"Underdeveloped" Record Does Not Force Conclusion That "Complete Medical History" Requirement Of Regulation Forecloses Use Of A Summary Form
BAILEY v. ROOB (June 8, 2009)
The State of Indiana has a Medicaid for the Disabled program that provides medical benefits to persons who suffer from disabilities. A consent decree resulting from earlier litigation required the State to follow certain procedures in collecting and evaluating applications. It must obtain complete medical histories for twelve months, it must get additional medical information when necessary, and it must ensure that the medical records are complete before an eligibility determination. Plaintiffs filed a petition to hold the defendants in civil contempt for violating these requirements of the consent decree. In discovery, the State produced a representative sample of benefit applications, consisting of 26 files. The district court reviewed the files and concluded 17 were complete, five contained only a summary form of medical history, and four were “less complete” than the five that contained the form. The court denied the contempt motion, however, because neither party presented evidence of what should be considered a "complete" history. In fact, the court invited the plaintiffs to refile their motion and introduce testimony on that issue. Instead, plaintiffs appeal.
In their opinion, Judges Flaum, Manion and Rovner affirmed. The Court first rejected plaintiffs’ argument that the district court imposed an erroneous burden of proof. Plaintiffs claimed that the court required them to prove the State's lack of reasonable diligence instead of treating it as an affirmative defense. The Court held that it is a plaintiff's burden to foreclose a finding of reasonable diligence by clear and convincing evidence. Alternatively, the Court concluded that the district court rejected plaintiffs’ motion simply because they had not shown a violation, not that they had failed to foreclose reasonable diligence. The Court next rejected plaintiffs’ argument that it had shown a violation, at least with respect to the four least-complete files. The Court concluded that the district court did not abuse its discretion in declining to make factual findings that the four files violated the consent order. The district court found the arguments of the parties inconclusive on what constituted a complete medical file. Finally, the Court rejected the plaintiffs’ argument that "complete medical history" always requires a treating physician's records. A court reads the requirements of the consent decree just like it reads the requirements of a contract. The Court concluded that, in similar contexts, it has not interpreted "complete" in a strict, absolute sense. The Court was unable, on the incomplete record, to categorically conclude that a summary form of medical history is always a violation of the regulation.
Michael Rigney practices in the law offices of GVC Ltd. in Chicago. In this blog, he reports on select