Court Opinion

ID: 9459772
Source: CourtListenerOpinion
Date Created: 2023-08-04 21:31:41.742305+00
Date Added: 2024-06-11T17:36:20.216824
License: Public Domain

ALDISERT, Circuit Judge
(dissenting).
Blue Shield is an insurance carrier under contract with the Social Security Administration to administer a portion of the Medicare program. We are to decide whether the denial by Blue Shield of reimbursement to an individual for dental services necessitated by a broken jaw raises (a) a question of “entitlement” for which there is a statutory right of administrative review by the Secretary of Health, Education and Wel*923fare and thereafter judicial review or, (b) a question of “amount”, for which there is no such statutory right of re-, view. Coneededly there is ambiguity over the meaning of the word “entitlement” as used in the statute.
The Secretary interprets the word to mean eligibility to participate in the Medicare program, i. e., eligibility for any benefits of Medicare. Thus, if an applicant is denied the coverage of the Medicare provisions of the Social Security Act, he is entitled to an appeal to the Secretary and thence to the federal courts. The interpretation of Mrs. Boh-len, accepted by the district court and the majority, and by the Fourth Circuit in Ridgeley v. Secretary of HEW, 475 F.2d 1222 (4th Cir., 1973), is that the word means eligibility not only to participate in the Medicare program, but eligibility for a certain benefit; and that therefore, when the applicant is denied a certain requested Medicare benefit, he has a right to exhaustive administrative and judicial review.
To solve this issue we must wade into the morass of statutory construction; and I am the first to concede that a reasonable case can be made for the majority. In approaching this question, I am reminded of a favorite expression of one of the departed brothers of this court, The Honorable Abraham L. Freedman, who was fond of saying, “The way you come out on this question depends on the way you go 'in.” This was a cryptic method of expressing modern notions of public policy or social welfare, sometimes called Cardoza’s “sociological method,” sometimes called “result-orientation.” I do not use the notion “result-orientation” in a pejorative sense, but merely as some consideration of the relative desirability of the result of one decision or another. Cardozo referred to this type of decision making as “along the lines of justice, morals and social welfare, the mores of the day; and this I will call the method of sociology.”1 “Result-orientation,” according to Judge Henry Friendly, must “refer to a judge’s personal belief in what is desirable, formed before study of the case at' hand and resistance to contrary arguments . . . [t]he way to handle this kind of ‘result-orientation’ is to require that a judge keep his personal beliefs as to desirability in their appropriate subordinate place in the judicial process — not to insist on his pretending to an intellectual equilibrium on great policy matters that cannot be expected, nor in many instances, desired.” 2
In this ease, it is relatively easy to resolve the ambiguity in favor of the individual applicant who has claimed a wrong under the Medicare program. There is a strong feeling abroad in this land that there should be review upon review upon review of all decisions, especially those associated with the government. To reach this result one simply takes a broad view of the word “entitlement” in the following provision of 42 U.S.C. § 1395ff(b): “Any individual dissatisfied with any determination under subsection (a) of this section as to entitlement under Part A or Part B, or as to the amount of benefits under Part A . . .
The majority’s interpretation is a warmhearted, generous gesture that comports with the modern concept of unlimited judicial review of virtually every aspect of contemporary American life. Thus, as here, when an applicant for Medicare has a difficulty with her Blue Shield claim she is then entitled to the following: (1) a right to exhaust the entire Blue Shield administrative procedure; (2) if dissatisfied, she then may institute and prosecute an administrative process through the various levels in the Department of Health, Education and Welfare; (3) if dissatisfied, she may file an action in the district court; (4) if dissatisfied there, to the United States Court of Appeals; and (5) if dis*924satisfied here, to the United States Supreme Court. All this because of a dispute over a Medicare dental bill.
I do not agree. And rather than become involved in an exercise of semantics or the juxtaposition of phrases, I choosé another route. I acknowledge Judge Friendly’s description of the task of statutory construction as “excruciating in its demand for judicial objectivity.” 3 Perhaps, the best advice is that offered by Judge Learned Hand —the judge “must try as best he can to put into concrete form what [the common] will is, not by slavishly following the words, but by trying honestly to say that was the underlying purpose expressed.” 4
