SC Administrative Law Court Decisions

Medicaid "is intended to enable each state . . . to furnish medical assistance on behalf of . . . permanently and totally disabled individuals, whose income and resources are insufficient to meet the cost of necessary medical services." 79 Am. Jur.2d Welfare Law § 38. Manning argues she is totally disabled and entitled to Medicaid benefits. Having not received benefits, this appeal arose.

An appellate body may reverse or modify the decision of a hearing officer if substantial rights of the appellant have been prejudiced because the administrative findings, inferences, conclusions or decisions of the hearing officer 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. 1997). Since Manning challenges the factual basis supporting the hearing officer's conclusion, the ALJ must determine whether the hearing officer's findings are supported by substantial evidence. Accordingly, under normal circumstances two matters would be decided. First, what did the hearing officer find as the basis for her decision? Second, are the hearing officer's findings supported by substantial evidence? In this case, the first question cannot be answered to the degree needed for proper appellate review. Thus, the second question is not reached, but instead a remand is ordered.

A. Implicit Findings

In this case the findings of fact are implicit findings not sufficiently detailed to allow for a meaningful review of the conclusion that Manning is not totally disabled. A meaningful review cannot be made where the findings of fact are implicit findings that merely outline the conclusions and rational used by the parties. "[A] recital of conflicting testimony followed by a general conclusion is patently insufficient to enable a reviewing court to address the issues." Able Communications, Inc. v. South Carolina Public Serv. Comm'n, 290 S.C. 409, 411, 351 S.E.2d 151, 152 (1986), quoted in Brayboy v. Clark Heating Co., Inc., 306 S.C. 56, 59, 409 S.E.2d 767, 768 (1991). Three examples establish the difficulty in this case

1. Examples

First, the hearing officer found "the reviewer indicated that [Manning] could return to this past relevant work, as performed in the national economy." (emphasis added; Order, p. 3, paragraph 15). Given such language, the reviewer found Manning could return to prior work, but the hearing officer made no specific determination on the issue. Consequently, not having reached the issue, the hearing officer could not and did not state what facts she would have relied upon to reach such a conclusion.

Second, and quite similar to the first, the hearing officer found "[t]he Department determined [Manning] could perform light work." (emphasis added; Order, p. 3, paragraph 16). Again, the Department made a determination on the light work issue, but the hearing officer did not. Obviously, Manning opposed such a view and presented evidence challenging such a position. The hearing officer must decide such factual disputes and give sufficient rational for her decision so as to allow the reviewing body to decide if substantial evidence supports the conclusion reached. Brayboy v. Clark Heating Co., Inc., 306 S.C. 56, 59, 409 S.E.2d 767, 768 (1991). The rational for a finding is important. Lack of a clear explanation of the agency's reasoning prevents the reviewing court from determining if the decision is arbitrary or capricious. See Hatcher v. South Carolina Dist. Council of Assemblies of God, Inc., 267 S.C. 107, 226 S.E.2d 253 (1976) ("A decision is arbitrary if it is without a rational basis, is based alone on one's will and not upon any course of reasoning and exercise of judgment, is made at pleasure, without adequate determining principles, or is governed by no fixed rules or standards").

Finally, the hearing officer found that "if [Manning] is limited to sedentary work . . . [she] would fall under 20 CFR Rule 201.29 which warrants a finding of not disabled." (emphasis added; Order p. 3, paragraph 16). In other words if someone were to make a factual finding that Manning could perform sedentary work, she would not be totally disabled. No explicit finding is made that Manning can perform sedentary work, no factual finding is made of how long she can sit, and no factual finding expresses a rational as to how such a conclusion on the ability to perform sedentary work was reached.

2. Fundamental Problem

The above three examples are merely indicators of a more fundamental problem. The fundamental problem is that an appellate review cannot be intelligently made in this case since the decision lacks findings on the ultimate facts in dispute, i.e., a finding of fact clearly indicating the hearing officer's decision on Manning's ability to lift, walk, sit and stand and a resulting finding on her ability to work. Those facts are critical in determining whether Manning is totally disabled; those facts must be specifically decided; and, those facts must not be so vaguely decided as to force the appellate body to guess at the hearing officer's basis for concluding Manning's work capacity. At best the order recites what the physician for Vocational Rehabilitation found, i.e., "The Department determined [Manning] could perform light work." At best, the order recites what the DHHS reviewer found, i.e., "[t]he reviewer indicated that [Manning] could return to . . . past relevant work." What is needed is explicit fact finding. Without it the appellate body must guess at the basis for the decision.

