Justia Government & Administrative Law Opinion Summaries

Plaintiff, MSP Recovery Claims, Series LLC (“MSP”) appealed from the district court’s judgment dismissing for lack of standing its putative class action against Defendant Hereford Insurance Company (“Hereford”) and denying leave to amend. MSP has brought several lawsuits around the country seeking to recover from insurance companies that allegedly owe payments to Medicare Advantage Organizations (“MAOs”) under the Medicare Secondary Payer Act (the “MSP Act”). In the putative class action brought here, MSP charges Hereford with “deliberate and systematic avoidance” of Hereford’s reimbursement obligations under the MSP Act.   The Second Circuit affirmed. The court concluded that MSP lacked standing because its allegations do not support an inference that it has suffered a cognizable injury or that the injury it claims is traceable to Hereford. The court also concluded that the district court did not abuse its discretion when it denied MSP leave to amend based on MSP’s repeated failures to cure. The court explained that the plain language of Section 111 provides that when a no-fault insurance provider such as Hereford reports a claim pursuant to Section 111, it does not thereby admit that it is liable for the claim. The statutory context of the section’s reporting obligation and the purpose of the reporting obligation confirms the correctness of this interpretation. Because MSP’s argument that the payments made by EmblemHealth are reimbursable by Hereford rests entirely on its proposed interpretation of Section 111, MSP has not adequately alleged a “concrete” or “actual” injury or that the injury it alleges is fairly traceable to Hereford. View "MSP v. Hereford" on Justia Law

The Supreme Court reversed the judgment of the circuit court affirming the rules of the West Virginia Health Care Authority (WVHCA) denying War Memorial Hospital, Inc.'s (Hospital) certificate of need exemption application that would have allowed Hospital to acquire and utilize a fixed magnetic resonance imagining (MRI) scanner at its medical office building, holding that the circuit court erred.The WVHCA denied the Hospital's exemption application on the grounds that the MRI device would not be used in the Hospital's facility but, rather, that the Hospital intended to place the MRI device in a building in another country that was owned by the Hospital's parent corporation. The circuit court affirmed. The Supreme Court reversed, holding that there is no location-specific requirement in W. Va. Code 16-2D-11(c)(27) that the MRI the Hospital sought to acquire be utilized at its "primary hospital location." View "War Memorial Hospital v. W. Va. Health Care Authority" on Justia Law

The Office of Personnel Management (OPM) administers retirement benefits for civilian employees of the U.S. government. OPM typically pays retirement benefits to retirees themselves. But when a retiree’s benefits are subject to division pursuant to a divorce decree, OPM divides them between the retiree and his or her former spouse according to the terms of the decree. The Federal Law Enforcement Officers Association (Association) brought this action against OPM in district court, claiming that OPM’s method of apportioning one type of retirement benefit, the Annuity Supplement, violates the Administrative Procedure Act. OPM moved to dismiss the complaint on jurisdictional grounds.   The district court acknowledged that federal employees’ claims for retirement benefits are generally routed through that system of review, but held that the Association’s claims fell within an exception allowing pre-enforcement challenges to agency rules to proceed in district court. Exercising jurisdiction, the district court dismissed one of the Association’s counts for failure to state a legally cognizable claim and, after the administrative record was filed, granted summary judgment to OPM as to the others.   The DC Circuit vacated the district court’s orders and remanded with instructions to dismiss for lack of jurisdiction. The court held that the CSRA’s system of review—which channels disputes about FERS retirement benefits through an administrative process, subject to direct review in the Federal Circuit—precludes district court review of the Association’s claims. View "Federal Law Enforcement Officers Association v. Kiran Ahuja" on Justia Law

Plaintiff appealed the district court’s order upholding a decision by the Commissioner of the Social Security Administration denying her disability insurance benefits and supplemental security income. She argued that the Commissioner’s decision was not supported by substantial evidence. Plaintiff contends that the ALJ failed to sufficiently articulate his rationale for rejecting Plaintiff’s treating physician’s opinion, rendering the ALJ’s decision legally erroneous and unsupported by substantial evidence on the record as a whole.   The Eighth Circuit affirmed. The court held that ALJ was justified in finding the physician’s opinion unpersuasive. The opinion’s bare, formulaic conclusion presumptively warranted little evidentiary weight “because it was rendered on a check-box and fill-in-the-blank form.” The physician checked some boxes and left blank the short-answer section asking what objective medical findings supported his assessment. The ALJ also found the checkbox form “unsupported and highly inconsistent” with the record because the physician’s conservative treatment plan, other medical opinions, and Plaintiff’s own descriptions of her activities contradict the checkbox assessment. View "Vickie Nolen v. Kilolo Kijakazi" on Justia Law

