Articles Posted in Public Benefits

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Goodman served in the U.S. Army, 1972-1992, with service in Southwest Asia during the Persian Gulf War. During his service and at his discharge, Goodman underwent medical examinations that returned negative for rheumatoid arthritis; he denied having pain in his joints or arthritis. In 2007, Goodman sought treatment at a VA medical center for hand stiffness and knee pain, which he said had begun during service. He sought VA benefits for rheumatoid arthritis. The Board sought an independent medical advisory opinion from the Veterans Health Administration, which was conducted by a VA medical center Director of Rheumatology in 2014 and concluded that “it is less likely than not” that Goodman’s rheumatoid arthritis can be characterized as a medically unexplained chronic multi-symptom illness (MUCMI) under 38 C.F.R. 3.317, and that it “is less likely than not that his rheumatoid arthritis is related to a specific exposure event experienced … during service. The Board concluded that Goodman was not entitled to a presumptive service connection for a MUCMI; the Federal Circuit affirmed. The VA adjudicator may consider evidence of medical expert opinions and all other facts of record to make the final determination of whether a claimant has proven, based on the claimant’s unique symptoms, the existence of a MUCMI. View "Goodman v. Shulkin" on Justia Law

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Kisor served in the Marine Corps from 1962-1966. In 1982, he sought disability compensation benefits for PTSD with the Portland, Oregon VA Regional Office (RO), which received a letter from a Vet Center counselor, expressing concerns that Kisor had “depression, suicidal thoughts, and social withdraw[a]l.” In 1983, the RO obtained a psychiatric examination for Kisor, which noted that Kisor had served in Vietnam; that he had participated in “Operation Harvest Moon”; that he was on a search operation when his company came under attack; that he reported several contacts with snipers and occasional mortar rounds fired into his base of operation; and that he “was involved in one major ambush which resulted in 13 deaths in a large company.” The examiner expressed his “distinct impression” that Kisor suffered from “a personality disorder as opposed to PTSD,” which cannot be a basis for service connection. Kisor did not pursue an appeal. In 2006, Kisor submitted a request to reopen and presented a 2007 report of a psychiatric evaluation diagnosing PTSD. He was granted a 50% rating. The Veterans Court and Federal Circuit affirmed that Kisor was not entitled to an effective date earlier than June 2006 for the PTSD. Kisor’s remedy for the earlier denial would have been an appeal. View "Kisor v. Shulkin" on Justia Law

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Gazelle served in the U.S. Army, 1962-1965, and incurred service-connected disabilities. He receives compensation for: degenerative disc disease and joint disease of the cervical spine rated at 20 percent; degenerative disc disease and spondylosis of the thoracolumbar spine rated at 20 percent; left upper extremity radiculopathy rated at 10 percent; left lower extremity radiculopathy rated at percent; and post-traumatic stress disorder. In 2009, the VA increased Gazelle’s disability rating for his service-connected PTSD to 100 percent. Gazelle filed a Notice of Disagreement, alleging the VA failed to award him additional special monthly compensation under 38 U.S.C. 1114(s)(1). In 2011, Gazelle was denied entitlement to special monthly compensation because he did not have additional service-connected “disabilities . . . independently ratable as [60 percent] or more disabling.” Instead of adding together Gazelle’s additional service-connected disabilities at their respective amounts, the VA calculated the independent additional rating via the combined ratings table pursuant to 38 C.F.R. 4.25 (2010), which resulted in a combined rating of 50 percent. In 2014, the Board affirmed. The Veterans Court and Federal Circuit affirmed, holding that consistent with the plain meaning of subsection 1114(s), the Board appropriately applied the combined ratings table to determine eligibility for special monthly compensation benefits. View "Gazelle v. Shulkin" on Justia Law

