Sheffield v. State

THIS OPINION HAS NO
PRECEDENTIAL VALUE.  IT SHOULD NOT BE CITED OR RELIED ON AS PRECEDENT IN ANY
PROCEEDING EXCEPT AS PROVIDED BY RULE 239(d)(2), SCACR.

THE STATE OF SOUTH CAROLINA

In The Court of Appeals

Ex Parte: State
Budget and Control Board, Employee Insurance Program, Appellant,

In Re:

Doris B.
Sheffield, Respondent,

v.

The State of South Carolina, Defendant.

Appeal From Hampton County

 Carmen T. Mullen, Circuit Court Judge

Unpublished Opinion No. 2008-UP-310

Submitted June 2, 2008 – Filed June 18,
2008

REVERSED

James T. Hedgepath, of Greenville; and Michael T. Brittingham and Roshella
James, of Columbia, for Appellant.

Lee Deer Cope, of Hampton, for Respondent.

GOOLSBY, A.J.:  The State Budget and Control Board Employee Insurance Program (the Insurance
Program) appeals the trial court’s award of long-term disability benefits to
Doris B. Sheffield.  We reverse. [1]

FACTS

Sheffield taught special education in Hampton County School
District 1 (the District).  In 2004, Sheffield filed a claim for long-term
disability benefits, alleging she was unable to work because she suffered
rheumatoid arthritis and Sjögren’s syndrome.[2]

Sheffield’s
claim was initially reviewed by Standard Insurance Company (Standard), the
third-party claims administrator for her long term disability plan.  Standard
denied the claim, and Sheffield requested a review. Again, Standard denied the
claim.  In addition, Standard’s Quality Assurance Unit denied the claim
after conducting an independent review.  Sheffield next appealed to the
Employee Insurance Program’s Long-Term Disability Appeals Committee (Appeals
Committee).  The Appeals Committee reviewed Sheffield’s Long-Term Disability
Income Benefit Plan (the Plan), Sheffield’s medical records, and all other
documents contained in the administrative record.

According to the Plan, employees are disabled if a physical
disease, injury, pregnancy, or mental disorder renders them “unable to perform
with reasonable continuity the Material Duties of [their] Own Occupation.”  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 [the employee’s] regular and ordinary employment with the
Employer. . . .”

The job description for a “Classroom Teacher” in District 1
contains the following duties:

1.
Instruct students for specified time and in
specified subjects as outlined in the teacher’s contract, the
Defined Minimum Program and according to the district’s and the
school’s policies.

 

2. 
Supervise students in classroom, in halls, in
lunchroom, on playgrounds and in boarding buses and extra-curricular
activities.

Karol Paquette,
Sheffield’s vocational case manager, classified Sheffield’s occupation as
“Teacher, Mentally Impaired.”  Paquette added Sheffield’s position included
light physical demands. 

The Appeals Committee also reviewed Sheffield’s medical records.  The records included documents from Dr. Welcker, Sheffield’s
family physician, and Dr. Nussbaum, Sheffield’s rheumatologist.  In
addition, the Appeals Committee considered the opinions of Dr. Ingram and Dr. Fraback,
rheumatologists hired by Standard to review Sheffield’s medical records and
provide opinions as to her condition.  Although Sheffield also sought treatment
with an ear, nose, and throat specialist (ENT), she failed to submit ENT medical
records to Standard or the Appeals Committee.  The Appeals Committee,
therefore, did not review these medical records, and Dr. Ingram and Dr. Fraback
were unaware of any diagnosis or treatment by the ENT.    

