South Carolina              
Administrative Law Court
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SC Administrative Law Court Decisions

CAPTION:
Cornelia Howard vs. SCBCB

AGENCY:
South Carolina Budget and Control Board

PARTIES:
Appellant:
Cornelia Howard

Respondent:
South Carolina Budget and Control Board, Employee Insurance Program
 
DOCKET NUMBER:
06-ALJ-30-0782-AP

APPEARANCES:
Pheobe A. Clark, Esq.
For Appellant

James T. Hedgepath, Esq.
For Respondent
 

ORDERS:

ORDER

STATEMENT OF THE CASE

The above-captioned matter is before this Court pursuant to S.C. Code Ann. § 1-11-710(C) (2005) and S.C. Code Ann. § 1-23-600(D) (Supp. 2006) for an administrative appeal. In this matter, Appellant Cornelia Howard seeks review of a decision of Respondent South Carolina Budget and Control Board, Employee Insurance Program (“EIP”) denying her claim for long term disability benefits under the State of South Carolina Long Term Disability Income Benefit Plan (“Plan”). Specifically, by letter dated September 5, 2006, the Long Term Disability Appeals Committee of the EIP (“EIP Appeals Committee”) informed Ms. Howard that she is not eligible to receive long term disability benefits, as her medical records indicate that she has sacroiliac joint instability[1], which it contends is caused or contributed to by a chronic pain, musculoskeletal and connective tissue condition. (R. at 358-62). As this is a medical condition in which benefits are limited to twenty-four (24) months under the terms of the Plan, the EIP Appeals Committee upheld the decision by Standard Insurance Company (“The Standard”), the third party administrator for the Plan, that she is not eligible to receive continued benefits.[2]

In this appeal, Ms. Howard challenges EIP’s decision by contending that she suffers from sacroiliitis,[3] which she considers to be a neurological condition. Ms. Howard further argues that, as a result of this condition, she is physically incapacitated from the further performance of her job. EIP argues that Ms. Howard suffers from sacroiliac joint (“SI joint”) instability,[4] and her condition falls within the provision that limits benefits for certain named conditions, as EIP contends that SI joint instability is not considered to be a neurological disease. Accordingly, EIP argues that Ms. Howard has exhausted the twenty-four (24) month limitation period and is no longer entitled to receive disability benefits under the Plan.

After timely notice to the parties, oral arguments were held on March 7, 2007, at the South Carolina Administrative Law Court (“ALC” or “Court”) in Columbia, South Carolina. Based upon the Record on Appeal, the parties’ briefs and oral arguments, and upon the applicable law, I affirm the final decision of EIP in upholding the denial of Ms. Howard’s claim for long term disability benefits as there is substantial evidence in the record to support EIP’s determination that Ms. Howard is not eligible to receive disability benefits beyond twenty-four (24) months.

BACKGROUND

Procedural Background

Ms. Howard is a fifty-four-year-old woman who applied for disability benefits through EIP. Ms. Howard began employment on April 3, 2000, as a Human Resources Specialist with the Florence County Department of Social Services and ceased employment on December 18, 2002, as a result of her medical condition. (R. at 13). On July 16, 2003, The Standard informed Ms. Howard that her claim for long term disability benefits had been approved, and her payments would be retroactively applied, beginning March 18, 2003. (R. at 85). However, on May 25, 2004, The Standard notified Ms. Howard that under the Plan, disability benefits are limited to twenty-four (24) months during her entire lifetime for conditions caused or contributed to by a chronic pain, musculoskeletal and connective tissue condition. The relevant provisions of the Plan document state:

No LTD [long term disability] benefits are payable after you have been Disabled for 24 months during your entire lifetime (exclusive of any Benefit Waiting Periods), if your Disability is caused or contributed to by the following, or medical or surgical treatment of the following:

. . . .

