ORDERS:
ORDER
STATEMENT
OF THE CASE
The
above-captioned matter is before this Court on an administrative appeal
pursuant to S.C. Code Ann. § 1-11-710(C) (2008) and S.C. Code Ann. §1-23-600(D)
(2008). Appellant Claude Thomas (Thomas) seeks review of a decision by
Respondent South Carolina Budget and Control Board, Employee Insurance Program
(EIP) denying his claim for long-term disability (LTD) benefits under the State
of South Carolina Basic Long Term Disability Income Benefit Plan (Plan).
Specifically, by letter dated June 11, 2007, EIP’s Long Term Disability Appeals
Committee informed Thomas that his medical conditions did not qualify for LTD
benefits under the terms and conditions of the Plan.
STANDARD
OF REVIEW
As set forth above,
this case is before the Court as an appeal from a Final Order of EIP. The Plan
provides that EIP has “full and exclusive authority to control and manage the
Plan, to administer claims, and to interpret the Plan and resolve all questions
arising in the administration, interpretation and application of the Plan. Our
authority includes . . . the right to determine . . . entitlement to
benefits.” The Plan further provides: “Any decision we make in the exercise
of our authority is conclusive and binding, subject only to appellate judicial
review consistent with the standards provided in Section 1-23-380, Code of Laws
of South Carolina.”
In addition, the
enabling legislation for the Plan provides as follows:
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 [State Budget and Control Board], which shall
constitute the exclusive remedy for these claims, subject only to judicial
review consistent with the standards provided in Section 1-23-380.
S.C. Code Ann. § 1-11-710(C)
(2008).
Therefore, the Administrativ e Law Court’s review of this case is in an appellate capacity under the
standards of S.C. Code Ann. §1-23-380 (as amended by 2008 S.C. Act No. 334),
rather than as an independent finder of fact. Specifically, Section 1-23-380(5)
sets forth:
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).
The well settled case law in this state has also interpreted the substantial
evidence rule to mean 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). 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. Waters v. S.C. Land. Res. Conservation Comm’n,
321 S.C. 219, 467 S.E.2d 913 (1996).
When
applying the substantial evidence rule, the factual findings of the
administrative agency are presumed to be correct. Rodney v. Michelin Tire
Co., 320 S.C. 515, 466 S.E.2d 357 (1996). Furthermore, the reviewing court
is prohibited from substituting its judgment for that of the agency as to the
weight of the evidence on questions of fact. Grant v. S.C. Coastal Council,
319 S.C 348, 461 S.E.2d 388 (1995). Finally, the party challenging an agency
action has the burden of proving convincingly that the agency’s decision is
unsupported by substantial evidence. Waters, 467 S.E.2d at 913.
BACKGROUND
Procedural
Background
Thomas was formerly
employed by Greenwood County as a Deputy Director of Planning. As an employee
of the State of South Carolina, he participated in the Plan. Thomas stopped
working on December 15, 2005 and claimed total disability due to chronic renal
failure, coronary artery disease, peripheral neuropathy, diabetes and
hypertension. Notably, Thomas’ application for benefits did not mention any
diagnosis or symptoms related to a possible mental disorder. After Thomas
submitted his LTD claim, Standard Insurance Company (Standard), the third-party
claims administrator for the Plan, considered his claim.
Based on its review
of all the available medical information, Standard denied Thomas’ claim on
April 4, 2006. Thomas requested a review of Standard’s decision. After
reviewing additional medical records submitted by Thomas, Standard upheld the
initial denial decision and informed him of its decision in a November 17, 2006
letter. Standard informed Thomas that its Administrative Review Unit (ARU)
would conduct an independent review of his claim.
The ARU independently
reviewed all of the medical records and information submitted by Thomas and his
treating physicians. After considering all of the available information, the
ARU denied Thomas’ claim. The ARU informed Thomas of its decision on January
29, 2007.
