ORDERS:
ORDER
This matter is before me pursuant to the appeal of Erna Bingenheimer ("Appellant") from the
decision of the Respondent, South Carolina Department of Health and Human Services
("Department"), to deny the Appellant's application for Medicaid benefits. The Administrative
Law Judge Division ("Division") has jurisdiction to hear this matter pursuant to S.C. Code Ann. §
44-6-190 (Supp. 1995). A hearing was conducted on December 6, 1996. For the reasons stated
in this Decision and Order, the decision of the Department is AFFIRMED.
STATEMENT OF THE CASE
The Department administers the Medicaid program in South Carolina. As part of this program,
the Department has entered into a contract with the Department of Social Services (DSS)
whereby DSS acts as the Department's agent for processing applications for Medicaid eligibility
and rendering eligibility determinations. Any applicant who disagrees with an eligibility
determination may request a fair hearing which is conducted by the Department's Division of
Appeals and Hearings.
Appellant first applied for Medicaid benefits in March of 1995. On July 19, 1995, Appellant's
application was denied by DSS on the grounds that appellant's resources exceeded the applicable
limit for eligibility. The denial letter was received by the appellant's son, who had filed the
application on her behalf, on July 25, 1995. The letter stated that the application was denied
because appellant's resources exceeded the maximum allowable amount for eligibility, and it
further advised of the right to request a fair hearing before the Department by filing a written
request for a hearing within thirty days from the date of the notice.(1)
On March 19, 1996, the Department received a letter and a packet of other documents from DSS
which contained a request for a hearing for Appellant. These materials included a statement from
Appellant's caseworker at DSS which stated that she had heard nothing from the Appellant
concerning the denial letter of July 19, 1995, until she was contacted by someone from the state
DSS office on February 21, 1996. The Department assigned the case to a Hearing Officer, who
issued an Order on March 25, 1996, which required that both parties submit prehearing briefs on
the issue of the timeliness of the appeal. In response to this request, both parties submitted briefs.
The Appellant's attorney contended that she and Appellant's son had spoken with a DSS
caseworker on July 26, 1995, and had requested a review of the denial decision. She further
asserted that she had mailed a letter to the DSS caseworker on that date. A copy of the letter--a
one page, handwritten document which is dated July 26, 1995-- is contained in the record. It
bears no date stamp or any other indication that it was received by DSS or the Department. On
the other hand, the Department argued that the appeal was not timely filed, relying on the DSS
caseworker's assertions that she had not received any request from Appellant for a review of the
July 19, 1995 denial letter.
Based upon the written submissions of the parties, the Hearing Officer issued a written Order on
June 28, 1996. In the Order, the Hearing Officer made a factual finding that, based on the
evidence submitted by the parties, no notice of appeal was actually filed until March of 1996.
Accordingly, the Hearing Officer dismissed the case on the grounds that the notice of appeal was
not timely filed. Appellant then timely requested this appeal before the Division.
DISCUSSION
A. Standard of Review
In reviewing the factual findings of an agency, the Division is limited to determining whether
substantial rights of the appellant have been prejudiced because the administrative findings,
inferences, conclusions or decision are clearly erroneous in view of the reliable, probative and
substantial evidence on the whole record. S.C. Code Ann. § 1-23-380(A)(6)(e) (Supp. 1995). In
accordance with the foregoing provision, the Department's decision may only be set aside if
unsupported by "substantial evidence." " 'Substantial evidence' is not a mere scintilla of evidence
nor the evidence viewed blindly from one side of the case, but is evidence which, considering the
record as a whole, would allow reasonable minds to reach the conclusion that the administrative
agency reached or must have reached in order to justify its action." Lark v. Bi-Lo, Inc., 276 S.C.
130, 276 S.E.2d 304, 306 (1981).
Application of this standard is appropriate only in those cases where a "manifest or gross errror of
law has been committed by the administrative agency. The statute specifically states: 'The court
shall not substitute its judgment for that of the agency as to the weight of the evidence on
questions of fact.'" Id. at 307. Furthermore, the possibility that two inconsistent conclusions
could be drawn from the evidence does not prevent an administrative agency's finding from being
supported by substantial evidence. Brown v. R.L. Jordan Oil Co., 291 S.C. 272, 353 S.E.2d 280
(1987). The party challenging an agency action has the burden of proving convincingly that the
agency's decision is unsupported by substantial evidence. Waters v. S.C. Land Resources
Conservation Comm'n, ___ S.C. ___, 467 S.E.2d 913 (1996).
In this case, the Hearing Officer made a factual finding as to the timeliness of the hearing request,
based on her review of Appellant's assertions that a request for hearing was mailed on July 26,
1995, and of the Department's assertions that neither it nor DSS had received a request for a
hearing until March of 1996. In making this finding, the Hearing Officer weighed the conflicting
assertions and determined that the request for a hearing had not been timely filed. I find that this
decision is supported by the substantial evidence in the record.
B. Abuse of Discretion
Appellant also contends that the Hearing Officer abused her discretion by making a determination
as to the timeliness of the hearing request on the basis of written submissions rather than by
holding a hearing on the timeliness issue. In determining whether an administrative body properly
exercised its discretion with respect to its statutory functions, the inquiry is whether the action
under consideration measures up to any fair test of reason; if the facts and circumstances are such
that reasonable men may differ as to the wisdom and expediency of the decision, the decision
must be upheld, and a clear abuse of discretion is required to warrant judicial interference.
Gamble v. Williamsburg County School Dist., 305 S.C. 288, 408 S.E.2d 217 (1991). An exercise
of discretion by an administrative agency will not be disturbed unless there is an abuse of
discretion evidenced by a showing that the action of the agency was arbitrary or unlawful. 73A
C.J.S. Public Administrative Law and Procedure § 223a (1983).
In this case, the Hearing Officer was specifically authorized by regulation to "dismiss any appeal
for failure to comply with requirements under this Subarticle [including the requirement that a
notice of appeal be filed within applicable time limits]." 27 S.C. Code Regs. § 126-154 (1976).
Before dismissing the appeal, the Hearing Officer advised both parties that the timeliness of the
appeal was a threshold issue to be determined, and she issued an Order for the submission of
written prehearing briefs on that issue. Furthermore, by letter dated March 25, 1996, addressed
to Appellant's attorney, the Hearing Officer specifically stated that "no fair hearing will be
scheduled in this matter until it is determined whether or not the matter is appealable." The
Appellant had ample opportunity to present her position regarding the timeliness issue. Under
these circumstances, I find that the Hearing Officer did not abuse her discretion by dismissing the
appeal based on the written submissions.
ORDER
Based upon the record and the applicable law, the decision of the Hearing Officer is AFFIRMED.
AND IT IS SO ORDERED.
______________________________________
ALISON RENEE LEE
Administrative Law Judge
December _____, 1996
Columbia, South Carolina.
_______________
Fn.1. However, the applicable regulation which governs Medicaid appeals provides that the thirty
day time period runs from the date of receipt of notice of the agency's action. 27 S.C. Code Regs.
126-152 (1976). Therefore, the Appellant had until August 24, 1995, to request a fair hearing. |