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Prime Hospitals provide inpatient services under the Medicare program, submitting payment claims to private contractors, who make initial reimbursement determinations. Prime alleged that many short-stay claims were subject to post-payment review and denied. Prime appealed through the Medicare appeal process. Prime alleged short-stay claims audits were part of a larger initiative that substantially increased claim denials and that the Center for Medicare & Medicaid Services (CMS) was overwhelmed by the number of appeals. CMS began offering partial payment (68 percent) in exchange for dismissal of appeals. Prime alleged that it executed CMS's administrative settlement agreement so that CMS was contractually required to pay their 5,079 Medicare appeals ($23,205,245). CMS ultimately refused to allow the Prime to participate because it was aware of ongoing False Claims Act cases or investigations involving the facilities. Prime alleged that the settlement agreement did not authorize that exclusion. The district court denied a motion to dismiss Prime’s suit but transferred it to the Court of Federal Claims. The Federal Circuit affirmed in part. The breach of contract claim is fundamentally a suit to enforce a contract and does not arise under the Medicare Act, so the Claims Court has exclusive jurisdiction under the Tucker Act, 28 U.S.C. 1491. That court does not have jurisdiction, however, over Prime’s alternative claims seeking declaratory, injunctive, and mandamus relief from an alleged secret and illegal policy to prevent and delay Prime from exhausting administrative remedies. View "Alvarado Hospital, LLC v. Cochran" on Justia Law

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Manzanares served on active duty, 1986-1991. In 1992, she was awarded service connection for a history of stress fractures in both legs, with a non-compensable rating. In 2006, she sought an increased rating. The VA assigned a 10-percent rating for each ankle, with a February 2006 effective date. Manzanares filed a notice of disagreement and claimed: “[e]ntitlement to service connection for degenerative disc disease lumbar spine as secondary to bilateral ankle disabilities.” The VA granted secondary service connection for “degenerative arthritis and disc disease, lumbar spine” with a rating of 20 percent and an April 2007 effective date. Manzanares argued that the VA should have awarded a February 2006 effective date for the secondary service-connected condition, citing 38 C.F.R. 3.156(b), which provides that, for a pending claim, “[n]ew and material evidence received prior to the expiration of the appeal period . . . will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period.” The Board of Veterans’ Appeals, Veterans Court, and Federal Circuit rejected her argument. The effective date for service connection is the later of the date the VA receives the claim or the date that entitlement arose; Manzanares’s secondary service claim was not filed until April 2007 and was not part of the ankle claim. View "Manzanares v. Shulkin" on Justia Law

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Johnson served in the Army, 1970-1971. In 2008, the VA granted Johnson a 30% rating for posttraumatic stress disorder (PTSD), and a 10% rating for tinea corporis, a skin condition which Johnson described as jungle rot under Diagnostic Code (DC) 7806. The Board of Veterans Appeals increased his PTSD rating to 70% and remanded with respect to his skin condition. After several rounds of review, the Board denied Johnson’s request for an increased rating for tinea corporis in 2014, finding that Johnson’s skin condition affected only a limited area of his body, and his topical corticosteroid treatment of that area did not qualify as a “systemic therapy” under DC 7806. The Veterans Court held that DC 7806 unambiguously defines a topical corticosteroid treatment as “systemic therapy” rather than “topical therapy.” The Federal Circuit reversed, holding that the Veterans Court gave an overly broad reading of the term “systemic therapy” in DC 7806 that encompasses any and all forms of topical corticosteroid treatment. The court noted that Johnson did not challenge factual findings that his use of topical corticosteroids affected only the area to which he applied treatment and did not affect his body as a whole, and reinstated the Board’s findings. View "Johnson v. Shulkin" on Justia Law

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Presumptive service connection exists for veterans who served in the Persian Gulf War and have chronic: undiagnosed illness; medically unexplained chronic multisymptom illness (MUCMI); or any diagnosed illness as determined by the Secretary, 38 U.S.C. 1117(a)(2). VA regulations define MUCMI as “a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained.”. Both the statute and regulation identify sleep disturbances and signs or symptoms involving the respiratory system as possible MUCMI manifestations. The VA revised its M21-1 Manual, changing the definition of MUCMI to require “both an inconclusive pathology, and an inconclusive etiology.” Under the subsection “Signs and Symptoms of Undiagnosed Illnesses or MUCMIs,” the VA added, “Sleep apnea cannot be presumptively service-connected (SC) under the provisions of 38 C.F.R. 3.317 since it is a diagnosable condition.” The Federal Circuit dismissed a veterans’ group’s petition for review for lack of jurisdiction, reasoning that the revisions are not binding and not reviewable under 38 U.S.C. 502. View "Disabled American Veterans v. Secretary of Veterans Affairs" on Justia Law

