ORDERS:
ORDER
This
matter is before the Administrative Law Court (“ALC”) in its appellate
jurisdiction pursuant to S.C. Code Ann. § 1-23-600(D) (as amended by 2008 S.C.
Act No. 334) and §
1-11-710(C) (2005). Lavinia White (“White”) appeals the decision of the South
Carolina Budget and Control Board, Employee Insurance Program (“EIP”) closing her
claim for basic long-term disability (“LTD”) benefits under the State of South
Carolina’s Basic Long Term Disability Income Benefit Plan (“Plan”). By letter
dated October 12, 2007, EIP’s Long Term Disability Appeals Committee (“Appeals
Committee”) informed White that her medical conditions did not qualify her for
continued disability income benefits under the terms and conditions of the
Plan.
BACKGROUND
White
was employed as a communications specialist for the Charleston County Detention
Center. Her occupation was considered a sedentary occupation. On February 14,
2004, White was informed that Charleston County could not permanently
accommodate her doctor’s order for a day-shift work restriction and thereafter
terminated White from her position. After filing a claim for LTD benefits, Standard
Insurance Company (“Standard”), the third-party claims administrator for the
Plan, initially approved White for LTD benefits beginning on May 14, 2004 based
in part on Dr. Steven Beeson’s medical
opinion that he did not believe that White “can work in any occupation that
requires significant visual acuity, particularly for fine tasks such as
reading.” (R. at 00672-73.) However, Dr. Beeson also determined that White’s
eye conditions “will probably wax and wane over time, and may well be treatable
conditions.” (Id.) Therefore, Dr. Beeson recommended that White’s
claim be reviewed again in six months.
On
July 2, 2005, upon considering additional medical evidence submitted by White,
Dr. Beeson issued a report stating that “[i]t is difficult to find anything
that would prevent White from working.” (R. at 00513.) Based in part on Dr.
Beeson’s report, Standard determined that White’s condition no longer disabled
her from performing her “Own Occupation” under the Plan’s definition and
therefore closed White’s claim for LTD benefits with payment through July 12,
2005. Specifically, Standard concluded that
there is insufficient medical
documentation to support continued impairment due to visual acuity and/or
restrictions due to hip, back, leg and shoulder pain to preclude [you] from
performing your own occupation. Rather, the medical documentation supports
that you should be capable of performing the material duties of your own
occupation of Police Aide with
reasonable continuity.
(R. at 00504.) Standard
acknowledged that White’s vision would prevent her from working in occupations
that require very fine visual acuity but not in an occupation that
required significant visual effort. Standard determined that White’s job
required frequent near visual acuity, but not very fine visual acuity.
Following
Standard’s decision, White requested that Standard further review its decision
and submitted additional medical information. In January 2006, Dr. Beeson
reviewed the additional medical evidence submitted and again concluded that
White had no limitations on light or sedentary work on a full-time basis. Dr.
Beeson stated that White may have difficulty with occupations that require a
high level of visual acuity, but that there is no evidence that normal visual
requirements would be restricted. (See R. at 00270.) On January 26,
2006, Standard upheld the closure of White’s LTD benefits and forwarded White’s
claim to the Quality Assurance Unit (“QAU”) for independent review. QAU
requested that another independent physician consultant, Dr. Bradley Fancher,
review White’s medical records. Dr. Fancher determined that White was not
prevented from performing sedentary work, but was uncertain how much her visual
impairment affected her ability to perform her job. Dr. Fancher thought it
would be helpful to have the ophthalmologist comment on her ability to read
computer screens and documents of a normal font size. He also noted that White
did not stop working due to a visual impairment and that there was no
indication that White’s eye condition had worsened; rather, he noted that it
may have improved. (See R. at 00255-56.)