Dr.
Welker, who initially diagnosed Sheffield with rheumatoid arthritis and Sjögren’s syndrome, opined Sheffield was unable to work due to the
physical limitations resulting from her conditions.  He added Sheffield was unable to walk, sit, or stand for any period of time.  He also noted Sheffield suffered from garbled speech that could prevent public speaking.  Dr. Nussbaum noted
Sheffield suffered joint swelling, stiffness and pain, dry mouth due to
salivary gland failure, and low back pain.  He described Sheffield’s condition
as a “chronic illness which is unlikely to improve.”  Dr. Nussbaum, however,
opined by letter dated August 13, 2004, that Sheffield had difficulty with
prolonged standing and walking, but was otherwise able to work without
difficulty.  Dr. Nussbaum later opined Sheffield could walk or stand for up to
one hour at a time and Sheffield could walk or stand for four hours during an
eight hour work day.  Dr. Nussbaum added Sheffield could sit for up to two
hours at a time and she could sit for up to six hours during the work day.  Ultimately,
Dr. Nussbaum concluded Sheffield was not physically able to return to work. 

Dr. Ingram and Dr. Fraback opined Sheffield’s conditions did not preclude her from returning to her occupation.  Dr.
Ingram found Sheffield’s medical records “do not show significant rheumatoid
arthritis, such that her rheumatologist does not recommend that she begin a
second-line agent, which is recommended in all but the most minimal rheumatoid
arthritis.”    Dr. Fraback agreed, finding her rheumatoid arthritis
appeared to be mild to moderate.  With respect to Sheffield’s Sjögren’s syndrome, Dr. Ingram commented as follows:

The dry oral mucosa is documented, as well as at least two years
of treatment with agents to increase salivary production.  There is no mention
that she has been advised to use oral wetting agents, the typical
recommendations of sucking lemon drops or frequent sips of water.  Furthermore,
in the classroom, amplification and microphones are easily available to
teachers and there is no indication she has requested that modification . . .
. 

Dr. Fraback
noted, “While she does have Sjögren’s syndrome, the most recent note from
the rheumatologist indicated that [her condition] was somewhat better with a
new drug Evaxac . . . .”  Dr. Fraback added “It would be unusual for Sjögren’s syndrome to preclude speaking if the speaker had the
ability to sip water as needed.” 

The Appeals Committee unanimously denied
Sheffield’s claim, finding the administrative record did not indicate Sheffield was unable to perform the duties of her occupation as a teacher for the mentally
impaired.  The Appeals Committee relied on Dr. Nussbaum’s letter of August 13,
2004 that stated Sheffield had difficulty with prolonged standing and walking,
but was otherwise able to continue her employment.  The Appeals Committee
further noted Dr. Nussbaum’s opinion that Sheffield could walk or stand for
four hours and sit for six hours.  They added Standard’s rheumatologist
consultants agreed Sheffield’s claim file did not indicate Sheffield was
physically unable to perform her Own Occupation.  

Sheffield appealed this decision to the circuit court.  The circuit court reversed the
Appeals Committee’s decision.  This appeal followed. 

LAW / ANALYSIS

The Insurance Program argues the circuit
court erred in finding the Appeals Committee’s denial of Sheffield’s claim was
not supported by substantial evidence.  We agree.

Section
1-11-710(C) of the South Carolina Code (Supp. 2007) provides:

[C]laims 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 [South
Carolina Budget and Control Board], which shall constitute the exclusive remedy
for these claims, subject only to appellate judicial review consistent with the
standards provided in Section 1-23-380.

 Pursuant to section
1-23-380(A)(5) of the South Carolina Code (Supp 2007), an appellate court, when
reviewing the final decision of an agency, “may not substitute its judgment for
the judgment of the agency as to the weight of the evidence on questions of
fact.”  Rather, the decision of the agency should be affirmed unless it is
clearly erroneous in light of the substantial evidence on the record, is
arbitrary or capricious, or is affected by other error of law. Id.; see Wilson v. State Budget & Contol Bd. Employee Ins. Program, 374 S.C.
300, 648 S.E.2d 310 (Ct. App. 2007) (affirming the agency’s denial of benefits
and reversing the circuit court’s award of benefits when the employee submitted
evidence supporting her disability claim, but substantial evidence to the
contrary supported the agency’s decision).  “Substantial evidence is not a mere
scintilla of evidence, but evidence which, considering the record as a whole,
would allow reasonable minds to reach the conclusion the agency reached.”  Tiller
v. Nat’l Health Care Ctr, 334 S.C. 333, 338, 513 S.E.2d 843, 845 (1999).  

