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 Ernest McPhail seeks review of a decision of
Respondent South Carolina Budget and Control Board, Employee Insurance Program
(“EIP”) denying his claim for long term disability benefits under the State of
South Carolina Long Term Disability Income Benefit Plan (“Plan”). Specifically,
on August 1, 2006, the Long Term Disability Appeals Committee of the EIP (“EIP
Appeals Committee”) informed Mr. McPhail that his medical records as submitted
“did not contain documentation demonstrating that he was disabled from
performing his [job] throughout and beyond the 90-day Benefits Waiting Period”
as required under the Plan. (R. at 33).
In
this appeal, Mr. McPhail primarily challenges the constitutionality of S.C.
Code Ann. § 1-11-710(C) (2005). Appellant also challenges EIP’s final agency decision
by contending that he was disabled during the ninety (90) day waiting period because
of a myocardial infarction, or heart attack, suffered on December 2,
2003. In response, EIP argues that: (1) the constitutionality of Section
1-11-710(C) is not a proper issue for this Court’s consideration; and, (2)
there is substantial evidence in the record to support its decision that Mr. McPhail
failed to satisfy the Plan’s requirements for eligibility of long term
disability benefits.
After
timely notice to the parties, oral arguments were held on April 17, 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 Mr. McPhail’s claim for long term disability benefits
as there is substantial evidence in the record to support EIP’s determination
that Mr. McPhail’s condition did not satisfy the Plan’s Definition of
Disability.
BACKGROUND
Procedural
Background
Mr.
McPhail began employment on September 1, 2000, as a Human Services Assistant
with the South Carolina Department of Disability and Special Needs, and he ceased
employment on December 2, 2003, after suffering a heart attack on December 2,
2003. Appellant then pursued a claim for long term disability benefits under
the Plan. (R. at 180). On August 13, 2004, Standard Insurance Company (“The
Standard”), the third-party claims administrator for the Plan, informed Mr.
McPhail that his claim for long term disability benefits had been denied based
upon its conclusion that his medical condition was not completely limiting as
The Standard opined that he could return to work within ninety (90) after
suffering a heart attack. (R. at 140). Specifically, The Standard informed Mr.
McPhail that “[it] lack[ed] sufficient/conclusive documentation to support [his
doctor’s] recommendation and/or [his] inability to return to work . . . 12
weeks after [his] hospitalization on December 2, 2003.” (R. at 140). This
decision was based in part on the opinion of Dr. Bradley Fancher who reviewed
Mr. McPhail’s medical records and later determined that his condition would not
prevent him from returning to work within twelve (12) weeks of his heart attack
and resulting surgery.
Thereafter,
on December 17, 2004, Appellant requested a review of The Standard’s decision
to deny his disability claim, and on December 29, 2004, The Standard granted
this request and delayed the initial forty-five (45) day review.
(R. 137-8). On July 11, 2005, The Standard acknowledged Appellant’s request
for a review based upon additional information submitted, and it notified him
of its decision to affirm the initial decision to deny his claim for long term
disability benefits under the Plan. (R. at 126). Further,
The Standard informed Mr. McPhail that in order for him to be eligible for long
term disability benefits, “impairment from coronary artery disease needs to be
demonstrated by ongoing myocardial ischemia or persistent myocardial
dysfunction; [such impairment] is not documented in the medical record.” (R.
at 126).
The
Standard further informed Mr. McPhail that it would be forwarding its file on him
to a Benefits Review Specialist from the Quality Assurance (“QA”) Unit to
ensure an objective review of its decision to deny his claim. Subsequently, by
letter dated August 1, 2005, The Standard’s QA Unit notified Mr. McPhail that
after reviewing his claim, it affirmed the earlier decision to deny his claim
for long term disability benefits. (R. at 121-4). This decision was based in
part on the opinion of Dr. Janette Green who reviewed Mr. McPhail’s medical records
and later determined that his condition would not prevent him from returning to
work within twelve weeks of his heart attack and resulting surgery.