Based
in part on Dr. Fancher’s opinion, on March 1, 2006, Standard notified White
that the QAU affirmed the earlier decision to close White’s claim. On May 26,
2006, White appealed this decision to EIP and submitted additional medical
documentation. EIP forwarded the additional information back to Standard for a
follow-up review of White’s claim. Standard requested Dr. Fancher to conduct a
second review and opine as to White’s limitations and restrictions. Upon
follow-up review, Dr. Fancher did not change his opinion. On February 13, 2007,
Standard informed White that the additional medical evidence did not change
Standard’s decision to close White’s claim. White then submitted a statement
from Dr. Frederick H.D. Weidman, III, her treating ophthalmologist. On
February 13, 2007, Standard informed White that the review of this statement
did not change the decision and that EIP would proceed with its review. Standard
then forwarded White’s file to EIP to enable the Appeals Committee to conduct a de novo review of White’s claim. On October 12, 2007, the Appeals
Committee unanimously determined, based on White’s medical evidence, the
relevant provisions of the Plan, and the medical opinions of Standard’s
physician consultants, that “the facts and circumstances of [White’s] claim do
not qualify her for continued disability income benefits under the Plan.” (R.
at 00029.)
Having exhausted her administrative remedies with
EIP, White now appeals EIP’s decision to this court pursuant to S.C. Code Ann.
§ 1-23-600(D) (as amended by 2008 S.C. Act No. 334) and § 1-11-710(C) (2005).
Upon consideration of the record, the briefs, and oral arguments, the court affirms
the decision of EIP to close White’s claim for LTD benefits.
ISSUE
Did
EIP err in determining that White is no longer disabled from performing her own
occupation and therefore not entitled to continued LTD benefits?
STANDARD
OF REVIEW
As set forth above, this
matter is before the ALC in its appellate jurisdiction pursuant to S.C. Code Ann.
§ 1-11-710(C) (2005) and § 1-23-600(D)
(as amended by 2008 S.C. Act No. 334). Accordingly, the Administrative Procedures Act’s standard of review
governs this appeal. See S.C. Code Ann. §§ 1-23-600(E), -380 (as
amended by 2008 S.C. Act No. 334); see also Byerly Hosp. v. S.C. State Health & Human Servs. Fin. Comm’n, 319 S.C. 225, 229, 460 S.E.2d 383, 385 (1995). The standard
used by appellate bodies, including the ALC, to review agency decisions is
provided by S.C. Code Ann. § 1-23-380(5) (as amended by 2008 S.C. Act No. 334). See S.C. Code Ann. § 1-23-600(E) (as amended by 2008 S.C. Act No. 334)
(directing Administrative Law Judges to conduct appellate review in the same
manner prescribed in Section 1-23-380). This section provides:
The
court may not substitute its judgment for the judgment 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 [of the agency] 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 abuse of discretion or clearly
unwarranted exercise of discretion.
S.C. Code Ann. § 1-23-380(5) (as amended by
2008 S.C. Act No. 334).
A decision is supported by “substantial
evidence” when the record as a whole allows reasonable minds to reach the same
conclusion reached by the agency. Bilton v. Best Western Royal Motor
Lodge, 282 S.C. 634, 321 S.E.2d 63 (Ct. App. 1984). Further,
substantial evidence means that a decision will not be set aside simply because
reasonable minds may differ on the judgment. Lark v. Bi-Lo, 276
S.C.130, 276 S.E.2d 304 (1981). Substantial evidence is not a mere
scintilla of evidence, nor the evidence viewed blindly from one side of the
case, but is evidence that, considering the record as a whole, would allow
reasonable minds to reach the conclusion the agency reached in order to justify
its action. Hargrove v. Titan Textile Co., 360 S.C. 276, 289, 599
S.E.2d 604, 611 (Ct. App. 2004). The fact that the record, when considered as
a whole, presents the possibility of drawing two inconsistent conclusions from
the evidence does not prevent the agency’s finding from being supported by
substantial evidence. Id.; Waters v. S.C. Land Res.
Conservation Comm’n, 321 S.C. 219, 467 S.E.2d 913 (1996); Grant v. S.C.
Coastal Council, 319 S.C. 348, 461 S.E.2d 388 (1995). However, §
1-23-380(5) requires the reviewing tribunal to consider not only the amount of
evidence, but also the quality of that evidence; it must be both “reliable” and
“probative,” as well as “substantial.” See S.C. Code Ann. § 1-23-380(5)
(as amended by 2008 S.C. Act No. 334).