Thomas appealed Standard’s
decision to the EIP Long Term Disability Appeals Committee (Committee) for a de
novo review of the decision to deny his LTD claim. In that appeal, he also
submitted additional information in support of his claim. As a result,
Standard reconsidered its decision in light of the new information. After
reviewing the additional information, Standard upheld the denial of Thomas’
claim and informed Thomas of its decision in a June 11, 2007 letter. The
Committee then moved forward with its review.
The Committee
determined that the medical evidence did not demonstrate that Thomas was unable
to perform the duties of his occupation and denied his claim. On or about
March 19, 2008, Thomas filed his Notice of Appeal with this Court. After
timely notice to the parties, oral arguments were heard on December 4, 2008 at
the South Carolina Administrative Law Court in Columbia, South Carolina.
Applicable Plan Terms
The
Plan contains the following definition of disability:
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.
The
Plan also contains the following provision:
Proof of Loss
Proof of Loss means written proof
that you are Disabled and entitled to LTD Benefits. Proof of Loss must be
provided at your expense.
For claims of Disability due to
conditions other than Mental Disorders, we may require proof of physical impairment
that results from anatomical or physiological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic
techniques.
Medical
Evidence In The Record On Appeal
Thomas stopped
working on December 15, 2005. However, there was no evidence that a physician
recommended that he stop working at that time. Thomas supported his disability
claim based primarily upon the medical evaluation of Dr. Kolb a physician with Family
Medicine Associates in Abbeville, South Carolina. On March 21, 2007, Dr. Kolb
wrote a “To Whom It May Concern” letter in which he stated, “it is my feeling that
he is totally disabled.” Dr. Kolb listed various complaints and alleged
symptoms referenced by Thomas. Dr. Kolb noted the last VA report noted a
creatinine level of 3.1 and a GFR (glomerular filtration rate) of 24. Dr. Kolb
concluded that Thomas “is totally disabled for anything other than periodic
sedentary activity.”
However, the records
reflect that Thomas received most of his medical care from the Augusta Veterans
Administration Medical Clinic (VA). The medical records of the VA reflected
that prior to ceasing work, Thomas had not reported any disabling medical complaints
to his treating physicians. On September 29, 2005, he reported left foot pain
at a level of 2 on a scale of 1-10. He also reported that he had not seen a
nephrologist in two years and that he was not being routinely followed for his
knee, for which he had arthroscopic surgery in the past.
In support of his LTD
claim, Thomas also submitted an Attending Physician’s Statement (APS) from one
of his VA physicians, Dr. McKnight. Dr. McKnight listed a primary diagnosis of
diabetes mellitis and secondary diagnoses of renal failure and hypertension.
When asked to list Thomas’ current symptoms, Dr. McKnight wrote “none.” Dr.
McKnight concluded that Thomas could frequently lift up to 20 pounds, and that
he could walk/stand up to 4 hours in a work day and sit for up to 4 hours in a
work day. Dr. McKnight stated that Thomas had no cognitive limitations or
restrictions. Dr. McKnight did not recommend that Thomas stop working.
In fact, on March 31,
2006, Thomas reported he felt “fairly well” and that he had “stopped checking
his glucoses about 2 weeks after his last visit, states he has all the needed
supplies but simply lost interest and ‘let it go.’” He further reported that
his hypoglycemic episodes were “infrequent.” His physical examination evinced normal
findings with the exception of “slightly diminished” sensation in his right
foot.
On April 26, 2006, a
podiatrist, Dr. Kean, recorded that Thomas had some diminished foot sensation,
but that he was not having any foot or ankle problems. Dr. Kean instructed
Thomas to return in one year or sooner if he developed a foot or ankle problem.
On May 1, 2006, Dr.
Mulloy saw Thomas for a check up on his kidney disease. Dr. Mulloy noted
Thomas has had chronic kidney disease since the early 90s. Thomas stated he
felt fine and did not indicate any uremic symptoms or other problems.