As
a result of The Standard’s final decision, Mr. McPhail appealed to EIP for
review of the decision. (R. at 50). On June 23, 2006, the EIP Appeals
Committee met to consider Mr. McPhail’s request for review. On August 1, 2006,
the EIP Appeals Committee issued a final agency determination, based upon Mr. McPhail’s
medical records as submitted, the relevant provisions of the Plan, and the
medical opinions of The Standard’s Physician Consultants, and concluded that
the “facts and circumstances of [Mr. McPhail’s] claim do not qualify [him] for
disability income benefits under the Plan.” (R. at 30). Specifically, the EIP
Appeals Committee determined that:
1. Appellant’s
medical records indicate that he has hypertension and had a heart attack on
December 2, 2003. (R. at 33).
2. As
a result of his heart attack, Appellant had a stent placed during surgery. The
Standard’s Physician Consultants opined that Mr. McPhail was successfully
treated after suffering a heart attack. (R. at 33).
3.
Medical documentation in Appellant’s file did not indicate impairment from coronary
artery disease. Specifically, there was no significant myocardial dysfunction
evident from Mr. McPhail’s cardiogram, and there was no recurrent chest pain.
(R. at 33).
4.
Therefore, Appellant’s coronary artery disease would not prevent Appellant from
performing the material duties of his [job] on a full-time basis within twelve
weeks following his hospitalization as a result of suffering a heart attack on
December 2, 2003. (R. at 33-4).
On
August 22, 2006, Mr. McPhail filed a Notice of Appeal with this Court to
challenge EIP’s final agency determination.
Mr. McPhail’s
Medical Condition
Appellant
suffered a heart attack on December 2, 2003, and as a result, Appellant
underwent stent surgery at McLeod Regional Medical Center (“MRMC”) on December
2, 2003. (R. at 210). Appellant was discharged from MRMC on December 5, 2003.
According to his discharge summary, Appellant was to follow-up with Dr. Linda
Shuck, his cardiologist, within two weeks following his release from MRMC, and
he was to also follow-up with Dr. Harless, his primary care physician, in
approximately three weeks. (R. at 210). Further, the discharge summary
instructed Appellant to “be evaluated by [Dr. Harless and Dr. Shuck] before
returning to work.” (R. at 210). The discharge summary did not indicate any complications
that occurred during Appellant’s procedure, but it did instruct Appellant to inform
his physician should any post-surgery problems arise such as “recurrent chest
pain, any shortness of breath . . . or any dizziness.” (R. at 210).
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, pursuant to Section 1-23-380(A)(5) (Supp. 2006),
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
The
gist of Appellant’s appeal, aside from his constitutional challenge to S.C.
Code Ann. § 1-11-710(C) (2005), which will be addressed in turn, is that EIP’s
decision to uphold the denial of Mr. McPhail’s claim for long term disability
benefits was clearly erroneous in view of the reliable, probative, and
substantial evidence on the whole record regarding Mr. McPhail’s medical
condition. S.C. Code Ann. § 1-23-380(A)(5)(e) (Supp. 2006). Mr. McPhail further
argues that his physical condition, resulting from a heart attack that occurred
on December 2, 2003, has rendered him permanently and physically disabled and
therefore incapable of performing his duties as a Human Services Assistant with
the South Carolina Department of Disability and Special Needs, such that he
should be entitled to long term disability benefits from EIP.
On
that assertion, there is support in the record to substantiate EIP’s decision
to uphold the denial of Mr. McPhail’s claim for long term disability benefits.
In a record of over two hundred (200) pages, Mr. McPhail could only direct this
Court to a handful of documents that, he claims, would require this Court to
reverse EIP’s decision. Appellant’s entire medical record, as submitted to EIP
or The Standard, can be summarized as follows and as provided in EIP’s
appellate brief. (Respt.’s Br. 7-8). [Chart Summary on the following page]
DATE |
PHYSICIAN |
SUMMARY |
12/9/03 |
Harless |
Approximately four days after
his release from MRMC following his stent surgery, Dr. Harless evaluated
Appellant and held him out of work until his next appointment in four weeks.
