SSR 74-22c: Sections 205(g) and 1869(b) (42 U.S.C. 405(g) and 1395ff(b))—Health Insurance Benefits—Determinations—Appeals
20 CFR Part 405.730
Martha and Lawrence Pankau v.Weinberger, U.S.D.C., W.D. of Mo., St. Joseph Div., No. 73-Cv--32--SJ and No. 73--Cv--33--SJ (11/13/73)
Where hospital insurance beneficiaries were denied payment for expenses for hospitalization amounting to $325.50 and $408.75, respectively, and sought judicial review of the Secretary's decision, held under the provisions of section 1869(b) of the Social Security Act, as amended, the court lacks jurisdiction to review final decisions of the Secretary under Part A of title XVIII where the amount in controversy is less than $1,000.
DUNCAN, Senior Judge:
In each of the above entitled cases the plaintiff seeks to have this court review a decision of the defendant Secretary of Health, Education and Welfare, denying hospital benefits under the Medicare program, Part A, Title XVIII of the Social Security Act, 42 U.S.C. §1395 et. seq.
The Secretary has filed Motion to Dismiss each of the cases on the ground that the court lacks jurisdiction over the subject matter. Since the cases contain common issues of law and fact they will be consolidated for the purpose of this order.
The material facts are established by the affidavits of H. Dale Cook, Chairman of the Appeals Council and Director of the Bureau of Hearings and Appeals, Social Security Administration, Department of Health, Education and Welfare. The plaintiffs have not filed counter-affidavits nor have they filed suggestions in opposition to the Secretary's motions as required by Rule 10(c) of the Local Rules of this court.
Prior to August 1971 both of the plaintiffs were enrolled in Part A of the Medicare program. On August 22, 1971, while they were enrollees under the Act, each of the plaintiffs was admitted to the Missouri Methodist Hospital in St. Joseph, Missouri. They remained in the hospital as patients through August 29, 1971. The expenses for Martha Pankau's hospitalization totaled $325.50, and the expenses for Lawrence Pankau's hospitalization totaled $408.75.
The Secretary denied payment for such amounts for the reason that they were not incurred as a result of necessary hospital care. Payment was denied pursuant to §1862(a)(1) of the Social Security Act.
On March 9, 1972, following a hearing, the determinations of the Secretary were affirmed by an administrative law judge (hearing examiner). The Appeals Council of the Social Security Administration on May 1, 1973, denied a request by each of the plaintiffs for a review of the hearing examiner's decision. The plaintiffs filed these actions on June 27, 1973 seeking a review of the decisions by this court under sections 205(g) and 1869(b) of the Act. 42 U.S.C. §§405(g), 1395ff(b).
In his motion to dismiss the Secretary contends that this court lacks jurisdiction to review such determinations since the amount in controversy in each of the cases is less than $1,000.00.
In October 1972 section 1869(b) of the Social Security Act was amended by Public Law No. 92-603 §2990. The amendment states in part:
(a) Section 1869(b) of the Social Security Act is amended to read as follows: (b)(1) any individual dissatisfied with any determination under subsection (a) as to—
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(c) the amount of benefits under Part A (including a determination where such amount is determined to be zero) shall be entitled to a hearing thereon by the Secretary to the same extent as is provided in section 205(b) and to judicial review of the Secretary's final decision after such hearing as is provided in section 205(g).
(2) Notwithstanding the provision of subparagraph (c) of paragraph (1) of this subsection, a hearing shall not be available to an individual by reason of such subparagraph (c) if the amount in controversy is less than $100; nor shall judicial review be available to an individual by reasons of such subparagraph (c) if the amount in controversy is less than $1000. [Emphasis supplied]
Clearly, under the provisions of §1869(b), as amended, this court does not have jurisdiction to review final decisions of the Secretary under Part A of Title XVIII of the Act, where the amounts in controversy do not exceed $1,000. [*] Since the expenses which are the subject matter of these sections were incurred in August, 1971 and the amendment to §1869(b) was enacted on October 30, 1972, it becomes important to determine the effective date of the amendment. In this regard §2990(b) of Public Law 92-603 provides that:
"(2) The provision of paragraph (2) and of subparagraph (c) of paragraph (1) of section 1869(b) of the Social Security Act, as amended by subsection (a) of this section, shall be effective with respect to any claims under part A of title XVIII of such Act, filed—
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(I) before the month in which this Act is enacted [Oct. 1972], but only if a civil action with respect to a final decision of the Secretary of Health, Education, and Welfare on such claim has not been commenced under such section 1869(b) before such month." [Emphasis supplied]
Simply stated, the 1972 amendment of section 1869(b) applies to all claims filed with the Secretary prior to October 1972, if a civil action with respect to those claims has not been commenced prior to that date. Since these actions were brought subsequent to October 1972 the 1972 amendment applies. [**]
In view of the clear and unequivocal provisions of §1869(b) as amended, this court is without jurisdiction over the subject matter of the actions. The motions of the Secretary to dismiss are sustained. IT IS SO ORDERED.
[*] Section 1869(b), as amended, provides that judicial review shall not be available to an individual if the amount in controversy is less than $1,000 rather than $1,000 or less. (Ed.)
[**] The amendment merely clarifies the original intent of section 1869(b). See H.R. Rep. No. 92-1605, 92d Cong., 2d Sess. 61 (1972). Also see the remarks of Sen. Bennett of Utah upon introducing this amendment. 118 Cong. Rec. S 17049 (daily ed 10/5/72). (Ed.)