Plaintiff appealed the district court’s order affirming the Social Security Administration’s (“SSA”) denial of her application for Social Security Disability Insurance (“SSDI”). In her application, she alleged major depressive disorder (“MDD”), anxiety disorder, and attention deficit disorder (“ADHD”). Following a formal hearing, the Administrative Law Judge (“ALJ”) determined that Plaintiff suffered from severe depression with suicidal ideations, anxiety features and ADHD, but he nonetheless denied her claim based on his finding that she could perform other simple, routine jobs and was, therefore, not disabled. Plaintiff contends that the ALJ erred by (1) according to only little weight to the opinion of her long-time treating psychiatrist (“Dr. B”) and (2) disregarding her subjective complaints based on their alleged inconsistency with the objective medical evidence in the record.   The Fourth Circuit reversed and remanded with instructions to grant disability benefits. The court agreed with Plaintiff that the ALJ failed to sufficiently consider the requisite factors and record evidence by extending little weight to Dr. B’s opinion. The ALJ also erred by improperly disregarding Plaintiff’s subjective statements. Finally, the court found that the ALJ’s analysis did not account for the unique nature of the relevant mental health impairments, specifically chronic depression. The court explained that because substantial evidence in the record clearly establishes Plaintiff’s disability, remanding for a rehearing would only “delay justice.” View "Shelley C. v. Commissioner of Social Security Administration" on Justia Law

The Supreme Court affirmed the judgment of the district court enjoining a regulation to the extent it required insurers to give retroactive premium refunds but otherwise rejecting the lawsuit brought by National Association of Mutual Insurance Companies (NAMIC), holding that the Nevada Division of Insurance (Division) had the statutory and constitutional authority to promulgate R087-20.While the Nevada Insurance Code permits insurers to use customer credit information when underwriting and rating personal property and casualty insurance, the Division promulgated a regulation, R087-20, after the governor's COVID-19 declaration of emergency led to mass unemployment across the state. R087-20 prohibited insurers from adversely using consumer credit information changes that occurred during the emergency declaration, plus two years. On behalf of itself and its members, NAMIC sued to invalidate the regulation. The district court largely rejected NAMIC's claims. The Supreme Court affirmed, holding that the Division did not exceed its authority in promulgating R087-20. View "Nat'l Ass'n of Mutual Insurance Cos." on Justia Law

This insurance coverage dispute between a public entity joint insurance fund (JIF) and Star Insurance Company (Star), a commercial general liability insurance company, turned on whether the JIF provided “insurance” to its members or, instead, the JIF members protect against liability through “self-insurance.” That distinction was pertinent here because Star’s insurance policy included a clause under which its coverage obligations began only after coverage available through “other insurance” has been exhausted; the clause, however, did not mention “self-insurance.” Star argued the JIF provided insurance and therefore Star’s coverage was excess to the JIF; the JIF disagreed, contending that because its members were instead “self-insured,” Star’s coverage was primary. The New Jersey Supreme Court found that under the plain language of N.J.S.A. 40A:10-48, a JIF “was not an insurance company or an insurer under New Jersey law, and its “authorized activities . . . do not constitute the transaction of insurance nor doing an insurance business.” By the statute’s plain terms, JIFs cannot provide insurance in exchange for premiums, as insurance companies typically do; instead, JIF members reduce insurance costs by pooling financial resources, distributing and retaining risk, and paying claims through member assessments. Therefore, JIFs protect members against liability through “self-insurance.” “Self-insurance” is not insurance. The Court affirmed the grant of summary judgment to the JIF and denial of summary judgment to Star. View "Statewide Insurance Fund v. Star Insurance Company" on Justia Law