In this case, the difficulty of a meaningful appellate review can be seen by a casual examination of the record. The only direct evidence in the record of Manning's ability to sit, walk, stand or lift is from Manning, Manning's husband and from Manning's witness Phillipe Cote. All three testified to Manning's inability to walk or sit for any appreciable period of time and to her inability to lift a weight even on an occasional basis.

No observation testimony contradicts these witnesses statements. On the contrary, the only evidence opposing the force of these three witnesses' personal observations is a document read into the record. The document is a report by a physician. The physician, who never saw Manning, never talked to her, never examined her, and never appeared at the hearing, concluded that Manning should be able to stand or walk for six hours in an eight hour day. Obviously, the absent physician was not cross examined, and no explanation is given by the physician on how he determined Manning's work capacity. Equally as obvious, Manning disagrees with the findings and produced witnesses who specifically contradicted the physician's conclusions.

Further, the record supports Manning's conclusion that she was struck by an automobile. It is admitted that the hospital records for that accident were not reviewed by the physician who made the assessment of Manning's ability to walk, stand and lift. The hearing officer does not address what extent such records may be relevant in assessing Manning's disability.

The above matters are not listed here in an attempt to suggest the conclusion the hearing officer should reach. Rather, these matters are listed to show how seriously contested is the issue of whether Manning can sit, walk or stand to the degree necessary to accomplish sedentary or light work. Without explicit findings of fact on this critically disputed issue by the very agency with expertise, a meaningful appellate review is not possible. See Hamm v. South Carolina Public Service Comm'n, 298 S.C. 309, 380 S.E.2d 428 (1989) ("We recognize, of course, that the PSC--and not this Court--has been designated the 'expert' to regulate the rates and services of public utilities operating in South Carolina. 'Expert' status, however, does not somehow diminish the PSC's duty to support its conclusions with factual findings; indeed, that status heightens the duty to make the explicit findings of fact which allow meaningful appellate review of these complex issues. The insufficient Order here precludes a decision by this Court on whether substantial evidence on the whole record supports the PSC's ultimate conclusions." (internal citations omitted)).

B. Conclusion

Under appropriate circumstances, a remand for further proceedings is proper. S.C. Code Ann. § 1-23-380(A)(6) (Supp. 1997). See Medikal Works, Inc. v. South Carolina Dep't of Health and Human Servs., 95-ALJ-08-0563-AP (April 2, 1996); Mansion Homes, Inc. v. South Carolina Dep't of Labor, Licensing and Regulation, S.C. Manufactured Housing Bd., 96-ALJ-11-0300-AP (January 7, 1997). Because the Administrative Determination lacks detailed, definitive findings of fact concerning Manning's ability to sit, lift, stand or walk, the case must be remanded. See Hamm v. South Carolina Public Service Comm'n, 291 S.C. 119, 352 S.E.2d 476, (1987) (case remanded where agency's finding that utility made reasonable effort to minimize additional fuel costs caused by shutdown was unsupported by record); Bridges v. Wyandotte Worsted Co., 239 S.C. 37, 121 S.E.2d 300 (1961) (abuse of discretion occurs when factual conclusions of lower court are without reasonable evidentiary support), cited in Rampey v. Rampey, 332 S.E.2d 213, 286 S.C. 153 (Ct. App. 1985).

IT IS THEREFORE ORDERED that the hearing officer's order be vacated and this matter be REMANDED for reconsideration in light of the matters discussed in this decision. To the extent deemed necessary, the hearing officer may hold additional hearings to allow proper development of the issues.

AND IT IS SO ORDERED.

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RAY N. STEVENS

Administrative Law Judge

May 11, 1998

Columbia, South Carolina