Lewis Coal Co. v. Director, O.W.C.P.

• Decision Date: 24 June 2004
• Docket Number: No. 03-1425.,03-1425.
• Citation: 373 F.3d 570
• Parties: LEWIS COAL COMPANY; Old Republic Insurance Company, Petitioners, v. DIRECTOR, OFFICE OF WORKERS' COMPENSATION PROGRAMS, UNITED STATES DEPARTMENT OF LABOR; Hershel U. McCoy, Respondents.
• Court: U.S. Court of Appeals — Fourth Circuit

373 F.3d 570

LEWIS COAL COMPANY; Old Republic Insurance Company, Petitioners, v. DIRECTOR, OFFICE OF WORKERS' COMPENSATION PROGRAMS, UNITED STATES DEPARTMENT OF LABOR; Hershel U. McCoy, Respondents.

No. 03-1425.

United States Court of Appeals, Fourth Circuit.

Argued: February 25, 2004.

Decided: June 24, 2004.

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ARGUED: Mark Elliott Solomons, Greenberg Traurig, L.L.P., Washington, D.C., for Petitioners. Gary K. Stearman, Office of the Solicitor, United States Department of Labor, Washington, D.C., for Respondents. ON BRIEF: Laura Metcoff Klaus, Greenberg Traurig, L.L.P., Washington, D.C., for Petitioners. Howard M. Radzely, Acting Solicitor of Labor, Allen H. Feldman, Associate Solicitor for Special Appellate and Supreme Court Litigation, Nathaniel I. Spiller, Deputy Associate Solicitor, United States Department of Labor, Washington, D.C., for Federal Respondent. Susan D. Oglebay, Castlewood, Virginia, for Respondent McCoy.

Before WIDENER and DUNCAN, Circuit Judges, and William D. QUARLES, Jr., United States District Judge for the District of Maryland, sitting by designation.

Petition denied by published opinion. Judge DUNCAN wrote the opinion, in which Judge WIDENER and Judge QUARLES joined.

OPINION

DUNCAN, Circuit Judge:

Lewis Coal Company, Inc. and its insurer, Old Republic Insurance Company, petition for review of the final Decision and Order of the Benefits Review Board ("BRB") directing them to pay medical benefits to Respondent Hershel McCoy. McCoy is a former coal miner and employee of Lewis Coal adjudged to be totally disabled due to pneumoconiosis, a pulmonary condition commonly referred to as "black lung disease." The BRB directed that Lewis Coal reimburse McCoy for approximately $1800 in medical expenses that it concluded were related to his disability, based in large part on the presumption in this circuit that a miner applying for medical benefits may demonstrate his eligibility by showing that he has been adjudged to be disabled by pneumoconiosis. Because we find the challenges to the legal and evidentiary underpinnings of the BRB's Order to be meritless, the petition for review is denied.

I.

The essential facts underlying McCoy's medical benefits claim are as follows. McCoy ended his roughly twenty-year career as a coal miner in 1972, at the age of forty-three, due to "chest problems" he began experiencing in 1971. Before ending his employment with Lewis Coal, McCoy filed a disability claim with the Social Security Administration ("SSA") under Part B of the antecedent to the Black Lung Benefits Act (codified as amended at 30 U.S.C. § 901 et seq.) ("the BLBA").¹ Part B of the BLBA established a federally funded program administered by the SSA to provide monthly disability payments to miners who claimed to be totally disabled due to pneumoconiosis within the meaning of the BLBA on or before June 30, 1973. See Usery v. Turner Elkhorn Mining Co., 428 U.S. 1, 8-11, 96 S.Ct. 2882, 49 L.Ed.2d 752 (1976) (discussing statutory history and organization of BLBA). Based on McCoy's claim and supporting medical evidence, the SSA concluded McCoy was totally disabled and awarded disability payments under Part B.

In 1978, Congress amended Part C of the BLBA, which established an industry-funded disability program administered by the Department of Labor ("DoL") for all BLBA claims filed on or after July 1, 1973. Id. As part of its 1978 amendments to Part C, Congress permitted miners with a Part B disability determination to file claims for "medical benefits only" under Part C.² See Doris Coal Co. v. Director, Office of Workers' Comp. Programs, 938 F.2d 492, 494 (4th Cir.1991). The DoL designated Lewis Coal as the mine operator responsible for McCoy's disability, and thus responsible for covering McCoy's medical benefits payments. Although Lewis Coal initially contested McCoy's claim, it withdrew its challenge in 1981 and entered into a settlement agreement with McCoy. Significantly, the agreement stated that Lewis Coal "agrees to accept the... initial determination that the claimant, Herschel U. McCoy, meets the standards of total disability under the [BLBA]," and that it understood that the agreement "may be the basis for the issuance of an Award of Medical Benefits and Order to Pay Medical Benefits in this claim." J.A. 18.