An
abuse of discretion occurs when a decision 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 judge 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. Ex Parte Capital U-Drive-It, Inc., 369
S.C. 1, 5, 630 S.E.2d 464, 467 (2006). A decision is arbitrary or capricious
when no rational basis for the conclusion exists, when it is based on one’s
will and not upon any course of reasoning and exercise of judgment. Converse Power Corp. v. S.C. Dep’t of Health & Envtl. Control, 350 S.C. 39, 564 S.E.2d 341 (Ct. App. 2002); Deese v. S.C.
State Bd. of Dentistry, 286 S.C. 182, 184-85, 332 S.E.2d 539, 541 (Ct. App. 1985). A decision may be arbitrary or
capricious when it is made at one’s pleasure without adequate determining
principles, or is governed by no fixed rules or principles. Deese,
286 S.C. at 184-85, 332 S.E.2d at 341. Non-uniform,
inconsistent, or selective application of authority can indicate arbitrariness. See Mungo v. Smith, 289
S.C. 560, 571, 347 S.E.2d 514, 521 (Ct. App. 1986).
It
is helpful to note that the standard of review in this case is analogous to the
standard used in cases arising under the federal Employee Retirement Income
Security Act (“ERISA”). See, e.g., Bynum v. Cigna Healthcare
of N.C., Inc., 287 F.3d 305 (4th Cir. 2002) (holding that an insurer’s
decision could be overturned if “a coverage decision is unreasonable” and the
insurer “abused its discretion”); see also Booth v. Wal-Mart
Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335, 342 (4th Cir.
2002); Feder v. Paul Revere Life Ins. Co., 228 F.3d 518, 522 (4th Cir.
2000). Accordingly, although not binding, ERISA case law provides guidance in
analyzing the issue before the court.
DISCUSSION
I. Applicable Plan
Language
The
Plan provides LTD benefits for twenty-four months, after a ninety-day waiting
period, when it is found that the employee is disabled and may not perform the
material duties of her own occupation with reasonable continuity. The Plan
further provides:
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.
(R. at 00009.) The
Plan defines “Material Duties” as “the essential task, functions and
operations, and the skills, abilities, knowledge, training and experience,
generally required by employers from those engaged in a particular occupation.”
(R. at 00010.) Based on the evidence presented, the Appeals Committee found
that the documentation in White’s claim file did not support her claim that she
met the “Own Occupation” definition to continue receive benefits under the
Plan.
II. Evidence
White
asserts that EIP’s decision was “clearly erroneous in view of the reliable,
probative and substantial evidence on the whole record, was arbitrary and
capricious, and was an abuse of discretion.” Specifically, White contends that
(1) EIP abused its discretion in relying on the opinions of the independent
medical consultants over White’s treating physicians, and (2) EIP abused its
discretion in failing to consider the totality of White’s medical conditions.
1. Treating
Physician
Under
the “treating physician rule,” the opinion of the physician treating the
patient is entitled to greater deference because of that physician’s firsthand
knowledge of the patient’s specific injury; in other words, a court can afford
special weight to the opinion of a claimant’s treating physician. See, e.g., Mitchell v. Schweiker, 699 F.2d 185, 187 (4th Cir. 1983). Whether the
treating physician rule should be applied can depend on the context of the case. For example, the treating physician rule is applied in determining
whether a claimant is entitled to federal social security disability benefits. See 20 C.F.R. § 404.1527(d) (“Generally, we give more weight to opinions
from your treating sources, since these sources are likely to be the medical
professionals most able to provide a detailed, longitudinal picture of your
medical impairment(s) and may bring a unique perspective to the medical
evidence that cannot be obtained from the objective medical findings alone or
from reports of individual examinations, such as consultative examinations or
brief hospitalizations.”). By
contrast, the United States Supreme Court has held that the
treating physician rule does not apply in ERISA cases. Black &
Decker Disability Plan v. Nord, 538 U.S. 822,
834 (2003) (“[C]ourts have no warrant to require administrators
automatically to accord special weight to the opinions of a claimant’s
physician; nor may courts impose on plan administrators a discrete burden of
explanation when they credit reliable evidence that conflicts with a
treating physician’s evaluation.”)
