Ridgely v. Secretary of Dept. of Health, Ed. & Welf. of US, 72-2181.

• Decision Date: 03 April 1973
• Docket Number: No. 72-2181.,72-2181.
• Citation: 475 F.2d 1222
• Parties: Ethel L. RIDGELY, Administratrix of the Estate of Susanna Hape, Appellee, v. SECRETARY OF the DEPARTMENT OF HEALTH, EDUCATION & WELFARE OF the UNITED STATES of America, Appellant.
• Court: U.S. Court of Appeals — Fourth Circuit

475 F.2d 1222 (1973)

Ethel L. RIDGELY, Administratrix of the Estate of Susanna Hape, Appellee, v. SECRETARY OF the DEPARTMENT OF HEALTH, EDUCATION & WELFARE OF the UNITED STATES of America, Appellant.

No. 72-2181.

United States Court of Appeals, Fourth Circuit.

Argued February 8, 1973.

Decided April 3, 1973.

Robert E. Kopp, Atty. U. S. Department of Justice (Harlington Wood, Jr., Asst. Atty. Gen., George Beall, U. S. Atty., Walter H. Fleischer and Stanton R. Koppel, Attys., U. S. Department of Justice, on brief), for appellant.

Robert Barker Harrison, III, Baltimore, Md. (George W. White, Jr., and Buckmaster, White, Mindel & Clarke, Baltimore, Md., on brief), for appellee.

Before CRAVEN, FIELD and WIDENER, Circuit Judges.

FIELD, Circuit Judge:

The Secretary of Health, Education and Welfare appeals from an order of the district court which ruled that Mrs. Ethel L. Ridgely, Administratrix of her mother's estate, was entitled to judicial review of a decision of the Social Security Administration Appeals Council and, additionally, held that the hearing examiner's findings were not supported by substantial evidence.¹

The decedent, Mrs. Hape, was hospitalized for treatment of a broken hip at Baltimore County General Hospital from March 15, 1970, until April 1, 1970. On April 1 she was transferred to Foxleigh Nursing Center, an extended care facility, where she remained until September 17, 1970, when she was returned to the hospital and died a few days later. The Social Security Administration granted coverage through June 10, 1970, but denied payment for the remaining twenty-nine days to July 9, 1970.²

Mrs. Ridgely sought $497.20 in hospital insurance benefits under the Medicare program which was disallowed by the hearing examiner upon a determination that the treatment afforded Mrs. Hape was not skilled nursing care but only custodial in nature, which is excluded from coverage.³ The Appeals Council affirmed the hearing examiner's opinion which became the final decision of the Secretary.

Mrs. Ridgely filed a complaint in the district court seeking judicial review of the adverse administrative decision under 42 U.S.C. § 1395ff(b). The Secretary moved the court to dismiss the case upon the ground that judicial review under the Act is limited to cases in which the amount in controversy exceeds $1,000. Despite the deficiency in the jurisdictional amount, the district court concluded that judicial review was appropriate under the alternative jurisdictional provision of "entitlement" to benefits.

As of the date of this controversy Section 1395ff(b) provided:

"Any individual dissatisfied with any determination under subsection (a) of this section as to entitlement under part A or part B, or as to amount of benefits under part A where the matter in controversy is $100 or more, shall be entitled to a hearing thereon by the Secretary to the same extent as is provided in section 405(b) of this title, and, in the case of a determination as to entitlement or as to amount of benefits where the amount in controversy is $1,000 or more, to judicial review of the Secretary\'s final decision after such hearing as is provided in section 405(g) of this title." (Emphasis supplied.)

The district court conceived the issue to be whether Mrs. Ridgely was entitled to the benefits rather than a dispute as to amount, and noted that the hearing examiner had also framed the issue in terms of entitlement and not a question of the amount which might be due. The district court relied on Cardno v. Finch, 311 F.Supp. 251 (E.D.La. 1970), which in a case quite similar to this concluded that judicial review was available based on the "entitlement" provision of Section 1395ff(b). We agree with the district court and the opinion in Cardno that the reasonable construction of the statutory language limits the amount in controversy requirement only to judicial review of determinations as to the amount of benefits, and that determinations as to entitlement to benefits are properly subject to judicial review regardless of the amount.

Counsel for the Secretary has pointed out to us that the language of Section 1395ff(b) was changed by the Social Security Amendments of 1972,⁴ under which the term "entitlement" was eliminated and judicial review limited to the question of eligibility to receive benefits or cases where the amount in controversy was $1,000 or more. The purpose of the amendment as stated in the Senate floor debate was to clarify the original intent of the law that "entitlement" was intended to mean eligibility for any benefits of medicare but not to decisions on a claim for payment for a given service. 118 Cong.Rec. 17048, 17049 (Oct. 5, 1972). Counsel suggests that this amendment and its legislative history confirms the Secretary's position in the present controversy. It may well be that the amendment was designed to eliminate ambiguity in the statute as originally enacted, but in our opinion under the statutory language prior to the 1972 amendment judicial review of Mrs. Ridgely's claim was appropriate.

With respect to the merits, the district court properly recognized that it could not try the case de novo and that its function was to apply the substantial evidence test to the Secretary's findings.⁵

A careful review of the record by the district court disclosed that the Secretary's determination that Mrs. Hape needed only care of a custodial nature was based solely on the records of the extended care facility, and the district...