ORDERS:
ORDER
STATEMENT OF THE CASE
This matter is before me pursuant to the appeal of Sharon Wood (Appellant), from a final
decision of the Respondent, South Carolina Department of Health and Human Services
(Department), denying the Appellant’s application for Medicaid coverage. The Administrative
Law Judge Division (Division) has jurisdiction to hear this matter pursuant to S.C. Code Ann.
§ 1-23-600 (1986 & Supp. 2002). A hearing on the appeal was held on January 6, 2004, at the
offices of the Division in Columbia, South Carolina. Upon consideration of the briefs and the
arguments presented at the hearing, together with a review of the applicable law, the decision of
the Department is affirmed.
ISSUE ON APPEAL
The issue on appeal is whether substantial evidence exists in the record to uphold the
Hearing Officer’s decision that the Department properly denied Medicaid coverage for Sharon
Wood based on her failure to meet the disability criteria.
STANDARD OF REVIEW
As set forth above, this case is before the Division as an appeal of an agency action
pursuant to S.C. Code Ann. § 1-23-600(D) of the Administrative Procedures Act (APA) upon
appeal from a Final Order of the Department. As such, the Administrative Law Judge sits in an
appellate capacity under the APA rather than as an independent finder of fact. In South
Carolina, the provisions of the APA -- specifically Section 1-23-380(A)(6) -- govern the
circumstances in which an appellate body may reverse or modify an agency decision. That
section states:
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 abuse of discretion or clearly
unwarranted exercise of discretion.
S.C. Code Ann. § 1-23-380(A)(6) (1986 & Supp. 2002).
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. South Carolina Land
Resources Conservation Comm’n, 321 S.C. 219, 467 S.E.2d 913 (1996); Grant v. South
Carolina Coastal Council, 319 S.C. 348, 461 S.E.2d 388 (1995).
In 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), citing Kearse v. State Health and Human Services Finance Comm'n, 318 S.C. 198, 456
S.E.2d 892 (1995). 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.
South Carolina Coastal Council, 319 S.C. 348, 461 S.E.2d 388 (1995), citing Gibson v. Florence
Country Club, 282 S.C. 384, 318 S.E.2d 365 (1984). Finally, the party challenging an agency
action has the burden of proving convincingly that the agency's decision is unsupported by
substantial evidence. Waters, supra, citing Hamm v. AT&T, 302 S.C. 210, 394 S.E.2d 842
(1994).
DISCUSSION
In argument before the Division, the Appellant restated her position that she could not
perform any work for which she was fitted by experience or training unless she had the knee
surgery her doctor ordered to replace her knee joint. Further, she stated that she couldn’t afford
this operation but that if she could be declared disabled and subsequently have the operation paid
for by Medicaid, she could then return to work. The Respondent, while sympathetic to
Appellant’s arguments, argued that federal law found at 20 C.F.R. § 416.930 precludes a finding
of disability in this case.
Regulation 20 C.F.R. § 416.930 (a) simply states: “In order to get benefits, you must
follow treatment prescribed by your physician if this treatment can restore your ability to work . .
. .” The Regulation further sets forth under § 416.930 (c) that: “We will consider your physical,
mental, educational, and linguistic limitations . . . when determining if you have an acceptable
reason for failure to follow the prescribed treatment.” That list of considerations does not
reference an individual’s inability to pay for the treatment. The Appellant argued that the listing
of exceptions was not an all-inclusive list and other factors could and should be considered in
making a disability determination. However, the South Carolina Supreme Court held in German
Evangelical Lutheran Church of Charleston v. City of Charleston, 352 S.C. 600, 607, 576 S.E.
2nd 150, 153 (2003) that:
The canon of construction "expressio unius est exclusio alterius" or "inclusio
unius est exclusio alterius" holds that "to express or include one thing implies the
exclusion of another, or of the alternative." Black's Law Dictionary 602 (7th ed.
1999). . . . The enumeration of exclusions from the operation of a statute indicates
that the statute should apply to all cases not specifically excluded.
Here, though the list in Regulation 416.930 (c) does not specifically enumerate every possible
reason that is acceptable for not following a doctor’s order, the inability to pay is not listed as a
general factor that can be considered. Therefore, since the regulation does not reference an
individual’s inability to pay for doctor recommended treatment as a permissible exception to the
regulation warranting a finding of disability, the implication arises that an individual’s inability
to pay is excluded from consideration. Consequently, I find that the above principle precludes
this Court from interpreting 20 C.F.R. § 416.930 as allowing individuals to be placed on
Medicaid when they have not followed their doctor’s recommended treatment because they
lacked the funds to pay for the treatment.
Additionally, it is well established that the construction given a statute should be rational
and reasonable and not lead to an absurd result. Bolton v. Doe, 266 S.C. 344, 223 S.E.2d 187
(1976). I cannot find that the Department’s interpretation of Regulation 416.930 leads to an
absurd result. It is certainly conceivable that if such a stringent approach to receiving Medicaid
benefits was not taken the coffers of the government could be overwhelmed by individuals who
knowingly relied upon the government to cover their serious medical expenses.
I therefore find that the Order of the Hearing Officer should be upheld.
AND IT IS SO ORDERED.
___________________________
Ralph King Anderson, III
Administrative Law Judge
February 24, 2004
Columbia, South Carolina |
