Heckler v. Ringer

LOCATION: The D&B Corporation

DOCKET NO.: 82-1772
DECIDED BY: Burger Court (1981-1986)
LOWER COURT: United States Court of Appeals for the Ninth Circuit

CITATION: 466 US 602 (1984)
ARGUED: Feb 27, 1984
DECIDED: May 14, 1984

Edwin S. Kneedler - on behalf of the Petitioner
Malcolm J. Harkins, III - on behalf of the Respondents

Facts of the case


Media for Heckler v. Ringer

Audio Transcription for Oral Argument - February 27, 1984 in Heckler v. Ringer

Malcolm J. Harkins, III:

"As explained above, we have previously issued policy in manual instructions excluding this service from Medicare coverage. "

Warren E. Burger:

We will hear arguments next in Heckler against Ringer.

Mr. Kneedler, you may proceed whenever you are ready.

Edwin S. Kneedler:

Thank you, Mr. Chief Justice, and may it please the Court.

This case presents questions of fundamental importance to the orderly administration and adjudication of the millions of claims that are filed under the Social Security Act each year.

Congress has enacted a special self-contained procedure for the administrative and judicial review of Social Security claims, and it has assigned to the Secretary of Health and Human Services the responsibility for prescribing the administrative steps in that process that must be pursued before a claimant seeks judicial review.

The Court of Appeals in this case, however, excused the respondents from exhausting the administrative procedures the Secretary has prescribed before they sought judicial review within the special statutory procedure that Congress has enacted, and in addition, the Court of Appeals held that respondents could challenge the Secretary's interlocutory decisions denying their claims outside of that special procedure by bringing a separate action under the general grants of subject matter jurisdiction in Sections 1331 and 1361 of the Judicial Code.

We have sought review in this case because the Court of Appeals' decision is flatly inconsistent, in our view, with this Court's prior decisions in Weinberger versus Salfi and later cases with attached legislative history and consistent administrative implementation of the Act.

If the Court of Appeals' interpretation were affirmed by this Court, the interlocutory and piecemeal review of the Court of Appeals has permitted would substantially disrupt the administrative and judicial review of Social Security claims.

There is a pressing need in this area involving many claims for the Secretary and the courts to have clear rules that can be easily and uniformly applied in all cases without the need to litigate in particular cases their applicability, and the rules the Secretary and Congress have established for this purpose are fair and reasonable.

Before stating the facts of this case, I would like to briefly outline those procedures that Congress and the Secretary have prescribed.

The basic statutory framework is simple and straightforward.

It is contained in Section 205 of the Act, which was enacted in 1939, and is now codified in Section 405 of Title 42.

Section 405(b) directs the Secretary to make findings and decisions on claims for benefits under the Act.

Section 405(b) then provides that if the claimant is dissatisfied with the Secretary's initial determination, the Secretary must afford him an opportunity for a hearing on the claim.

Sandra Day O'Connor:

Mr. Kneedler, can the claim be made before the surgery?

Edwin S. Kneedler:

No, under the Medicare program, as under most insurance programs, the claimant files a claim for payment which can be made only for services that have already been rendered.

Sandra Day O'Connor:

Then how it is possible for someone who wants the surgery performed to get a determination about reimbursement before having the surgery?

Edwin S. Kneedler:

The Act does not provide for this sort of procedure.

The administrative procedure that Congress has established, particularly Section 405(b), refers to determinations and hearings on applications or determining the rights of people who have applied for payment under the Act, and a person wouldn't even have a right to payment until he applied for benefits after having the surgery.

Sandra Day O'Connor:

Well, under your view, is there any way at all that a person could get that kind of determination--

Edwin S. Kneedler:

Well, the person could request, I suppose, the Secretary to perhaps offer advice, but for part of the reasons, I suppose, that were developed in the preceding case for one of the intermediaries to suggest the particular service might be covered before the person has even had the surgery might create problems, and ordinarily the intermediary would decline to do that.

Sandra Day O'Connor:

--Well, for someone looking at elective surgery, something that isn't going to done no matter what, and of modest means, it does put them in a difficult position, doesn't it?

Edwin S. Kneedler:

Well, it might.

In the typical Medicare claim situation, the rules are fairly well established, and by reference to what private insurance carriers do, but even quite aside from whether... from any policy of general applicability the Secretary has, in any individual case, surgery can only be paid for if it is reasonable and necessary, and that is a determination that could not be made until after the individual had the surgery in any event.

Sandra Day O'Connor:

Oh, well--

Harry A. Blackmun:

--Of course, this is Mr. Ringer's position, the one that Justice O'Connor refers to, isn't it?

Mr. Ringer's.

Edwin S. Kneedler:

That he is entitled to review now?

Harry A. Blackmun:

No, that he... he is in a position where he wants this procedure, but can't afford to pay for it, and how does he find out?