Here, Sheffield submitted evidence of her disability. Substantial evidence to the contrary,
however, supports the decision of the Appeals Committee.  As set forth above, Dr.
Nussbaum stated Sheffield could walk or stand for four hours and sit for six
hours.  In addition, Dr. Ingram and Dr. Fraback concluded Sheffield’s
conditions did not preclude her from returning to work.  Specifically, Dr.
Ingram and Dr. Fraback agreed Sheffield’s rheumatoid arthritis was mild to
moderate and her dry mouth condition was treatable.  Because substantial
evidence supports the Appeals Committee’s decision, the circuit court’s award
of benefits is   

REVERSED.

KONDUROS, J., concurs.

SHORT, J., dissents
in a separate opinion.

SHORT,
J., (dissenting):  I respectfully dissent.

I
recognize the very restrictive standard of review this court must employ when
reviewing the decision of an agency under the Administrative Procedures Act, as
noted in the majority opinion.  See S.C. Code Ann. § 1-23-380(A)(5) (Supp.
2007).  After reviewing the Appeals Committee’s decision with great deference,
however, I find the Committee erred in denying Sheffield’s claim.  I would
affirm the circuit court.

Sheffield was diagnosed with rheumatoid arthritis and Sjögrens syndrome.  Sheffield’s
family doctor, Glenn Welcker, saw and treated Sheffield.  Welcker referred Sheffield to an ENT specialist, Dr. C. Willy Schwenzfeier, who treated her for the Sjögrens
syndrome.  Schwenzfeier referred Sheffield to a rheumatoid arthritis
specialist, Dr. Alan Nussbaum.  Nussbaum saw and treated Sheffield for
arthritis, concluding: (1) she had a “chronic illness which is unlikely to
improve;” and (2) “she is unable to function as a classroom teacher.”  Nussbaum
found Sheffield’s arthritis worsening.  Furthermore, Nussbaum responded “Never”
to the insurance form question asking when he expected a fundamental change in
condition.  Welcker likewise concluded Sheffield was unable to continue
working. 

In
comparison, the medical opinions relied upon by the Committee to deny benefits
were made by two physicians, Shirley Ingram and Ronald Fraback, hired by the
disability plan.  Neither of these physicians ever examined Sheffield.  Ingram
opined Sheffield’s arthritis was not “significant” because Nussbaum did not
recommend a particular treatment.  Ingram also questioned the impact of Sheffield’s Sjögrens syndrome because she could not review records of an ENT.  However, Sheffield was referred to and treated by an ENT and thereafter by Welcker.  Furthermore,
Ingram concluded she was “unable to assess [Sheffield’s] limitations” as to her
Sjögrens syndrome.  Fraback apparently incorrectly believed Sheffield was never
referred to an ENT stating his belief “an [ENT] consultation would be
expected.”  Fraback otherwise concluded Sheffield’s arthritis was only “mild to
moderate” because she was being treated with “minimal medication.”  As found by
the circuit court, these reviewing doctors did not specifically dispute
Sheffield’s condition or the physical limitations imposed by Sheffield’s
treating physicians.  Rather, they advocated different treatment methods. 
Accordingly, I agree with the circuit court’s finding that the Committee’s
decision to deny the claim was erroneous.  I would affirm.

[1]  Because oral argument would not aid the court in
resolving the issues on appeal, we decide this case without oral argument
pursuant to Rule 215, SCACR.

[2]  Sjögren’s syndrome is a disease that causes extreme
dry mouth.