Lewis Coal paid McCoy's medical bills pursuant to the agreement until 1986, at which point Lewis Coal and its workers' compensation insurer, Old Republic Insurance Co. (collectively "Lewis Coal"), took the position that the bills reflected unnecessary treatment. Specifically, Lewis Coal alleged that McCoy's condition reflected "[n]o CWP [coal workers' pneumoconiosis] or Very Minimal Disease," and that pneumoconiosis present at those levels "rarely requires medical attention or interacts to exacerbate other health problems." J.A. 19. McCoy filed a complaint with the DoL regarding Lewis Coal's denial of benefits, which the DoL referred to an administrative law judge ("ALJ") for a hearing. At the hearing, McCoy presented evidence that the medical treatments for which he sought compensation under Part C were related to the disabling conditions on which his Part B award was based. In response, Lewis Coal presented medical evidence from several sources suggesting that McCoy no longer suffered from a Part B disability and that the pulmonary conditions for which he sought compensation were attributable to cigarette smoking rather than disabling pneumoconiosis. Applying this court's presumption in Doris Coal that "most pulmonary disorders are going to be related or at least aggravated by the presence of pneumoconiosis," 938 F.2d at 496, the ALJ concluded that Lewis Coal's medical evidence did not provide a basis for denying McCoy's continuing requests for medical benefits, and the BRB affirmed the ALJ's determination on that basis. Lewis Coal timely petitioned this Court for review.

II.

Our review of the BRB's order is limited. We review the BRB's decision to assess whether substantial evidence supports the factual findings of the ALJ and whether the legal conclusions of the BRB and ALJ are rational and consistent with applicable law. Milburn Colliery Co. v. Hicks, 138 F.3d 524, 528 (4th Cir.1998). Substantial evidence "is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Bill Branch Coal Corp. v. Sparks, 213 F.3d 186, 190 (4th Cir.2000) (internal quotation marks omitted). As presented in its petition for review, Lewis Coal's claims require once again that we assess whether the BRB "properly applied our precedent in Doris Coal to the facts at hand." Gulf & Western Indus. v. Ling, 176 F.3d 226, 231 (4th Cir.1999).

A.

Through Doris Coal and its progeny, this court has clarified the process by which a miner whose lung disease has been adjudged to be totally disabling under Part B may sustain a claim for medical benefits under Part C. In order to demonstrate his eligibility, the miner must show that the mine operator was responsible for his pneumoconiosis and that the particular medical expenses for which he seeks reimbursement were necessary to treat his disabling condition. Doris Coal, 938 F.2d at 495. An expense is deemed necessary to treat pneumoconiosis if the treatment "relates to any pulmonary condition resulting from or substantially aggravated by the miner's pneumoconiosis." Id. at 496 (emphasis added). In establishing this regime, this court presumed that "most pulmonary disorders are going to be related or at least aggravated by the presence of pneumoconiosis." Id. As a result, "when a miner receives treatment for a pulmonary disorder, a presumption arises that the disorder was caused or at least aggravated by the miner's pneumoconiosis." Id. at 496-97.

In practice, the Doris Coal presumption permits a miner to satisfy his initial burden of production regarding his eligibility for Part C benefits by presenting his underlying Part B award, which specifies the conditions and symptoms that were found to be disabling, and the expenses he claims are related to those conditions and symptoms. Doris Coal, 938 F.2d at 496. The mine operator may then rebut the presumption of relatedness by showing that a particular expense is actually: 1) "for a pulmonary disorder apart from those previously associated with the miner's disability"; 2) "beyond that necessary to effectively treat a covered disorder"; or 3) "not for a pulmonary disorder at all." Ling, 176 F.3d at 233. Throughout the process, however, the burden of persuasion as to relatedness remains with the miner. Gen. Trucking Corp. v. Salyers, 175 F.3d 322 (4th Cir.1999).

As we have often stated, the Doris Coal presumption precludes a mine operator from attempting to rebut the presumption of relatedness by attacking the underlying Part B award. Permitting a mine operator to contest a Part C claim by requiring the miner to prove his qualifying disability would "place a significant burden on the Black Lung benefits system, increase litigation costs for all of the parties involved, and further delay important medical benefits that a miner suffering from pneumoconiosis needs." Doris Coal, 938 F.2d at 497; see also Ling, 176 F.3d at 233-34. Consequently, "mine operators can only use subsequent proceedings to challenge the necessity of certain medical charges for the treatment of a pneumoconiosis related disorder or challenge medical charges not related to pneumoconiosis"; they may not "require the miner to prove again that he has pneumoconiosis each time he makes a claim for health benefits." Doris Coal, 938 F.2d at 497.

B.

In accordance with Doris Coal, McCoy presented evidence regarding his 1973 Part B disability determination and the treatment for which he sought reimbursement under Part C. Although neither McCoy nor Lewis Coal introduced a copy of McCoy's actual Part B award from the SSA that discussed the conditions and symptoms the SSA...