ORDERS:
ORDER
STATEMENT
OF THE CASE
The
above-captioned matter was heard by this Court on appeal pursuant to S.C. Code
Ann. § 1-11-710(C) (2008). In this matter, Appellant Brenda Hinson-Austin (“Hinson-Austin”)
seeks review of a decision by Respondent South Carolina Budget and Control
Board, Employee Insurance Program (“EIP”) denying her claim for long-term
disability (“LTD”) benefits under the State of South Carolina Basic Long Term
Disability Income Benefit Plan (the “Plan”). Specifically, by letter dated December
19, 2006, EIP’s Long Term Disability Appeals Committee informed Hinson-Austin
that her medical conditions did not qualify for LTD benefits under the terms
and conditions of the Plan.
In
this appeal, Hinson-Austin challenges EIP’s decision by contending that she is
unable to perform her occupation as an elementary school teacher.
Hinson-Austin argues that the evidence in the Record on Appeal demonstrates
that her depression and arthritic pain prevent her from performing her
occupation. In support of this argument, Hinson-Austin asserts that EIP’s
decision was arbitrary and capricious because EIP failed to consider the
effects of the combination of her mental and physical conditions.
EIP
argues that the substantial evidence in the Record on Appeal, including the
records of Hinson-Austin’s treating physicians and the independent medical opinions
of Dr. Beeson and Dr. Gwinnell demonstrate that Hinson-Austin’s conditions,
alone or in combination, do not prevent her from performing the material duties
of her occupation as an elementary school teacher.
Based
upon the Record on Appeal, the parties’ briefs and oral arguments and the
applicable law, I affirm EIP’s decision to deny Hinson-Austin’s claim for LTD
benefits as there is substantial evidence in the record to support EIP’s
determination that Hinson-Austin is not disabled from performing her
occupation.
PROCEDURAL
BACKGROUND AND FACTUAL HISTORY
I. Definition
of Disability
The Plan contains the
following relevant provisions:
A. Own
Occupation Definition of Disability
During the Benefit Waiting Period
and the Own Occupation Period you are required to be Disabled only from your
Own Occupation.
You are Disabled from your Own
Occupation if, as a result of Physical Disease, Injury, Pregnancy or Mental
Disorder, you are unable to perform with reasonable continuity the Material
Duties of your Own Occupation.
Own Occupation means any
employment, business, trade, profession, calling or vocation that involves
Material Duties of the same general character as your regular and ordinary
employment with the Employer. Your Own Occupation is not limited to your job
with your Employer.
Thus,
to qualify for LTD benefits under the Plan, Hinson-Austin’s condition had to
satisfy the Own Occupation Definition of Disability for the Plan’s entire
90-day Benefit Waiting Period and beyond.
II. Hinson-Austin’s
Medical Records
A. Dr.
Oehme
Dr. Oehme, Hinson-Austin’s family
doctor, provided general medical care to Hinson-Austin prior to and during the
relevant time period. Dr. Oehme’s October 13, 2004 chart note states that
Hinson-Austin had no lower back pain and was mentally alert. Dr. Oehme’s
December 7, 2004 chart note had a completely different tone and noted that
Hinson-Austin “finds it increasingly difficult to do things. Is getting more
and more depressed.” He then stated he would “[s]ee her back in three months.
I am going to write a letter. Need to stabilize her medications. Follow-up
with Dr. Paulson.”
On December 13, 2004, Dr. Oehme
wrote a To Whom It May Concern letter in which he stated Hinson-Austin needed
to take a year off work to “stabilize her medical conditions as well as her
medications.” Dr. Oehme did not explain what specific limitations or
restrictions Hinson-Austin’s medical conditions were causing nor did he specify
what problems her medications were causing. He also gave no explanation for
the one year period he stated Hinson-Austin needed to adjust to stabilize her
condition. Dr. Oehme did not see Hinson-Austin again until April 27, 2005.
The chart notes in the Record on
Appeal indicate that Dr. Oehme continued to treat Hinson-Austin periodically
through February 8, 2006. However, his records do not provide any description
of limitations or restrictions that would have prevented Hinson-Austin from
working in her occupation.
B. Dr. Wilson
Dr. Wilson, a rheumatologist,
treated Hinson-Austin for osteoporosis, back pain, and low-grade arthritis.
From July 23, 2002 through March 29, 2005, Dr. Wilson saw Hinson-Austin at
least 10 times. During that time, Dr. Wilson noted that Hinson-Austin’s
arthritis was “grossly stable” that her osteoporosis was stable; and that her
physical condition was stable with medication.