First, I am impressed by the interpretation of this statute by the Secretary of Health, Education and Welfare. The expertise of his department is entitled to some, if not considerable, weight; and here I am willing to accept their view. The Secretary has interpreted the statute to mean that “entitlement” relates only to an individual’s right to participate in the Medicare program. Mrs. Bohlen was not denied the right to participate in the program. She was simply denied the dental services she claimed. The Secretary contends, “It is apparent from the language of the Medicare provision that Congress intended that the Secretary delegate to carriers the day-to-day administration of the Supplementary Medical Insurance Program. Specifically, the Secretary is directed to arrange for carriers to perform the functions of payor, auditor, regulator, innovator of efficient utilization procedures, and communicator of program ideas (42 U.S.C. 1395u(a)). In addition, pursuant to contracts with the Secretary, carriers are to ‘otherwise assist, in such manner as the contract may provide, in discharging administrative duties necessary to carry out the purposes of’ the program (42 U.S.C. 1395u(a)(4)), and to
* * * establish and maintain procedures pursuant to which an individual enrolled under this part will be granted an opportunity for a fair hearing by the carrier when requests for’payment under this part with respect to services furnished him are denied or are not acted upon with reasonable promptness or when the amount of such payment is in controversy * * *.
(42 U.S.C. 1395u(b)(3)(C).”
Conforming with the statutory language, the Secretary by contract and regulation has required carriers to make a determination as to what items and services furnished are covered, but the Secretary has precluded carriers from determining “whether an individual is entitled to coverage under the Supplementary Medical Insurance Plan” because this is a “factor for which thé Social Security Administration has sole responsibility.” 20 C.F.R. 405.803(c). And this is the aspect of the Medicare program which the Secretary deems subject to administrative and judicial review. The Secretary presents a sound argument and no semantic excursions in other directions can convince me otherwise.
Secondly, I am aware that as a general proposition one session of Congress cannot, by subsequent statutory declaration, legislate the intention of a previous Congress. Nevertheless I am impressed that the statutory provision at issue is relatively new legislation adopted in 1965 and that seven years later Congress acted to remove the ambiguity. The Congressional amendment provided:
(b)(1) Any individual dissatisfied with any determination under subsection (a) as to—
(A) Whether he meets the conditions of § 226 of this act or § 103 of the Social Security amendments of 1965, or
*925(B) Whether he is eligible to enroll or has enrolled pursuant to the provisions of Part B of this title . . . ,
shall be entitled to a hearing thereon by the Secretary to the same extent as is provided in § 205(b) and to judicial review of the Secretary’s final decision after such hearing as is provided in § 205(g). § 2990 Social Security Amendments of 1972 (Pub.L. 92-603 October 30, 1972).
In the Senate debates on H.R. 1, the bill encompassing the 1972 amendment, Senator Bennett stated: “[T]he purpose of the amendment is to make sure existing law, which gives the right of a person to go to court on the question of eligibility to receive welfare [i. e., Medicare benefits], is not interpreted to mean he can take the question of the federal claim to court. If he did we would never have an end to it. This is to reconfirm the original intention of the law that the courts can determine only eligibility.
“The situations in which Medicare decisions are appealable to the courts were intended in the original law to be greatly restricted in order to avoid overloading the courts with minor matters. The law refers to ‘entitlement’ as being an issue subject to court review and the word was intended to mean eligibility to any benefits of Medicare but not to decisions on the claim for payment for a given service.” 5 (Emphasis supplied.) At the risk of repetition, I am aware that Congressional interpretation of previous legislation is not binding. Although not binding, I believe that it is a legitimate consideration in judical statutory interpretation.
My third reason is my own application of Cardozo’s “method of sociology,” otherwise stated as “public policy.” I am persuaded that the federal courts of 1973 are overloaded with cases which do not properly belong here. Recently this court had before us an action for civil damages for $3.00, brought by a prisoner against a guard for an alleged theft of seven packs of cigarettes, Russell v. Bodner, (unreported) (3d Cir. 1973). There are certain aspects of public disputes which should come within the doctrine of “de minimis,” especially where, as here, there is a procedure instituted within the Blue Shield carrier to process disputes. I do not believe that the district court should become the arbiter for determining the propriety of disputes over dental bills between an applicant and Blue Shield in the administration of the Medicare program. Similarly I do not believe that this court of appeals, which increased its caseload over 100% in a five-year period, nor the Supreme Court, already choked with an astronomical caseload, should become involved in this type of litigation. The majority recognize this, but seem to complain: “We know this but Congress made us do it.” I disagree. The majority should properly say, “The statute is ambiguous, but we are interpreting it in such a way as to mean that Congress made us do it.”
I would reverse the judgment of the district court and dismiss the complaint for want of jurisdiction in the federal courts.

. Cardozo, The Nature of the Judicial Proeess, 31.

. Friendly, Reactions of a Lawyer-Newly Become Judge, 71 Yale L.J. 218, 231 (1961).

. Friendly, supra, at 232.

. Hand, The Spirit of Liberty, 84 (1952).

. 118 Cong.Rec. S 17048,49 (daily ed. October 5,1972).