In addition to the
medical records of Thomas’ treating physicians, the Record on Appeal also
contains detailed medical opinions from Dr. Fancher and Dr. Beeson, two
board-certified internists from whom Standard obtained independent medical
opinions regarding Thomas’ ability to continue working given his physical and
alleged mental conditions.
Dr.
Fancher acknowledged that Thomas had had diabetes mellitus for 9 years and
hypertension for 16 years and also noted that Thomas had a history of coronary
artery disease, but that a heart catheterization did not demonstrate any
obstructive lesions. With respect to Thomas’ kidney disease, Dr. Fancher
observed that Thomas did not have any uremic symptoms and made the following
statement:
The claimant does have advanced renal
disease. The medical record suggests the claimant is having no symptoms from
his renal disease. I am aware that the Social Security Administration
generally does not reward disability benefits for chronic renal failure unless
the GFR is less than 20. This is a reasonable guideline, as the vast majority
of patients will not have uremic symptoms if their GFR is greater than 20. The
medical records clearly suggest the claimant is having no symptoms from his
renal disease. His diabetes seems to be under reasonable control; although the
claimant is not checking his blood sugars regularly.
Dr.
Fancher then concluded as follows:
After reviewing the available medical
records, I cannot identify any physical illness that would prevent the claimant
from performing sedentary work . . . The claimant will likely have progressive
deterioration of his renal function. It is quite likely the claimant will
require dialysis in the next several years. However, at this time, the
claimant would not be impaired from working due to his renal failure.
After
reviewing additional information Thomas provided after Standard’s initial
denial decision, Dr. Fancher again concluded that Thomas was capable of
performing sedentary work. Subsequently, Dr. Fancher also reviewed the VA’s
partial disability determination and provided the following comments regarding
the VA determination:
· “[I]n regard to Mr. Thomas’
cardiac condition the medical records had not supported a condition of such
severity to result in limitations to sedentary occupational activity . . .
[his] ejection fraction of 60% is normal.
· “[H]ypoglycemic episodes twice
weekly (which is not supported by the contemporaneous medical records) would
not prevent sedentary occupational activity.
· Thomas’ “renal condition is
documented as being asymptomatic and [his] creatinine levels do not support
impairment.”
· “[W]hile ankle edema is noted in
the VA rating decision this would not prevent the performance of sedentary
occupational activity.”
· “Thomas’ visual acuity status is
20/25 corrected bilateral and . . . while he has very mild narrowing of his
peripheral vision due to cataracts this would not prevent driving, reading
reports, or working on a computer.
Dr. Beeson confirmed Dr. Fancher’s assessment and provided
the following opinion:
This patient has a history of diabetes
that appears to be relatively well controlled. He has chronic renal failure
that appears to be asymptomatic. He apparently has a history of coronary
disease; however, this is not detailed in the medical record available. There
is clearly no evidence of ongoing angina or symptoms of myocardial
dysfunction. I can find no reason why this patient could not continue to work
in sedentary, and possibly even a light work occupation; medium work or greater
would probably be contraindicated. The fact that he has significant renal
insufficiency, in and of itself, is not reason for work cessation. There is no
evidence that the patient was seen at or about the time that he ceased work.
There is no evidence that the symptomatology worsened at that time. It appears
the patient made a unilateral decision to cease working.
DISCUSSION
Thomas argues that EIP
“abused its discretion” by ignoring the records and opinions of his treating
physicians. In support of this argument, Thomas relies almost exclusively on
Dr. Kolb’s disability determination after an examination in March 2007 and on
the VA’s partial disability rating, particularly the VA’s findings regarding
Thomas’ alleged mental condition. Nevertheless, as noted the above, appellate
review of this case is made not from the perspective of what evidence supports
Appellant’s view of the evidence, but whether there is evidence to support
EIP’s decision to deny his LTD claim. I find that there is substantial
evidence in the Record to support that decision.