Chronic Pain, Musculoskeletal and Connective Tissue Conditions. Chronic Pain, Musculoskeletal and Connective Tissue Conditions means conditions such as fibromyalgia, reflex sympathetic dystrophy or myofascial pain, carpal tunnel or repetitive motion syndrome, temporomandibular joint disorder, craniomandibular joint disorder, arthritis, diseases or disorders of the cervical, thoracic, or lumbosacral back and its surrounding soft tissue, and sprains or strains of joints or muscles.

However, Disabilities as a result of the following conditions are not limited: neoplastic diseases, neurologic diseases . . . .

(R. at 400) (emphasis added).

After receiving Ms. Howard’s request for a review of its decision to “limit and close” – that is, deny her claim, The Standard forwarded its medical file on Ms. Howard to Dr. Shih,[5] a Physician Consultant, for review. Dr. Shih’s opinion concurred with The Standard’s initial decision that Ms. Howard’s condition fell within the medical conditions limited to receiving benefits for a period of twenty-four (24) months. Thereafter, on April 15, 2005, The Standard upheld its previous decision to limit Ms. Howard’s benefits based upon Dr. Shih’s opinion and other information contained in Ms. Howard’s file. (R. at 313-4). Further, The Standard informed Ms. Howard that it would be forwarding its file to a Benefits Review Specialist from the Quality Assurance (“QA”) Unit to ensure an objective review of its decision to close her claim. However, by letter dated July 19, 2005, The Standard’s QA Unit notified Ms. Howard that after reviewing her claim, it affirmed the earlier decision to limit and close her claim for long term disability benefits. (R. at 317-9).

As a result of The Standard’s decision, Ms. Howard appealed to the EIP for review of this decision. (R. at 353). On July 18, 2006, the EIP Appeals Committee met to consider Ms. Howard’s request for review, and on September 5, 2006, the EIP issued a Final Agency Determination. Based upon Ms. Howard’s medical records as submitted, the relevant provisions of the Plan, and the medical opinion of a Physician Consultant, the EIP Appeals Committee concluded that the “facts and circumstances of [Ms. Howard’s] claim do not qualify [her] for continued disability benefits under the Plan.” (R. at 362). Specifically, the EIP Appeals Committee determined that:

1. Long-term disability benefits payable due to Musculoskeletal and Connective Tissue Disorders and Mental Disorders are limited to a twenty-four (24) month period during a person’s lifetime. (R. at 361).

2. Ms. Howard was approved for disability benefits due to SI joint instability. She received monthly disability benefits beginning March 18, 2003, and ending March 17, 2005, the limited twenty-four (24) month period as defined under the Plan. (R. at 358-9).

3. Medical records submitted to the EIP Appeals Committee by Dr. Hyler, Ms. Howard’s physician, stated she in fact had sacroiliitis, while “The Standard’s Physician Consultant opined that the documentation in the file did not support a diagnosis of sacroiliitis.” (R. at 358). Further, “[t]he Committee found that the documentation supported the conclusion that Ms. Howard has SI joint instability, which is a condition subject to the Limited Pay Period provision of the Plan.” (R. at 358).

4. Although Ms. Howard is unable to perform her own occupation and has a medical condition “that may require continuing treatment” for SI joint instability, she has received the maximum amount of benefits, i.e., twenty-four months, which she is eligible to receive under the terms of the Plan. (R. at 358).

On October 3, 2006, Ms. Howard filed a Notice of Appeal with this Court to challenge EIP’s final agency determination.

Ms. Howard’s Medical Condition

I. Dr. Perry, Pain Management Center

Dr. Alan Lippitt, Orthopedic Medicine & Surgery

Prior to ceasing employment with the Florence County Department of Social Services, Ms. Howard began receiving right sacroiliac joint injections from Dr. Perry of the Pain Management Center, McLeod Regional Medical Center. (R. at 230). Dr. Perry, in his December 16, 2002 letter, indicated that although Ms. Howard had been receiving this treatment from him for the past several years, she did not benefit from her last sacroiliac joint injection. As a result, Dr. Perry discussed the possibility of referring Ms. Howard to Dr. Alan Lippitt, an orthopedic surgeon, for a “possible sacroiliac joint effusion.” (R. at 230). On March 19, 2003, Dr. Lippitt evaluated Ms. Howard and concluded that she suffered from “an unstable right sacroiliac joint.” (R. at 210). At that time, Dr. Lippitt recommended a specific treatment[6] for Ms. Howard and indicated that should this treatment fail, he would then consider surgery for her condition. Drs. Perry and Lippitt did not disclose any neurological aspect associated with her medical condition, and she was never referred by either doctor to a neurologist for an evaluation.

