Benefits Determinations Disguised as FTCA Medical Negligence Are Jurisdictionally Barred: The Fifth Circuit’s Reaffirmation in Smart v. United States

Introduction

In Smart v. United States, No. 25-50120 (5th Cir. Nov. 6, 2025) (per curiam) (unpublished), the Fifth Circuit affirmed the dismissal of a veteran’s Federal Tort Claims Act (FTCA) suit that alleged “medical negligence” by the Department of Veterans Affairs (VA). The core of the lawsuit was the VA’s alleged failure to recognize and treat the plaintiff’s mental health conditions and to pay a non-VA mental health provider for care that had been authorized for years. The court held that the suit, though framed as malpractice, was in substance a challenge to benefits determinations barred from district court review by 38 U.S.C. § 511 (the Veterans’ Judicial Review Act, or VJRA). The panel also affirmed the district court’s Rule 12(b)(6) dismissal of the plaintiff’s “armed escort” allegations and rejected his recusal request.

The case squarely reinforces a critical jurisdictional boundary: when a veteran’s claim requires a court to evaluate whether the VA improperly approved, authorized, or paid for treatment, that claim amounts to a benefits dispute and must travel through the specialized veterans’ benefits review system—not the FTCA in district court. At the same time, the opinion distinguishes such benefits-centric disputes from true FTCA medical malpractice claims based on negligent clinical care by VA professionals.

Key takeaways

Section 511 of the VJRA channels disputes “necessary to a decision” affecting VA benefits away from district courts; repackaging such disputes as FTCA “medical negligence” does not create jurisdiction.
Approval, authorization, or payment for non-VA treatment are “quintessential benefits determinations” beyond district court review.
FTCA claims premised on negligent clinical care (e.g., misdiagnosis, surgical error) remain viable—so long as adjudication does not require revisiting a benefits decision.
Allegations about VA security practices (e.g., armed escorts) require well-pleaded elements of a tort claim and may also raise sovereign-immunity defenses (such as the discretionary function exception), though the Fifth Circuit here affirmed on Rule 12(b)(6) grounds without reaching immunity.
Adverse judicial rulings, without more, do not warrant recusal; a showing of extrajudicial bias or pervasive antagonism is required.

Summary of the Opinion

The appellant, Michael C. Smart, a Gulf War veteran, alleged that the VA failed to recognize and treat his mental health conditions while requiring him to be escorted by armed officers at VA facilities. He also alleged that the VA failed to ensure he received authorized care from a non-VA provider, who later ceased treating him purportedly because the VA had not paid for eight years of services. Smart sued under the FTCA for medical negligence. The United States moved to dismiss, arguing lack of jurisdiction under the VJRA and, alternatively, failure to state a claim; it also raised the FTCA’s discretionary function exception as to the escort allegations.

The district court dismissed the mental-health-treatment-and-payment aspects of the claim for lack of subject-matter jurisdiction under § 511 and dismissed the armed-escort allegations for failure to state a claim under Rule 12(b)(6). The court also denied a recusal motion, construed from a motion to transfer. On appeal, the Fifth Circuit:

Affirmed the § 511 dismissal, holding that Smart’s claim—at bottom—challenged the VA’s failure to pay or authorize treatment, which constitutes a nonreviewable benefits determination.
Affirmed the Rule 12(b)(6) dismissal of the escort-related allegations.
Affirmed the denial of recusal, emphasizing that adverse rulings alone do not show bias.

