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). Amy D. Martin (“Martin”) 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 January 9, 2008, EIP’s Long Term Disability Appeals Committee (“Appeals
Committee”) informed Martin that her medical condition did not qualify her for
continued disability income benefits under the Plan.
PROCEDURAL
BACKGROUND
Martin
was previously employed as a procurement clerk (Buyer II) by Florence County. On
June 25, 2004, Martin was involved in a motor vehicle accident, which caused
pain in her back, neck, and shoulders. Martin initially received conservative
treatment that ultimately proved to be unsuccessful in alleviating her pain;
for that reason, Martin ceased working for Florence County on February 10, 2005.
On March 9, 2005, Martin underwent an anterior cervical discectomy and fusion performed
by Dr. Willie Edwards. Dr. Edwards reported that, although Martin had normal
motor strength and suffered no complications from the surgery, Martin was still
experiencing some right upper extremity symptoms three months after surgery.
Dr. Edwards then referred Martin to Dr. Danny Nicholls for further evaluation.
Dr. Nicholls confirmed Martin’s right shoulder pain, and on July 19, 2005, Dr. Nicholls
gave Martin an injection for her pain. After the injection, Dr. Nicholls
reported that Martin had full active range of motion in her right shoulder and
full strength. Dr. Nicholls did not list any restrictions or limitations in
his July 19, 2005 report on Martin. Martin returned to Dr. Nicholls on
September 1, 2005, indicating that the injection had relieved her pain only temporarily.
After
Martin filed a claim for LTD benefits, Standard Insurance Company (“Standard”),
the third-party claims administrator for the Plan, initially denied Martin for
LTD benefits. However, Standard later approved Martin for LTD benefits through
July 19, 2005. Standard determined that after July 19, 2005, Martin’s
condition no longer disabled her from performing her “Own Occupation” under the
Plan’s definition and therefore closed Martin’s claim for LTD benefits with
payment through July 19, 2005. Specifically, Standard concluded that
Ms. Martin was seen by
Dr. Nicholls on July 19, 2005. During this exam, Ms. Martin’s x-ray film along
with an MRI were reviewed. Dr. Nichol[l]s injected Ms. Martin’s right
shoulder, noting 100% improvement, and stated that he would like to see her
over the next 6 weeks.
Based on the information
available, there is no documentation to support limitations and restrictions
beyond July 19, 2005. No chart notes or exams were provided beyond that date.
(R. at 00086).
Following
Standard’s decision, Martin requested that Standard further review its decision,
and Martin submitted additional medical information. Standard referred the
documentation to an independent physician consultant who determined that Martin
should avoid repetitive overhead right arm activity. On December 8, 2006,
Standard upheld the closure of Martin’s LTD benefits and forwarded Martin’s
claim to the Administrative Review Unit (“ARU”) for independent review. On February
9, 2007, Standard notified Martin that the ARU affirmed the earlier decision to
close Martin’s claim. Specifically, Standard determined that
Martin is not precluded
from performing occasional overhead reaching with her right shoulder, and []
she can perform the frequent reaching, handing, and fingering demands that are
required during the performance of her sedentary level occupation. . . . [T]he
medical documentation in the claim file does not support that she is precluded
from performing the Material Duties of her Own Occupation as Buyer II on a
full-time basis.
(R. at 00048).
On
March 1, 2007, Martin appealed this decision to EIP. EIP forwarded the
additional information to Standard for a follow-up review of Martin’s claim. On
May 4, 2007, Standard informed Martin that it was upholding its original
decision to close Martin’s claim. Standard then forwarded Martin’s file to EIP
to enable the Appeals Committee to conduct a de novo review of Martin’s claim.
On January 9, 2008, the Appeals Committee determined, based upon Martin’s
medical evidence, the relevant provisions of the Plan, and the medical opinions
of Standard’s physician consultants, that “the facts and circumstances of [Martin’s]
claim do not qualify her for continuing disability income benefits under the
Plan.” (R. at 00026.)
Having exhausted her administrative remedies with
EIP, Martin 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 Martin’s claim for LTD benefits.
ISSUE
Did
EIP err in determining that Martin 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).
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 Martin’s claim file did not support
her claim that she met the “Own Occupation” definition to continue receive
benefits under the Plan.
II. Substantial
Evidence
Martin
asserts that because she continues to experience persistent pain, she is still
disabled from performing her Own Occupation. Martin relies on Dr. Edwards’s
opinion that Martin has “some impingement symptoms in the right shoulder.” (R.
at 00212). Martin also relies on the opinion of a vocational expert, Joel
Leonard, who reviewed Martin’s claim for disability retirement benefits.
Leonard determined that because Martin “is unable to use her right hand in the
performance of gross, repetitive tasks without the onset of pain . . . . Martin
is not presently capable of meeting the specific physical demands of her job.”
(R. at 00225). Martin did not submit any documentation of any treatments
beyond September 1, 2005.
Standard’s
independent physician consultant, Dr. David Waldram, determined that Martin
should not perform repetitive right overhead activity. (R. at 00249). Based
on this determination, Standard referred the claim to a vocational case manager,
Jeff Scharn, who determined that Martin’s occupation required only “incidental”
overhead reaching of a few times each day; Scharn stated that most of the
reaching is below shoulder level. (R. at 00128). A second independent
physician consultant, Dr. Joseph Mandiberg, an orthopedic surgeon, similarly
stated that Martin could not perform frequent overhead reaching, but that “[i]f
she did not have to reach overhead, but rather reach up to chest level with
only occasional overhead lifting, then she could perform the job.” (R. at 00230).
The
court finds that, although there was evidence in the Record to support Martin’s
claim, there was substantial evidence to support EIP’s decision. See Hargrove
v. Titan Textile Co., 360 S.C. 276, 289, 599 S.E.2d 604, 611 (Ct. App.
2004) (holding that 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”); see also Wilson v. State Budget &
Control Bd. Employee Ins. Program, 374 S.C. 300, 305, 648 S.E.2d 310, 313
(Ct. App. 2007) (holding that, although there was evidence supporting both
parties’ arguments, the court “remain[s] cognizant
that as an appellate court, we must affirm an agency’s decision when
substantial evidence supports the decision.”). Here, the record
demonstrates that the Appeals Committee reached its determination after
considering all of Martin’s medical evidence as well the opinions of Standard’s
physician consultants. Furthermore, the Record supports EIP’s determination
that Martin’s Own Occupation does not require frequent overhead reaching.
There is no evidence of any other restrictions or limitations.
CONCLUSION
AND ORDER
The
court concludes that there is sufficient evidence in the record to demonstrate
that EIP’s decision to close Martin’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 Martin’s claim for LTD disability benefits is
affirmed.
IT
IS SO ORDERED.
______________________________________
PAIGE J. GOSSETT
Administrative Law Judge
October 6, 2008
Columbia, South Carolina
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