II. Dr. Hyler, Ms. Howard’s Primary Physician

Beginning January 7, 2003, Dr. Hyler’s medical notes document Ms. Howard’s right hip joint pain, and Dr. Hyler further states in his January 28, 2003 patient notes that Ms. Howard has chronic sacroiliitis. (R. at 258-61). Dr. Hyler continued to treat Ms. Howard for chronic sacroiliitis as evidenced by her medical records dated through September 29, 2004. (R. at 293). Throughout this time period, Dr. Hyler never indicated in Ms. Howard’s patient records that her condition included any neurological aspect, nor did he ever refer her to a neurologist, as he had previously referred her to an orthopedic surgeon in March of 2003. (R. at 262).

On February 11, 2005, Dr. Hyler wrote a letter to The Standard indicating that, in his opinion, Ms. Howard suffers from “sacroiliitis which would be classified as a neurologic disease.” (R. at 294). This letter was in response to The Standard notifying Ms. Howard that it was limiting her benefits to twenty-four (24) months as a result of her condition falling within the provision that limits benefits for conditions caused or contributed to by a chronic pain, musculoskeletal and connective tissue condition.

STANDARD OF REVIEW

Pursuant to S.C. Code Ann. § 1-11-710(C) (2005), this Court’s appellate review of EIP’s final decision is governed by the standards provided in S.C. Code Ann. § 1-23-380 (Supp. 2006). Section 1-23-380 provides that this Court “may not substitute its judgment for the judgment of the [Board] as to the weight of the evidence on questions of fact.” S.C. Code Ann. § 1-23-380(A)(5), (B) (Supp. 2006). However, this Court

may reverse or modify the decision if substantial rights of the appellant have been prejudiced because the administrative findings, inferences, conclusions or decisions are:

(a) in violation of constitutional or statutory provisions;

(b) in excess of the statutory authority of the [Board];

(c) made upon unlawful procedure;

(d) affected by other error of law;

(e) clearly erroneous in view of the reliable, probative, and substantial evidence on the whole record; or

(f) arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion.

Id.; see also Lark v. Bi-Lo, Inc., 276 S.C. 130, 276 S.E.2d 304 (1981) (stating “‘[s]ubstantial evidence’ is not a mere scintilla of evidence nor the evidence viewed blindly from one side of the case, but is evidence which, considering the Record as a whole, would allow reasonable minds to reach the conclusion that the administrative agency reached or must have reached in order to justify its action.” Id. at 135, 276 S.E.2d at 306. Accordingly, “[t]he ‘possibility of drawing two inconsistent conclusions from the evidence does not prevent an administrative agency’s finding from being supported by substantial evidence.’” Grant v. South Carolina Coastal Council, 319 S.C. 348, 461 S.E.2d 388 (1995) (citing Palmetto Alliance, Inc. v. South Carolina Public Service Commission, 282 S.C. 430, 432, 319 S.E.2d 695, 696 (1984)). Further, an abuse of discretion occurs when an administrative agency’s ruling is based upon an error of law, such as application of the wrong legal principle; or, when based upon factual conclusions, the ruling is without evidentiary support; or, when the trial court is vested with discretion, but the ruling reveals no discretion was exercised; or, when the ruling does not fall within the range of permissible decisions applicable in a particular case, such that it may be deemed arbitrary and capricious. Cf. State v. Allen, 370 S.C. 88, 634 S.E.2d 653 (2006) (application of standard to circuit court) (citing Fontaine v. Peitz, 291 S.C. 536, 539, 354 S.E.2d 565, 566 (1987)).