(emphasis added). The Nord Court further explained:
The
treating physician rule has not attracted universal adherence outside the
Social Security context. Some courts have approved a rule similar to the
Social Security Commissioner’s for disability determinations under the
Longshore and Harbor Workers’ Compensation Act, and the Secretary of Labor has
adopted a version of the rule for benefit determinations under the Black Lung
Benefits Act. One Court of Appeals, however, has rejected a treating physician
rule for the assessment of claims of entitlement to veterans’ benefits for
service-connected disabilities, and another has rejected such a rule for
disability determinations under the Railroad Retirement Act of 1974.
Furthermore, there appears to be no uniform practice regarding application of a
treating physician rule under state workers’ compensation statutes.
Nord,
538 U.S. at 830 n.3 (citations omitted).
Although
South Carolina has not expressly addressed whether the treating physician rule
should be applied in EIP cases, case law suggests that it may be appropriate in
some cases to accord greater weight to opinions of treating physicians. In James
v. S.C. Employee Insurance Program, 371
S.C. 637, 640 S.E.2d 474 (Ct. App. 2006), the South Carolina
Court of Appeals upheld the circuit court’s
determination of coverage for a medical device known as a Dynamic Orthotic
Cranioplasty (“DOC”) Band to correct a claimant’s child’s conditions of
plagiocephaly (assymetrical head shape) and torticollis (twisted neck
syndrome). In that case, EIP based its denial upon the Plan exclusionary
language, finding that the DOC Band treatment was for cosmetic purposes and not
medically necessary. The Court of Appeals found that EIP erred in denying
coverage, emphasizing the fact that “the
only physician who personally examined and treated the [patient] stated
unequivocally that the treatment was medically necessary.” James, 371 S.C. at 646, 640 S.E.2d at 479.
More
recently, by contrast, the Court of Appeals implicitly gave no particular
deference to the treating physicians of a claimant seeking long-term disability
benefits in Wilson v. State Budget and Control Board Employee Insurance Program, 374 S.C. 300, 648 S.E.2d 310 (Ct. App. 2007). In that case,
Wilson applied for long-term disability benefits from EIP based upon injuries
to her back and knee. Wilson claimed she was unable to continue performing her
job duties, which required “light to sedentary work.” Wilson, 374 S.C. at 305, 648 S.E.2d at 313. The record in Wilson included opinions from six physicians: three treating physicians, including a
family doctor, a radiologist, and a neurologist; another neurologist who
examined Wilson’s records upon referral from her treating family doctor; an
internist who provided an opinion for EIP’s third-party insurer; and finally,
an independent surgeon who examined Wilson during the pendency of her appeal to
the circuit court. This examination was conducted at the court’s suggestion
and with the agreement of the parties.
The evidence in the record as to whether Wilson was disabled
clearly diverged. The tests performed by two of her treating physicians
revealed “no abnormalities.” Wilson, 374 S.C. at 305, 648 S.E.2d at 313. Although the opinions of the
third-party insurer’s expert and that of Wilson’s treating neurologist flatly
contradicted each other, the Court of Appeals noted that “both parties
consented to allowing Dr. Johnson to perform an independent medical examination
of Wilson for the circuit court’s benefit. Dr. Johnson’s opinion reaffirmed
the opinion of [EIP] that Wilson was capable of performing light work.” Id. at 305, 648 S.E.2d at 313. Accordingly, the Court of Appeals found
that EIP’s determination was supported by substantial evidence.
Reading Wilson and James together, it
is apparent that South Carolina has not adopted a rule of per se deference to the opinions of treating physicians; rather, the amount of
deference that should be given to a treating physician’s opinion depends on the
evidence and issue presented in a particular case. Accordingly, whether to
accord more weight to the opinions of treating physicians than to that
of some other medical expert must be determined on a case-by-case basis. On
appeal, the ALC must review EIP’s determination regarding the medical experts
within the parameters of § 1-23-380(5) requiring the evidence, viewed in light
of the record as a whole, to be reliable, probative, and substantial.