Importantly, though
Appellant places emphasis on the assertion that Dr. Kolb’s determination was
one made by Appellant’s primary treating physician there is credible evidence
to the contrary. The evidence reflected that Thomas infrequently received
treatment from Family Medicine Associates in Abbeville, South Carolina.[1] In fact,
Thomas submitted only one medical record from Family Medicine Associates. The
only contemporaneous record submitted by Family Medicine Associates is a May
21, 2007 note signed by Dr. Kolb in which Dr. Kolb notes that Thomas was “in
today for evaluation regarding disability.”[2]
Furthermore, Dr. Kolb disability determination was submitted with no supporting
documentation.
To the contrary, EIP
based its determination on the medical opinions of Dr. Fancher and Dr. Beeson
who determined that Appellant was not disabled. Dr. Fancher’s and Dr. Beeson’s
opinions are supported by Appellant’s medical records. In particular, the
medical records submitted by Appellant, including Dr. McKnight’s APS and the
numerous medical records from the VA support Dr. Fancher’s and Dr. Beeson’s
opinions. The medical records demonstrate that Thomas has very few, if any,
symptoms due to his chronic kidney disease. While Thomas’ condition could
deteriorate in the future, at the time Thomas stopped working, no physician had
recommended that he stop working and Thomas was suffering no symptoms from his
chronic kidney disease. The medical records also demonstrate that Thomas’
blood pressure was well controlled; that his diabetes was well controlled with
only “very infrequent” hypoglycemic events; that his knee pain did not cause
limitations or restrictions that would prevent sedentary work activity; and
that his coronary artery disease caused very few, if any, physical
limitations.
Additionally, there is
no evidence that any physician observed Thomas having any symptoms related to
any of his medical conditions. To the contrary, one month after Thomas
voluntarily stopped working, Dr. McKnight stated that Thomas had no physical
symptoms; that he could sit or stand 8 hours in a work day and lift up to 20
pounds frequently.[3]
The Record also reveals no evidence that any physician, treating or otherwise,
established any limitations or restrictions, based on a physical or mental condition,
which prevents Thomas from working in his occupation.
As
a final matter, while Appellant argued in his Brief and at oral argument that
EIP’s decision was arbitrary and capricious because EIP “ignored” Thomas’
mental condition, the Court finds no merit to Appellant’s assertion. The Plan
places the burden of proving disability squarely on a claimant. In this case,
Appellant has submitted no records of any mental status examination or other
mental health treatment. The Court also notes that both Standard and EIP
addressed Thomas’ mental condition on multiple occasions and pointed out that
Thomas has never submitted any medical records that support a finding of
disability based on any mental condition. Notably, not one of Thomas’ treating
physicians has set forth any physical or mental restrictions or limitations
regarding his ability to work in his sedentary occupation. To the contrary,
the only treating physician who offered any opinion regarding physical or
mental restrictions opined that Thomas had no mental or cognitive limitations
or restrictions.
“Once
admitted, expert testimony is to be considered just like any other testimony.” Tiller
v. Nat’l Health Care Ctr. of Sumter, 334 S.C. 333, 340, 513 S.E.2d 843, 846
(1999). Therefore, “while medical testimony is entitled to great respect, the
fact finder may disregard it if there is other competent evidence in the
record.” 513 S.E.2d at 846. Here, there clearly was other competent
medical evidence supporting EPI’s conclusion. Thus, the substantial evidence
in the Record on Appeal support a determination that Appellant failed to
provide satisfactory proof of loss to support his claim.
ORDER
For the reasons set
forth above,
IT IS HEREBY
ORDERED that EIP’s final agency determination denying Appellant’s claim for
LTD benefits is affirmed.
AND IT IS SO
ORDERED.
__________________________
Ralph
King Anderson, III
Administrative
Law Judge
January 23, 2009
Columbia, South Carolina
Although the medical records from the VA indicate
that Appellant had almost no symptoms or complaints related to his various
diagnoses, on September 1, 2005, long before Appellant stopped working, the VA
issued a determination that Appellant was partially disabled. The VA’s
determination however is not binding on the Plan.
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