On December 28, 2004, Dr. Wilson
stated that he did not believe the conditions he was treating Hinson-Austin for
were disabling:
[I] would agree that the
arthritis does not seem to be bad enough, certainly not by itself, to apply for
disability. She is basing this upon other features . ... Recheck in 3-4
months.
C. Dr.
Mandell
Dr. Mandell, a
neurologist, also treated Hinson-Austin. Dr. Mandell’s records demonstrate
that he saw Hinson-Austin every 5-6 months. On November 22, 2004, Dr. Mandell
observed that Hinson-Austin had not been doing well over the last four weeks. This
downturn in Hinson-Austin’s condition appeared to be directly related to
Hinson-Austin no longer being able to take Vioxx because it was removed from
the market. Dr. Mandell advised Hinson-Austin to see a psychiatrist and to
continue seeing Dr. Wells, a psychologist. Dr. Mandell prescribed Wellbutrin
and noted that Wellbutrin had helped Hinson-Austin in the past.
On February 25, 2005,
Dr. Mandell noted Hinson-Austin “is doing better now that she has stopped
work. There is a great degree of stress in her life which really contributes
to her symptomatology. Wellbutrin has once again proven itself to be a
helpful medication for her. I will see her again in 3-6 months (emphasis
added).” Notably, with the exception of a non-contemporaneous conclusory
affidavit, Dr. Mandell never opined that Hinson-Austin was unable to perform
her occupation.
D. Dr.
Paulson
Hinson-Austin began
seeing Dr. Paulson, a psychiatrist, on November 30, 2004. Dr. Paulson noted
that Hinson-Austin “felt reasonably well until Vioxx went off [the] market.” After
going off Vioxx, Hinson-Austin reported increased pain, decreased mobility,
decreased energy and concentration, and decreased ability to perform her teaching
duties. Dr. Paulson also noted Hinson-Austin has had episodic depression most
of her adult life, usually triggered by stress. Dr. Paulson agreed with Dr.
Mandell and prescribed Wellbutrin.
On May 3, 2005, Dr.
Paulson noted an episode of increased depressive symptoms due to stressors, but
concluded that the “[c]urrent symptoms should resolve without need for
medication adjustment.” On August 3, 2005, Dr. Paulson noted that
Hinson-Austin had been stable since her last visit and that she had been able
to reduce her medications. He also observed that Hinson-Austin “has had no
significant side effects with her current medication regimen.”
Hinson-Austin’s
mental condition was stable from September through March 2006. Dr. Paulson has
offered no opinion regarding whether Hinson-Austin can perform the duties of
her Own Occupation and has not set forth any limitations or restrictions that
would support a finding that Hinson-Austin was unable to perform her occupation
after February 25, 2005.
E. Dr. Wells
Dr. Wells, a
psychologist, provided counseling to Hinson-Austin. Dr. Wells’ records date
back to September 2001 and demonstrate that Hinson-Austin has a long history of
episodic depression for most of her adult life. Dr. Wells’ counseling notes do
not support the assertion that Hinson-Austin was unable to work after February
25, 2005.
On October 26, 2004,
Dr. Wells noted that Hinson-Austin was “now much better able to take care of
herself and prioritize her time. She is certainly more self-confident.” Dr.
Wells noted a GAF score of 65.
Hinson-Austin next
saw Dr. Wells on November 10, 2004. Dr. Wells’ notes record a common theme of Hinson-Austin’s
wanting to move away from her husband and quit working. During the time Dr.
Wells treated Hinson-Austin, she consistently complained about her husband’s
behavior and treatment of her, about being attracted to a man other than her
husband, and about her desire for a divorce. During the November 10 session,
Dr. Wells noted as follows:
She has decided that she wants to
move to Pensacola, Florida within one year. She has family there and needs the
resilience of the family provides. She also feels much more comfortable near
the water. She recognizes the problems she is beginning to have with her arthritic
condition. She is trying to plan for her future. She wants to be sending her
writings to a publisher in one year and expects to have a publisher in two
years.
On December 17, 2004,
Dr. Wells noted that Hinson-Austin appeared “extremely tired and lethargic
today,” and that she and her husband were selling their house due to financial
difficulties. Dr. Wells recorded a GAF score of 55.
On January 31, 2005,
Dr. Wells noted Hinson-Austin “has gained insight into her behavior and has
gained her power (inner) from the recent group she has been attending.” Dr.
Wells suggested that she “consider getting a Master’s Degree.” . Such a
suggestion certainly does not reflect a concern that Hinson-Austin would
struggle with a stressful and difficult environment.