Analysis

Precedents Cited and Their Role in the Decision

Zuspann v. Brown, 60 F.3d 1156 (5th Cir. 1995): The panel relied on Zuspann to reiterate that the VJRA confers exclusive jurisdiction over veterans’ benefits determinations to the specialized system culminating in the Court of Veterans Appeals (now the Court of Appeals for Veterans Claims), not to Article III district courts. Zuspann anchors the Fifth Circuit’s longstanding approach to § 511’s jurisdictional bar.
King v. United States VA, 728 F.3d 410 (5th Cir. 2013): King provides the Fifth Circuit’s key articulation that district courts lack jurisdiction over claims that require analyzing whether VA officials knew or should have known a benefits denial was wrong. The panel quotes and applies King’s “repackaging” insight: relabeling a benefits dispute as a tort claim does not circumvent § 511.
Smith v. United States, 7 F.4th 963 (11th Cir. 2021): The panel approvingly cites Smith’s distinction between clinical negligence (potentially cognizable under the FTCA) and “quintessential benefits determinations” involving approval, authorization, or payment for care—matters that § 511 channels out of district court. Smith thus supports cross-circuit consensus on the benefits/tort boundary.
Standards of Review: The court cites McLin v. Twenty-First Judicial District, 79 F.4th 411 (5th Cir. 2023) and Ramming v. United States, 281 F.3d 158 (5th Cir. 2001) (de novo review for Rule 12(b)(1)); Sonnier v. State Farm, 509 F.3d 673 (5th Cir. 2007) (de novo review for Rule 12(b)(6)); and Johnson v. Lumpkin, 74 F.4th 334 (5th Cir. 2023) and Trevino v. Johnson, 168 F.3d 173 (5th Cir. 1999) (abuse of discretion for recusal). These authorities frame the appellate posture and the lens through which the panel affirms.
Recusal Doctrine: Liteky v. United States, 510 U.S. 540 (1994), and Matter of Hipp, Inc., 5 F.3d 109 (5th Cir. 1993), underscore that adverse rulings almost never supply a valid basis for recusal absent evidence of extrajudicial bias or extraordinary antagonism.

Legal Reasoning

1) Section 511’s Jurisdictional Bar and the “Repackaging” Problem

Section 511(a) instructs that the Secretary of Veterans Affairs “shall decide all questions of law and fact necessary” to decisions affecting the provision of benefits, and that those decisions are “final and conclusive” and “may not be reviewed by any … court.” The Fifth Circuit applied this channeling provision as it has in prior cases: if adjudicating an FTCA claim would require a district court to decide whether the VA wrongly authorized, approved, or paid for care, then the claim “amounts to an appeal” of a benefits decision and falls outside the court’s jurisdiction.

The panel examined Smart’s allegations that the VA failed to ensure he received authorized mental health treatment from a non-VA provider (Mr. Leal) and failed to pay for years of such treatment. To adjudicate that claim, a district court would have to evaluate whether the VA correctly handled approval and payment—classic benefits determinations. As the court put it, deciding Smart’s claim would require it “to analyze whether the VA’s agents knew or should have known that the denial of [Smart’s] benefits was wrong.” That inquiry is foreclosed by § 511 and King.

The panel also addressed Smart’s reliance on the Eleventh Circuit’s observation in Smith that veterans can bring FTCA suits for medical negligence by VA practitioners. The court agreed with that general principle but emphasized Smith’s limiting rule: “approval and authorization of a particular treatment or the payment thereof are quintessential benefits determinations.” Because Smart’s allegations ultimately challenge payment/authorization failures—not clinical malpractice—§ 511 strips district court jurisdiction.

2) The FTCA Claim About Armed Escorts: Failure to State a Claim

Separate from the payment/authorization theory, Smart alleged that the VA’s requirement that he be escorted by armed officers on VA property breached a medical duty and created a risk he could be shot. The district court dismissed these “armed escort” allegations under Rule 12(b)(6), and the Fifth Circuit affirmed.

The appellate opinion does not elaborate on the Rule 12(b)(6) analysis, but several principles likely informed the outcome:

To state an FTCA negligence claim, a plaintiff must plausibly plead duty, breach, causation, and damages under the law of the state where the act occurred. Mere fear of injury, without actionable harm recognized by state law, is typically insufficient.
Labeling a security measure as “medical negligence” does not make it medical care; “medical negligence” generally concerns clinical judgments by healthcare providers, not law-enforcement security protocols.
Although the United States also invoked the FTCA’s discretionary function exception (DFE), the appellate court had no need to reach sovereign-immunity defenses once it affirmed dismissal for failure to state a claim.

3) Recusal: No Showing of Extrajudicial Bias

Smart sought recusal based on perceived bias stemming from his litigation history and adverse rulings, including references to sanctions and the district court’s treatment of the “armed escort” allegations. Applying 28 U.S.C. § 455(a) and Liteky, the court held that adverse rulings do not demonstrate bias and that there was no indication of extrajudicial animus or knowledge. The denial of recusal was therefore not an abuse of discretion.