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Snyder represented a veteran, Beck, under a 2001 fee agreement (38 U.S.C. 5904). Eight months later, Snyder requested the Board of Veterans’ Appeals to cancel his fee agreement. In 2003 the VA awarded past-due benefits based on a 100% disability rating effective 1992. Snyder sought attorney fees. A VA regional officer (RO) determined that Snyder was entitled to $41,920.47, deductible from the past-due benefits. Beck filed notice of disagreement. Beck died. His widow sought to recover the disputed fees as accrued benefits. The RO denied that request. The Board dismissed Beck’s dispute over attorney fees, citing 38 C.F.R. 20.1302, and remanded Mrs. Beck’s claim. The RO determined Mrs. Beck could not recover the disputed attorney fees because her husband’s claim ceased to exist upon his death. She appealed. The VA’s General Counsel published a precedential opinion stating: A claim, pending at the time of a veteran’s death, challenging an attorney’s entitlement to payment of attorney fees under section 5904 from the veteran’s retroactive periodic monetary benefits may provide a basis for an accrued benefits claim under section 5121, because such a claim concerns entitlement to periodic monetary benefits allegedly due and unpaid to the veteran at the time of death. The Federal Circuit dismissed Snyder’s appeal. That 38 C.F.R. 20.1302 requires dismissal of a veteran’s appeal upon his death has no bearing on a claimant’s separate entitlement to accrued benefits under section 5121. The attorney fee dispute remains pending. View "Snyder v. Secretary of Veterans Affairs" on Justia Law

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Ollis, a veteran, sought disability benefits under 38 U.S.C. 1151, which provides benefits for certain injuries incurred as a result of VA medical care. Ollis suffers from atrial fibrillation and claims a disability resulting from complications of a heart procedure to treat that condition. The procedure (miniMAZE) was allegedly recommended by a VA doctor but was performed by a private doctor. The VA denied Ollis’s application for benefits. The Board of Veterans’ Appeals and the Court of Appeals for Veterans Claims affirmed. The Federal Circuit vacated in part, remanding the question of whether Ollis’s VA doctors were negligent by recommending the mini-MAZE procedure to him. The Veterans Court focused on whether VA medical treatment caused Ollis to utilize Dr. Hall and Methodist Medical Center, rather than on whether VA medical treatment caused him to have the mini-MAZE procedure itself. On remand, the Veterans Court must also address the “not reasonably foreseeable” and “proximate cause of the disability” requirements. The court affirmed rejection of an argument that VA’s failure to provide him notice that a referral to a private facility for his miniMAZE procedure could extinguish his eligibility for benefits constituted a violation of his right to due process. View "Ollis v. Shulkin" on Justia Law

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Monk served in the Marine Corps during the Vietnam War. In 2012, Monk sought VA disability benefits, alleging service-connected PTSD, diabetes, hypertension, and strokes. The VA denied the claim, finding that his discharge was “other than honorable.” Monk filed a Notice of Disagreement (NOD) and separately applied to the Board of Correction of Naval Records (BCNR) to upgrade his discharge status. In 2015, the VA informed Monk that it could not process his appeal until it received BCNR records. Monk sought a writ of mandamus with Veterans Court and requested that the court certify a class of all veterans who had applied for VA benefits, had timely filed an NOD, had not received a decision within 12 months, and had demonstrated medical or financial hardship (38 U.S.C. 7107(a)(2)(B)–(C)). The Veterans Court denied the request for class certification, denied another veteran’s request to join the action, and ordered the VA to respond to Monk’s petition regarding the denial of disability benefits. BCNR then granted Monk an upgraded discharge status. The Federal Circuit reversed the denial of class certification, finding that the Veterans Court has authority to certify a class for a class action and to maintain similar aggregate resolution procedures with respect to benefit denials. View "Monk v. Shulkin" on Justia Law