DISCUSSION

Ms. Howard argues that her back condition is the result of sacroiliitis and has rendered her permanently and physically disabled from the further performance of her duties as a Human Resources Specialist with the Florence County Department of Social Services, such that she should be entitled to long term disability benefits from EIP. In addition, Ms. Howard argues that the physicians involved in this matter “appear to agree as to the etiology of [her] pain, [but that] they disagree on [the] semantics” of her medical condition; therefore, Ms. Howard argues that the Plan’s language relating to the chronic pain, musculoskeletal and connective tissue condition limitation and neurological abnormalities exception is ambiguous, and “according to the Doctrine of Contra Proferentem[7] and South Carolina law, [should] be construed against the drafter in favor of coverage.” (Appellate Br. 3). However, by virtue of Appellant’s argument, she fails to acknowledge that this Court sits in an appellate capacity when reviewing a final agency determination from EIP, rather than a trial level capacity when hearing a contested case.[8] Because this tribunal is limited to granting or denying relief to Ms. Howard under Section 1-23-380, the question presented in this appeal is whether EIP’s decision to uphold the denial of Ms. Howard’s claim for long term disability benefits was “clearly erroneous in view of the reliable, probative, and substantial evidence on the whole record” regarding Ms. Howard’s medical condition. S.C. Code Ann. § 1-23-380(A)(5)(e) (Supp. 2006) (emphasis added). On that question, there is overwhelming documentation in the record to substantiate EIP’s decision to uphold the denial of Ms. Howard’s claim for long term disability benefits.

In a record of over four hundred (400) pages, Ms. Howard could direct this Court to only one document that, she claims, would require this Court to reverse EIP’s decision. While it is true that Ms. Howard’s primary physician provided one letter stating Ms. Howard suffers from sacroiliitis, which he considers to be a neurological disease, reasonable minds could come to the contrary determination reached by EIP – that there is no evidence, medical or otherwise, that supports the conclusion that sacroiliitis is a neurological condition – thus excluding Ms. Howard’s medical condition from the provision limiting disability benefits to twenty-four (24) months. Although Appellant argues in her brief that Dr. Perry, Ms. Howard’s treating physician at the Pain Management Center, corroborated Dr. Hyler’s assertion, there is no indication in the record that Dr. Perry affirms Dr. Hyler’s opinion that sacroiliitis is a neurological disease.[9] (Appellant’s Br. 4).

Further, Dr. Hyler’s letter stating that Ms. Howard’s medical condition is a neurological condition was submitted to the Committee at the conclusion of the administrative process once The Standard’s decision and reasoning was apparent. In fact, Ms. Howard was specifically advised on May 25, 2004, by The Standard, to provide additional information, if any, to The Standard if this information would support a conclusion that the chronic pain, musculoskeletal and connective tissue condition limitation should not apply to her claim. Nearly a year later, Ms. Howard submitted Dr. Hyler’s letter, dated February 11, 2005, which indicated his belief that Ms. Howard’s condition did not fall within the Plan’s limitation provision, as stated previously. Taken together with the entire record, this single letter, with no accompanying medical documentation or evidence, does not support a finding that EIP’s decision to uphold the denial of Ms. Howard’s claim was clearly erroneous or an abuse of discretion.

While her back condition coupled with the resulting chronic pain may have disabled Ms. Howard from her job, there is sufficient evidence in the record to substantiate EIP’s decision to uphold the denial of Ms. Howard’s claim. Therefore, although Ms. Howard suffers from low back pain as a result of a sacroiliac joint condition, the record does not mandate nor does she articulate or cite support for any grounds of appeal that would require this Court to reverse EIP’s decision.

ORDER

For the reasons set forth above,

IT IS HEREBY ORDERED that EIP’s final agency determination upholding the denial of Ms. Howard’s claim for long term disability benefits is AFFIRMED.