Impact

Although unpublished, Smart meaningfully reinforces a well-settled but frequently litigated jurisdictional boundary in the Fifth Circuit and beyond:

For veterans and counsel: When the gravamen of a dispute is that the VA failed to approve, authorize, or pay for care—whether at VA facilities or by outside providers—the proper avenue is the veterans’ benefits review system (agency adjudication, Board of Veterans’ Appeals, Court of Appeals for Veterans Claims, and Federal Circuit), not an FTCA suit in district court.
For VA and the United States: Smart supports early Rule 12(b)(1) dismissal where an FTCA complaint, however styled, would require second-guessing a benefits determination. It also encourages early Rule 12(b)(6) scrutiny of tort theories that rest on security measures or administrative policies rather than clinical negligence.
For district courts: The opinion underscores the importance of looking beyond labels to the “questions of law and fact” a complaint would require the court to decide. If answering those questions would revisit a benefits determination, § 511 deprives the court of jurisdiction.
For future FTCA malpractice litigation: The decision does not diminish genuine malpractice claims based on negligent clinical care by VA medical professionals. But plaintiffs must carefully plead such claims to avoid intermingling them with benefits-authorization or payment disputes that trigger § 511.

Complex Concepts Simplified

VJRA / 38 U.S.C. § 511: A statute that channels all questions necessary to benefits decisions into a specialized administrative and judicial track. District courts cannot review those questions. If a lawsuit would require a judge to decide whether VA wrongly authorized, approved, or paid for care, it belongs in the veterans’ benefits system, not federal district court. The court the opinion calls the “Court of Veterans Appeals” is today named the U.S. Court of Appeals for Veterans Claims.
FTCA (Federal Tort Claims Act): A limited waiver of federal sovereign immunity allowing suits against the United States for certain torts by federal employees. It generally adopts the substantive tort law of the state where the conduct occurred. However, the FTCA does not waive immunity for claims that another federal statute (like § 511) removes from district court review.
“Repackaging” a benefits claim: Courts look at the substance of a claim, not its label. Calling a benefits dispute “medical negligence” will not create jurisdiction if the court must evaluate the propriety of benefits approval, authorization, or payment.
Rule 12(b)(1) vs. Rule 12(b)(6): Rule 12(b)(1) dismissals address the court’s power to hear a case (subject-matter jurisdiction). Rule 12(b)(6) dismissals address whether the complaint, assuming its facts are true, plausibly states a claim for relief under applicable law.
Discretionary Function Exception (DFE): An FTCA carveout preserving sovereign immunity for claims based on discretionary policy judgments of federal employees (e.g., how to set or enforce security protocols). The government raised DFE here as to the escort allegations, but the appellate court affirmed dismissal on Rule 12(b)(6) grounds and did not reach DFE.
Recusal under 28 U.S.C. § 455(a): A judge must step aside if a reasonable person, knowing all the facts, would question the judge’s impartiality. Adverse rulings alone almost never suffice; there must be evidence of bias from outside the proceedings or extreme antagonism.

Conclusion

Smart v. United States reiterates a clear and consequential jurisdictional rule: FTCA lawsuits cannot be used to litigate disputes about the VA’s approval, authorization, or payment of medical care. Those matters are “quintessential benefits determinations” subject to exclusive review within the veterans’ benefits system. The Fifth Circuit’s reasoning aligns with its own precedents (Zuspann, King) and with the Eleventh Circuit’s articulation in Smith.

At the same time, the decision preserves the path for true FTCA medical malpractice claims grounded in negligent clinical care by VA providers—claims that do not require revisiting benefits decisions. And it underscores the importance of pleading viable tort elements when challenging non-clinical measures such as security escorts, while reminding litigants that adverse rulings, without more, do not establish judicial bias.

In short, the opinion fortifies the jurisdictional boundary between tort adjudication and benefits administration: benefits issues must go through the veterans’ review channel; tort claims should proceed only when they can be adjudicated without second-guessing the VA’s benefits determinations.