Bedard v. S.C. Pub. Emp. Benefit Auth., 22-ALJ-30-0096-AP

CourtSouth Carolina Administrative Law Court Decisions
Writing for the CourtDEBORAH BROOKS DURDEN, JUDGE
PartiesDeborah Bedard, Appellant, v. South Carolina Public Employee Benefit Authority, Employee Insurance Program, Respondent.
Docket Number22-ALJ-30-0096-AP
Decision Date15 September 2022

Deborah Bedard, Appellant,
v.

South Carolina Public Employee Benefit Authority, Employee Insurance Program, Respondent.

No. 22-ALJ-30-0096-AP

South Carolina Administrative Law Court Decisions

September 15, 2022


ORDER

DEBORAH BROOKS DURDEN, JUDGE

STATEMENT OF THE CASE

The above-captioned matter is before the Administrative Law Court (ALC or Court) on an administrative appeal pursuant to S.C. Code Ann. section 1-11-710(C) (2005) and S.C. Code Ann. section 1-23-600(D) (Supp. 2021). Deborah Bedard (Appellant) seeks review of a decision by the South Carolina Public Employee Benefit Authority, Employee Insurance Program (Department or PEBA) closing her claim for basic long-term disability (LTD) benefits under the State of South Carolina Basic Long Term Disability Income Benefit Plan (Plan). Specifically, the Department informed Appellant that her medical condition did not qualify her for LTD benefits beyond February 21, 2021, under the terms and conditions of the Plan. Appellant timely appealed to the ALC.

STANDARD OF REVIEW

This case is before the Court as an appeal from a March 7, 2022 decision of the Department. The Plan provides that the Department has 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 [Public Employee Benefit Authority], 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

§ 1-11-710(C).

1

Therefore, the ALC's review of this case is in an appellate capacity under the standards of S.C. Code Ann. section 1-23-380 (Supp. 2021), 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.

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, 641, 321 S.E.2d 63, 68 (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, Inc., 276 S.C. 130, 136, 276 S.E.2d 304, 307 (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, 226, 467 S.E.2d 913, 917 (1996).

When applying the substantial evidence rule, the factual findings of the administrative agency are presumed to be correct. Rodney v. Michelin Tire Corp., 320 S.C. 515, 519, 466 S.E.2d 357, 359 (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, 353, 461 S.E.2d 388, 391 (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, 321 S.C. at 226, 467 S.E.2d at 917.

2

BACKGROUND

Appellant was formerly employed by the Darlington County School District (School District) as a Medicaid Assistant, a "Sedentary strength range" occupation under the Plan. As an employee of the School District, Appellant participated in the Plan. Standard Insurance Company (Standard) is the third-party claims administrator for the Plan. The Plan contains the following relevant provisions:

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
...

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