AND IT IS SO ORDERED.

______________________________

JOHN D. GEATHERS

Administrative Law Judge

April 12, 2007

Columbia, South Carolina



[1]“According to the website ‘About: Orthopedics,’ the sacroiliac joint is a firm, small joint that lies at the junction of the spine and the pelvis. Most often when we think of joints, we think of knees, hips, and shoulders—joints that are made to undergo motion. The sacroiliac joint does not move much, but it is critical to transferring the load of your upper body to your lower body.” (Respt.’s Br. at 5) (citing http://orthopedics.about.com/cs/hipsurgery/a/sacroiliacjoint.htm).

[2] According to the Long Term Disability section of the Insurance Benefits Guide for the EIP, the following is the appeals process for any long term disability benefits claim that is denied:

If Standard Insurance Company [the third party administrator for the Plan] denies your claim for long term disability benefits, you can appeal the decision by writing to Standard Insurance Company within six months of receipt of the denial letter. If the company upholds its decision after a review by its Quality Assurance Unit, you may appeal that decision by writing to EIP within 90 days of the notice of denial. If the denial is upheld by EIP, you may file an appeal with the S.C. Administrative Law Court within 30 days of the date of receipt of the denial letter from EIP.

(Insurance Benefits Guide, South Carolina Budget and Control Board, Employee Insurance Program). Further, once a long term disability benefits claim is appealed to EIP, the claim is forwarded to the EIP Appeals Committee for a final agency determination. Thus, EIP’s final agency determination is essentially the EIP Appeals Committee’s decision.

[3] Sacroiliitis is defined as an inflammation of the sacroiliac joint, which is one of a pair of joints in the lower back near the pelvis. American Medical Association, Complete Medical Encyclopedia 1086 (Jerrold B. Leikin, MD & Martin S. Lipsky, MD, eds., Random House Reference 2003).

[4] Respondent’s Brief characterizes Ms. Howard’s medical condition as SI joint instability rather than sacroiliitis. (Respt.’s Br. 4-5). Respondent further states that regardless of how Ms. Howard’s medical condition is characterized, EIP’s decision remains the same as her condition would still fall into the provision limiting benefits for certain named conditions. (Respt.’s Br. 15, n.9).

[5] Dr. Mark Shih submitted his medical opinion of Ms. Howard’s medical records on April 4, 2005. (R. at 308-11).

[6] Dr. Lippitt recommended a trial of Prolotherapy, which is the injection of hardening solutions into the ligaments of the back as a treatment for back pain. Taber’s Cyclopedic Medical Dictionary 1784, 1958 (20th ed. 2005) (defining “prolotherapy” and “sclerose”).

[7] This doctrine establishes that, when interpreting documents, ambiguities are to be construed unfavorably against the drafter. Black’s Law Dictionary 328 (7th ed. 1999).

[8] Because this tribunal, sitting in an appellate capacity, is limited to deciding issues that were properly raised below, it is not appropriate to bring before this Court any argument pertaining to the ambiguity of the Plan’s language, as this issue has not been preserved for judicial review. Dorman v. S.C. Dep’t of Health and Environmental Control, 350 S.C. 159, 171, 565 S.E.2d 119, 125 (S.C. App. 2002) (stating that “issues not raised to and ruled on [below] are not preserved for judicial consideration); See also Holy Loch Distribs., Inc. v. Hitchcock, 340 S.C. 20, 24, 531 S.E.2d 282, 284 (2000); Smith v. Newberry County Assessor, 352 S.C. 572, 577, 567 S.E.2d 501, 504 (S.C. App. 2002).

[9] Appellant’s brief states that “Dr. Hyler . . . expressed his opinion that Claimant suffers from sacroiliitis which he opines is classified as a neurological disease, [and] this opinion is joined by Dr. Lee Perry who has been providing Claimant’s pain management.” (Appellant’s Br. 4).


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