra" on Justia Law

Enock Mensah, a social worker, was convicted of theft of public funds and health care fraud for billing publicly funded agencies for over 1,600 treatment sessions that never occurred. The United States District Court for the Eastern District of New York sentenced him to forty-two months of imprisonment, followed by one year of supervised release, and ordered him to pay $177,345 in restitution.Mensah appealed, arguing that the district court erred in three ways: (1) failing to excuse or further examine a juror who knew a government witness, (2) denying his post-trial motion for a new trial based on a prosecutor's comment that suggested Mensah had the ability to testify, and (3) applying a ten-level enhancement based on the loss amount in calculating the United States Sentencing Guidelines advisory range.The United States Court of Appeals for the Second Circuit reviewed the case. The court found that the district court did not abuse its discretion by allowing the juror to remain, as the connection was too attenuated to presume bias. The voir dire was deemed adequate in screening for actual bias. Regarding the prosecutor's comment, the court held that any potential prejudice was moot since Mensah chose to testify, and there was no evidence that the comment compelled him to do so. Finally, the court found no clear error in the district court's calculation of the loss amount, which was based on substantial evidence, including video surveillance, license-plate reading technology, and cellphone records.The Second Circuit affirmed the district court's judgment, upholding Mensah's conviction and sentence. View "United States v. Mensah" on Justia Law

A father, involved in a custody dispute in Montana, subpoenaed his child's therapy records from a therapist in Wyoming. The therapist filed a motion to quash the subpoena, arguing that the records were privileged and confidential under Wyoming law and HIPAA, and that disclosing them would not be in the child's best interests. The district court in Park County partially granted the motion, allowing the father access to some records but withholding treatment notes, interviews, and process notes, citing the child's best interests.The district court's decision was based on the belief that protecting the child's best interests justified withholding certain records. However, Wyoming law does not recognize a child's best interests as a valid reason to deny a parent access to their child's therapy records if the parent has waived the privilege. The court did not provide any statutory or procedural basis for its decision, relying instead on a New Hampshire case, In re Berg, which is not binding in Wyoming and involved different legal standards.The Wyoming Supreme Court reviewed the case and found that the district court abused its discretion. The court held that Wyoming law, specifically W.R.C.P. 45 and Wyo. Stat. Ann. § 33-38-113, does not allow a court to quash a subpoena based on a child's best interests once the privilege has been waived by a parent. The court also clarified that HIPAA does not create a privilege that would prevent the disclosure of therapy records in judicial proceedings. Consequently, the Wyoming Supreme Court reversed the district court's decision and remanded the case, instructing the lower court to issue an order fully denying the therapist's motion to quash the subpoena. View "Loyning v. Potter" on Justia Law