On February 22, 2005,
Hinson-Austin reported that she had been assisting her daughter in-law with
getting custody of a child. Dr. Wells reported no significant symptoms or
limitations during this visit. Dr. Wells’ notes continue through June 3,
2005. The post February notes reflect issues such as Hinson-Austin’s marital
problems and financial issues, but do not contain any limitations or
restrictions regarding Hinson-Austin’s ability to work. On April 25, 2005, Dr.
Wells noted a GAF score of 65, the same score Hinson-Austin had in October 2004
before she ceased working.
Dr. Wells also completed
a psychiatric report in support of Hinson-Austin’s LTD claim. The report,
dated March 16, 2005, states that Hinson-Austin is not working due to stress.
In the report, Dr. Wells concluded that Hinson-Austin was moderately impaired
and that he was “unable to say” whether she was “capable of working for the
current employer.” Dr. Wells further stated that he expected Hinson-Austin’s
condition to improve.
. Dr. Wells also signed
an affidavit dated May 5, 2006, which was submitted to support Hinson-Austin’s
claim. Dr. Wells’ affidavit provided no new information, but rather briefly
summarized Hinson-Austin’s subjective complaints and concluded that
Hinson-Austin “is and has been completely and totally disabled consistent with
the [Plan’s] definition of disability.” This conclusion is completely
inconsistent with Dr. Wells’ contemporaneous statement in March 2005 that he
was “unable to say” whether Hinson-Austin was unable to perform her own
occupation. These inconsistent statements by Dr. Wells certainly call into
question the accuracy of his affidavit, and EIP did not err by giving little
weight to the affidavit.
III. Dr.
Beeson and Dr. Gwinnell
As part of its review of Hinson-Austin’s
claim for benefits, Standard Insurance Company, the third-party claims
administrator for the Plan, obtained independent medical opinions from two
board-certified physicians, Dr. Beeson, board-certified in internal medicine,
and Dr. Gwinnell, board-certified in psychiatry. Specifically, on several
occasions, Standard requested that Dr. Beeson and Dr. Gwinnell review all of Hinson-Austin’s
medical records, which were submitted at various times, and opine as to whether
her conditions precluded her from working in her occupation as an elementary
school teacher.
In her initial opinion, Dr.
Gwinnell noted that Hinson-Austin had experienced “a substantial deterioration
in terms of depression subsequent to stopping Vioxx, which she had been taking
for arthritis.” However, Dr. Gwinnell also noted Hinson-Austin’s improvement
with Wellbutrin and an episode of depression in mid-April. Dr. Gwinnell
summarized her review of the medical records as follows:
The presentation to all of her
physicians was quite consistent in November and December, that she was
extremely depressed, with marked decrease in energy, hopelessness, a sense of
being unable to continue. There was some passive suicidal ideation.
However, by February 25, 2005,
she appears improved. Dr. Mandell notes improvement and Dr. Wells notes
improvement. Although Ms. Hinson-Austin continues to complain of tiredness,
she does not otherwise appear to have significant symptoms.
On April 19, 2005, she has another
period of depression in response to a situational stressor, but this appears to
have resolved in terms of the more significant symptoms by the time she returns
to see her psychologist. My impression is that the episode was brief in terms
of worsening symptoms.
Dr. Gwinnell
concluded that Hinson-Austin’s psychiatric condition would have prevented her
from performing her occupation of elementary school teacher from November 29,
2004 through February 25, 2005. She also concluded that Hinson-Austin’s condition did not preclude her from
performing her occupation after February 25, 2005, and that the medical records
did not demonstrate that the April episode of depression lasted beyond “one day
to four weeks.” Following his initial review of Hinson-Austin’s medical
records, Dr. Beeson concluded as follows:
From the point of view of the
patient’s asthma and allergic rhinitis, I can find no restrictions or
limitations whatsoever. It is clear from the notes that from the point of view
of her osteoarthritis and low-grade inflammatory arthritis that this would not
be a disabling condition. I believe she could continue to work in a sedentary
or light work occupation.
After Standard
initially denied Hinson-Austin’s claim, Standard’s Administrative Review Unit
conducted an independent review of her claim. During this independent review
process, Hinson-Austin’s counsel submitted additional medical records and the
affidavits of Dr. Mandell, Dr. Wells, and Hinson-Austin.
Dr. Beeson reviewed
the additional documents and opined that the “new information in no way changes
my previous opinion. From a physical point of view, I can find no evidence
that this patient could not continue to work in a sedentary or light work
occupation . . .. This is not the picture of a severe, disabling arthritis.”