Niyokia Lee and James Cooper sustained damages in separate, independent automobile accidents caused by negligent city emergency responders. Lee’s accident happened in Harrison County, and Cooper’s happened in Rankin County. The Mississippi Tort Claims Act afforded immunity to the negligent police officer, the fireman, and the governmental entities employing them. Because Lee and Cooper could not recover from the responders or municipalities, both sought recovery under their car insurance policies’ uninsured motorist provisions. Lee and Cooper had the same UM coverage carrier—State Farm Mutual Automobile Insurance Company. And State Farm denied UM coverage to both, citing Mississippi Code Section 83-11-101(1) of Mississippi’s Uninsured Motorist Act. As State Farm saw it, because the officer and fireman enjoyed police and fire protection immunity under the MTCA, neither policyholder was legally entitled to recover from the immune responders or their city employers. State Farm thus denied UM coverage to Lee and Cooper despite the fact that, in 2009, the state legislature had revised Mississippi Code Section 83-11-103(c) of the UM Act by adding a new subsection expanding the definition of “uninsured motor vehicle” to include “[a] motor vehicle owned or operated by a person protected by immunity under the [MTCA.]” The two trial courts considering the UM coverage issue reached opposite results. The Harrison County Circuit Court granted summary judgment in State Farm’s favor and dismissed Lee’s claims against State Farm, finding because the officer was immune, Lee was not "legally entitled to recover" and consequently, was not eligible for UM coverage. The Rankin County Court granted summary judgment in Cooper’s favor, against State Farm, ruling UM coverage did apply because, otherwise, the 2009 amendment to the UM Act, which expanded the definition of “uninsured motor vehicle” to include vehicles operated by persons who are immune under the MTCA, would be "rendered virtually meaningless." The Mississippi Supreme Court consolidating the two cases found that the plain language of the two provisions made it apparent that Lee and Cooper were entitled to UM coverage. It therefore reversed and remanded the decision of the Harrison County Circuit Court, and affirmed and remanded the decision of the Rankin County Circuit Court. View "Lee v. State Farm Mutual Automobile Insurance Company" on Justia Law

The 2010 ACA (Patient Protection and Affordable Care Act; Health Care and Education Reconciliation Act) created a three-year Risk Corridors program with the creation of new health-insurance marketplaces, which presented uncertain risks for participating health-insurance companies. Qualified health-plan issuers (QHP issuers) that offered their products in the new marketplaces were entitled to payments from HHS if they suffered sufficient losses, 42 U.S.C. 18062(b).The government failed to make those payments. QHP issuers sued under the Tucker Act, 28 U.S.C. 1491(a)(1). In two such lawsuits, the Quinn law firm was lead counsel for classes of QHP issuers seeking payments. In the opt-in notices sent to potential class members with court approval, Quinn represented that it would seek attorney’s fees out of any recovery, that it would seek no more than 5% of any judgment or settlement, and that the Claims Court would determine the exact amount by considering how many issuers participated, the amount at issue, and a “lodestar cross-check” (based on hours actually worked). Meanwhile, the Supreme Court, in other cases, held that QHP issuers were entitled to collect ACA-promised payments.The Claims Court entered judgments in favor of the classes, totaling about $3.7 billion, then awarded Quinn 5% of the common funds, rejecting objections. The total fee was about $185 million. The Federal Circuit vacated. The Claims Court’s analysis was inconsistent with the class opt-in notices and did not adequately justify the extraordinarily high award. View "Health Republic Insurance Co. v. United States" on Justia Law

This case arose out of a qui tam action against Prime Healthcare Services—Encino Hospital, LLC (Encino Hospital) and others to impose civil penalties for violation of the Insurance Fraud Prevention Act (IFPA), Insurance Code section 1871 et seq. The State of California and relator (Plaintiffs) appealed from a judgment entered after a bench trial in which the court found insufficient evidence to support their allegations that Defendants engaged in insurance fraud by billing insurers for services performed in a detox center for which they had no appropriate license, and by employing a referral agency to steer patients to the center.   The Second Appellate District affirmed the judgment. The court explained that, CDI alleged that Encino Hospital misrepresented to insurers that it was properly licensed to provide detox services when it was not. The trial court found no evidence suggesting that Defendants presented a false claim to any insurer. The court agreed, reasoning that no authority of which it is aware or to which it has been directed obligates Encino Hospital to hold any license other than its license as a general acute care hospital. Because Encino Hospital needed no separate license or approval, and no evidence showed it concealed any provider, the CDI’s cause of action for false claims failed for lack of a predicate. View "State of Cal. v. Encino Hospital Medical Center" on Justia Law