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, 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.
In
this appeal, Ms. Howard challenges EIP’s decision by contending that she
suffers from sacroiliitis, 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, 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, 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 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 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.
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. (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
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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