After additional
documents were submitted by Hinson-Austin’s counsel, Dr. Beeson provided a
third report in which he concluded: “I continue to find a lack of evidence in
the medical record that would indicate this patient could not continue to work
in a sedentary or light work occupation.”
Dr. Gwinnell also provided
an additional report and summarized her review of all of Hinson-Austin’s medical
records and her opinion as follows:
[N]otes from Dr. Paulson do tend
to support that she is psychiatrically stable, and though she has ongoing
complaints, she has not acutely deteriorated. Since Ms. Hinson-Austin has a
very long history of the various diagnoses she carries psychiatrically, and yet
has for the most part been able to continue working, the fact of ongoing
residual symptoms does not in and of itself support psychiatric limitations and
restrictions.
Therefore, though this newly
acquired information on the one hand suggests that Ms. Hinson-Austin has been
continuously impaired since 2004, Dr. Wells does not submit concurrently
maintained progress notes. Rather, his [affidavit] describes Ms. Hinson-Austin
without specifically identifying when exactly she had those specific complaints
and fulfilled those criteria. Indeed, his own progress notes document the
presence of very similar complaints for many years during which Ms. Austin was
apparently successfully working.
In the absence of concurrently
maintained progress notes from Dr. Wells showing otherwise, and in the presence
of notes from Dr. Paulson showing that Ms. Hinson-Austin had, in fact, been
psychiatrically stable for long periods of time during her time off work, I am
not finding the [affidavit] from Dr. Wells particularly useful in terms of
supporting Ms. Hinson-Austin’s psychiatric limitations and restrictions. In
fact, this new information does not change my opinion from my previous file
review.
IV. EIP’s Decision to
Deny Hinson-Austin’s Claim
After Standard
affirmed the denial of Hinson-Austin’s claim, the EIP Long Term Disability
Appeals Committee met on September 27, 2006 to consider Hinson-Austin’s
appeal. After its initial review of the administrative record, the Committee
asked Dr. Gwinnell to clarify whether she believed Hinson-Austin’s medical
records supported a finding of disability from February 25, 2005 through April
2005 due to the episode of increased depression symptoms Hinson-Austin
experienced in April 2005.
In response, Dr. Gwinnell opined
that the progress notes did not support that Hinson-Austin experienced
significant depression continuously from February through April. Dr. Gwinnell
observed that post-April “progress notes supported long periods of psychiatric
stability” and concluded that “the documentation does not support after
February 25, 2005, that she has ongoing impairment.”
The Committee met again on
November 17, 2006 to consider Hinson-Austin’s appeal. HI 1. The Committee’s
decision letter summarizes the significant medical records in the
administrative record, including those of Dr. Wells, Dr. Mandell, Dr. Paulson,
Dr. Oehme, and Dr. Wilson, and the opinions of Dr. Gwinnell and Dr. Beeson.
The Committee determined
Hinson-Austin’s condition may have prevented her from performing her Own
Occupation at the time she stopped working on November 29, 2004, but that “the
January and February 2005 medical information from Dr. Wells and Dr. Mandell
documented that [Hinson-Austin’s] symptoms improved while taking Wellbutrin and
attending psychotherapy.” HI 6. The Committee concluded “that by February 25,
2005, her psychiatric conditions were not sufficiently severe to preclude her
from performing her Own Occupation throughout and beyond the 90-day Benefit
Waiting Period.”
The Committee also
credited and agreed with the opinion of Dr. Gwinnell that Hinson-Austin “had
been psychiatrically stable . . . since ceasing work.” Further, “the Committee
found that [Hinson-Austin’s] medical records did not support physical
conditions that would result in limitations that would preclude her performance
of her Own Occupation as a school teacher” after February 25, 2005. Based upon
these conclusions, EIP denied Hinson-Austin’s claim, finding that her condition
did not satisfy the Plan’s Definition of Disability.
STANDARD OF REVIEW
Pursuant to S.C. Code Ann. §
1-11-710(C) (2008), this Court’s appellate review of EIP’s final decision is
governed by the standards provided in S.C. Code Ann. § 1-23-380 (2008).
Section 1-23-380(A)(5) provides as follows:
The court may not substitute its
judgment for that of the agency as to the weight of the evidence on questions
of fact. The court may affirm the decision of the agency or remand the case
for further proceedings. The 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 agency;
(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 an abuse of discretion or clearly unwarranted
exercise of discretion.