(R. at 238). |
12/23/03 |
Shuck |
Dr. Shuck evaluated Appellant
and stated that “[h]e is without complaints. He has had no further chest
pain. His only complaint today is numbness in his left hand and left cheek
area, occurring intermittently.” His physical examination did not reveal any
problems with his heart, i.e., irregular heart rate, murmurs, rubs or
gallops. (R. at 207). |
1/14/04 |
Harless |
Dr. Harless noted that Appellant
“has been feeling fairly well.” Again, Dr. Harless did not indicate any
problems associated with Appellant’s heart during this evaluation. (R. at
236). |
1/19/04 |
Shuck |
During this evaluation,
Appellant’s primary complaint was fatigue. Dr. Shuck indicated that she
planned to “check a [sic] overnight pulse oximeter” to determine the cause of
Appellant’s fatigue. (R. at 206). The results of this test were never
submitted into the record by Appellant. |
3/15/04 |
Harless |
Dr. Harless did not indicate
any problems associated with Appellant’s heart. Further, he states that
Appellant “is going back to work on the 20th of this month.” (R. at 235). |
4/19/04 |
Harless |
In the Attending Physician
Statement submitted by Dr. Harless to The Standard, in support of Appellant’s
claim for long term disability benefits, Dr. Harless recommended that
Appellant stop working as of April 16, 2004, due to “persistent dyspnea [shortness of breath] and angina [heart condition].”
(R. at 249-50) (emphasis added). |
4/21/04 |
Harless |
During this appointment, Dr.
Harless stated that Appellant “denies any significant pain, shortness of
breath, or other problems.” (R. at 234) (emphasis added). |
4/22/04 – 6/6/05 Appellant failed to submit any
medical documentation to EIP or The Standard. |
6/7/05 |
Harless |
Dr. Harless wrote a “[t]o whom
it may concern” letter in which he stated that Appellant “is 100% disabled.”
(R. at 199). |
6/22/05 |
Harless |
Dr. Harless submitted the cardiac
questionnaire to The Standard in support of Appellant’s long term disability
claim. (R. at 200-1). |
While
it is true that Mr. McPhail’s primary care physician provided one letter and the
cardiac questionnaire to The Standard which stated that Mr. McPhail was in fact
disabled because of his heart condition, reasonable minds could come to the
contrary determination reached by EIP – that there is no evidence, medical or
otherwise, that supports the conclusion that Mr. McPhail is disabled as a
result of his heart condition. For example, in the Attending Physician Statement
submitted by Dr. Harless to The Standard, he indicated that Appellant was unable
to work as a result of persistent dyspnea and angina. Interestingly, Dr.
Harless, in his evaluation of Appellant two days later, stated that Appellant
“denies any significant pain, shortness of breath, or other problems.”
(R. at 234) (emphasis added). Further, Dr. Harless’ letter, stating that Mr. McPhail
“is 100% disabled,” did not contain or reference any medical documentation to
support his assertion that Appellant was disabled. (R. at 199).
In
fact, Mr. McPhail was specifically advised on seven separate occasions to
submit additional medical documentation, if any, to The Standard or EIP if this
information would support a conclusion that he was disabled because of his
heart condition. (R. at 63, 70, 74, 76,
107, 111, 140). Although Dr. Harless submitted the cardiac questionnaire to
The Standard, on or about June 22, 2005, which indicated his belief that Mr. McPhail’s
condition was disabling, The Standard specifically stated in its initial denial
letter, dated August 13, 2004, that “[w]e must have supporting progress
notes from your treating cardiologist with the cardiology questionnaire.
(R. at 140) (emphasis in original). As of the date of this letter, Appellant
was put on notice that The Standard required that the cardiac questionnaire be
completed by his treating cardiologist, and that the questionnaire must be
accompanied by this physician’s progress notes of Appellant’s evaluations.