White
contends that the opinion of her treating ophthalmologist, Dr. Weidman,
warrants a determination that she is disabled from any occupation. Dr. Weidman’s statement opines that
White is disabled based on various ocular conditions including sarcoidosis,
diabetic macular edema, uveitis, and iritis. His opinion is based on treating
White from April 2006 through January 2007. White asserts that it was error
for EIP to rely on the opinions of Dr. Beeson and Dr. Fancher, who specialize
in internal medicine, rather than White’s treating ophthalmologist, Dr.
Weidman. In response, EIP argues that Dr. Weidman’s opinion fails to indicate
whether White was disabled as of July 2005 when EIP closed White’s claim. EIP
further points out that it was Dr. Beeson, not one of White’s treating
physicians, who initially opined that White’s vision would prevent her from
working.
The
Record on Appeal contains numerous opinions from Dr. Beeson and Dr. Fancher as
well as from White’s treating physicians. In fact, White submitted medical
documentation from numerous physicians who treated White at various points from
2002 through 2007. During that time, White received medical care from four
different ophthalmologists regarding her vision, four physicians regarding her
pain conditions, and three physicians regarding her sleep disorders—one of
which is White’s family physician who treats her diabetes. Of those physicians
only one, Dr. Weidman, expressly stated that White was disabled from performing
any occupation. However, he did not begin treating White until 2006. In 2004,
Dr. Peggy S. Lindsey limited White’s employment by indicating that White cannot
work in an occupation that requires fine visual acuity, but that she
anticipated White’ condition to improve. Based on that statement, Standard
granted White LTD benefits subject to a review in six months. In 2005, White
sought treatment from Dr. Pamela S. Chavis who stated that she could not
comment on White’s ability to return to work, but her report showed improved
visual acuity for White. Dr. Beeson considered her report, as well as reports
from other doctors, in determining that White could return to work.
Under
the facts of this case, the court finds that EIP did not err in accepting the
opinions of the non-examining physicians over those of Dr. Weidman.
Considering the fact that Dr. Weidman did not examine White until six months
after EIP determined that White no longer qualified for LTD benefits, his
opinion is not entitled to any additional deference. Furthermore, the opinions
from other physicians upon which White relies did not unequivocally state
whether or not White was able to work. Therefore, the court finds that
reversal of EIP’s decision is not warranted on this ground.
2. Totality
of White’s Conditions
White
also claims that she entitled to LTD disability benefits based on numerous
medical conditions that considered independently or as a whole render her
disabled. On appeal, she contends that EIP failed to consider the totality of
her conditions and that EIP’s decision was “illogical and unreasonable.” With
regard to White’s pain conditions and sleep disorder, most of White’s
physicians did not comment on whether White was capable of working and one
expressly indicated that, from a rheumatology standpoint, White was capable of
performing her occupation. (See R. at 489.)
There
is no evidence in the record that White’s conditions are expected to worsen.
In fact, there is evidence that White’s eye conditions may improve.
Additionally, the record demonstrates that the Appeals Committee reached its
determination after considering all of White’s medical evidence as well the
opinions of Standard’s physician consultants. Furthermore, the physician
consultants considered all of White’s medical conditions in making their
determinations. Accordingly, the court determines that EIP did not fail to
consider the totality of White’s conditions.
CONCLUSION
AND ORDER
The
court concludes that there is sufficient evidence in the record to demonstrate
that EIP’s decision to close White’s LTD claim was reasonable. Furthermore,
there is no evidence that EIP’s decision was arbitrary and capricious or an
abuse of discretion. It is therefore
ORDERED that EIP’s decision to close White’s claim for LTD disability benefits is
affirmed.
IT
IS SO ORDERED.
______________________________________
PAIGE J. GOSSETT
Administrative Law Judge
September 22, 2008
Columbia, South Carolina
James arose prior the enactment of 2006 S.C.
Act No. 387, which changed the appeals process for Employee Insurance Program
determinations, providing for appellate review by the ALC rather than the
circuit court.
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