Under Section
1-23-380, “substantial evidence” is the standard for judicial review of agency
decisions. Hendley v. S.C. State Budget & Control Bd., 333 S.C.
455, 510 S.E.2d 421 (1999). “Substantial evidence is not a mere scintilla of
evidence, but evidence which, considering the record as a whole, would allow
reasonable minds to reach the conclusion the agency reached.” Tiller v. National Health Care Center, 334 S.C. 333, 338, 513 S.E.2d 843, 845 (1999). Under the
substantial evidence rule, a final agency decision must be upheld unless it was
clearly erroneous in view of the substantial evidence in the record. See Central Transp., Inc. v. S.C. Public Service Comm'n, 289 S.C. 267, 346
S.E.2d 25 (1986) (reversing the Circuit Court when it exceeded the scope of
review and substituted its own judicial discretion for that of the Commission).
DISCUSSION
I. Substantial
Evidence Supports EIP’s Decision to Deny Hinson-Austin’s Claim for LTD Benefits.
The
issue before the Court is whether substantial evidence in the Record on Appeal
supports EIP’s decision. As set forth in the Plan, to qualify for benefits,
the objective medical information submitted by Hinson-Austin must demonstrate
that she was unable to perform with reasonable continuity the material duties
of her occupation throughout and beyond the 90-day Benefit Waiting Period. If
a reasonable mind can reach a conclusion that Hinson-Austin’s condition does
not satisfy the Plan’s Definition of Disability, then the Court must uphold EIP’s
decision. Although Hinson-Austin received treatment for depression and pain
and fatigue related to arthritis, the medical records and opinions of her
treating physicians and the opinions of Dr. Beeson and Dr. Gwinnell clearly
allow a reasonable mind to conclude that her conditions, individually or as a
whole, did not cause her to be unable to perform the material duties of her
occupation.
At
oral argument, Hinson-Austin asserted that EIP failed to consider the effect of
the combination of her mental and physical conditions. However, Hinson-Austin
could not identify any medical record in the Record on Appeal that supports her
underlying assertion that her physical condition and mental condition, in
combination, cause her to be unable to perform her occupation. Moreover none
of Hinson-Austin’s medical records offer any evidence that the combination of
her physical and mental condition caused impairment. Even further, the records
of the physicians who treated Hinson-Austin’s physical ailments expressly state
that her physical condition provides no basis for disability. Thus, there is
no support in the Record on Appeal for Hinson-Austin’s assertions, and her
argument is without merit.
On
the other hand, the evidence in the Record on Appeal provides substantial
evidence to support EIP’s decision. Although Hinson-Austin had an episode of
depression in late 2004 when she stopped taking Vioxx, the records of Dr.
Mandell and Dr. Paulson demonstrate that her condition improved once she began
taking Wellbutrin.
The
evidence in Dr. Wells’ notes also supports EIP’s decision. With the exception
of the November 29, 2004 through February 25, 2005 timeframe, Hinson-Austin’s
GAF scores were consistently in the 60-65 range, which indicates only mild
symptoms. And, with the exception of a conclusory affidavit, Dr. Wells never
opined that Hinson-Austin’s condition was severe or disabling. To the
contrary, during the relevant timeframe, he recommended that Hinson-Austin
consider pursuing a master’ degree, an undertaking wholly inconsistent with
attempting to minimize stress.
In
addition, the opinions of Dr. Gwinnell and Dr. Beeson support EIP’s decision.
Dr. Gwinnell opined that Hinson-Austin improved with Wellbutrin and was able to
return to work by February 25, 2005. More specifically, Dr. Gwinnell concluded
that Hinson-Austin’s long history of working through episodic depression
demonstrated that “ongoing residual symptoms [do] not in and of [themselves]
support psychiatric limitations and restrictions.” Dr. Beeson concluded that
Hinson-Austin’s osteoarthritis and low-grade arthritis would not prevent her
from performing the physical requirements of her own occupation.
Because
the medical records and opinions of Hinson-Austin’s treating physicians and Dr.
Gwinnell and Dr. Beeson provide significant evidence to support EIP’s decision,
the Court finds that EIP did not abuse its discretion in denying
Hinson-Austin’s LTD claim.
ORDER
For the reasons set
forth above,
IT IS HEREBY
ORDERED that EIP’s final agency determination denying Hinson-Austin’s claim
for LTD benefits is affirmed.
AND IT IS SO
ORDERED.
__________________________
Carolyn C. Matthews
Administrative
Law Judge
June 12, 2008
Columbia, South Carolina
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