Taken together with the entire record, Dr. Harless’ single letter and completed
cardiac questionnaire, with no accompanying medical documentation or evidence,
does not support a finding that EIP’s decision to uphold the denial of Mr. McPhail’s
claim was clearly erroneous or an abuse of discretion. Put simply, the record
was devoid of any evidence, medical or otherwise, that would support
Appellant’s claim of disability, as related to his heart condition.
Appellant’s
Constitutionality Argument
As
stated previously, Appellant’s primary contention is that S.C. Code Ann. § 1-11-710(C)
(2005) violates Article 1, Section 22 of the South Carolina Constitution, as
well as S.C. Code Ann. §§ 1-23-320, -330, & -350 (Supp. 2006).
(Appellant’s Br. 20-4, 26-30). Because this argument is a challenge to the
constitutionality of the provisions of Section 1-11-710(C), it cannot be
addressed by this tribunal. See, e.g., Video Gaming Consultants,
Inc. v. S.C. Dep’t of Revenue, 342 S.C. 34, 38, 535 S.E.2d 642, 644 (2000) (holding
that an administrative law judge has no authority to pass upon the
constitutionality of a statute or regulation); Brownlee v. S.C. Dep’t of
Health and Environmental Control, 372 S.C. 119,----, 641 S.E.2d 45, 53 (Ct.
App. 2007) (citing Dorman v. S.C. Dep’t of Health and Environmental Control,
350 S.C. 159, 171, 565 S.E.2d 119, 126 (Ct. App. 2002); however, to the extent
that Appellant’s argument addresses the Board’s application of Section 1-11-710(C),
it must fail. Section 1-11-710(C)
authorizes the Board to establish the procedure by which claims under EIP are
heard and resolved:
Notwithstanding
Sections 1-23-310 and 1-23-320 or any other provision of law, claims for
benefits under any self-insured plan of insurance offered by the State to state
and public school district employees and other eligible individuals must be resolved
by procedures established by the board, which shall constitute the exclusive
remedy for these claims, subject only to appellate judicial review
consistent with the standards provided in Section 1-23-380.
S.C. Code Ann. §
1-11-710(C) (2005) (emphasis added). Further, EIP’s review procedure states:
At your expense, you
must submit complete claims statements, your signed authorization for us to
obtain information, and any other items we may reasonably require in support of
your claim. If you do not provide the documentation within 60 days after we
mail you our request, your claim may be denied.
. . .
You must request in
writing a review of a denial of all or part of your claim within six months
after you receive notice of the denial from the Claims Administrator.
When you request a
review, you may send the Claims Administrator written comments or other items
to support your claim. You may review any non-privileged information that
relates to your request for review.
The Claims
Administrator will review your claim promptly after receipt of your request.
The Claims Administrator will send you a notice of its decision within 60 days
after receipt of your request, or within 120 days if special circumstances
require an extension. The Claims Administrator will state the reasons for its
decision and refer you to the relevant parts of the Plan.
After you receive
the Claims Administrator’s decision, you may request a final review from the
South Carolina Budget and Control Board Office of Insurance Services by
submitting written comments or other items to support your claim within 90 days
after you receive notice. The Office of Insurance Services will send you a
notice of its decision within 30 days after receipt of your request, or within
120 days if special circumstances require an extension.
(R. at 18-9)
(emphasis added). In the case at hand, the record contains sufficient evidence
that EIP adhered to its claims procedure, as related to the instant matter.
Accordingly, EIP provided Appellant with sufficient documentation apprising him
of the specific procedure established by EIP for its claims review process, and
in each communication between Appellant and EIP or The Standard, Appellant was
given notice of the medical documentation, or other evidence, that he was required
to submit in order for The Standard or EIP to make an informed decision
regarding his claim for long term disability benefits. As such, the record in
this matter mandates that EIP’s decision be affirmed.
ORDER
For
the reasons set forth above,
IT
IS HEREBY ORDERED that EIP’s final agency determination upholding the
denial of Mr. McPhail’s claim for long term disability benefits is AFFIRMED.
AND
IT IS SO ORDERED.
______________________________
JOHN D.
GEATHERS
Administrative
Law Judge
May 9, 2007
Columbia, South Carolina
|
