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24875 - Hendley, et al. v. S.C. Budget and Control Board, etc.

Davis Adv. Sh. No. 1
S.E. 2d



THE STATE OF SOUTH CAROLINA

In The Supreme Court

Janet C. Hendley and

William E. Hendley, Respondents,

v.

South Carolina State

Budget and Control

Board, acting by and

through its Division of

Insurance Services, Petitioner



ON WRIT OF CERTIORARI TO THE

COURT OF APPEALS

Appeal From York County

J. Buford Grier, Master-in-Equity





Opinion No. 24875

Heard May 14, 1998 - Filed January 4, 1999





REVERSED





Terry B. Millar, of Terry B. Millar, L.L.C., of Rock

Hill; Craig K. Davis and James F. Flanagan, both

of Davis Law Firm, P.C., of Columbia, for

petitioner.





James R. Honeycutt, of Fort Mill, and James B.

Richardson, Jr., of Svalina, Richardson & Larson, of

Columbia, for respondents.

p. 12


HENDLEY, et al. v. S.C. BUDGET AND CONTROL BOARD, etc.





FINNEY, C.J.: We granted certiorari to review the decision of

the Court of Appeals which held that the State Health Plan (Plan) is

obligated to pay for a "cranial hair vacuum prosthesis" for respondent

Janet Hendley, who suffers from a medical condition which causes the loss

of all body hair.1 Hendley v. South Carolina State Budget and Control

Board, 325 S.C. 413, 381 S.E.2d 159 (Ct. App. 1996). We reverse, finding

substantial evidence in the record supports the petitioner's decision to

deny coverage for this prosthetic device.





In this appeal brought pursuant to the Administrative

Procedures Act, respondents maintained that petitioner's decision to deny

coverage for the prosthesis was not supported by substantial evidence.

The Plan covers only an item which is medically necessary, one "that is

required to identify or treat an illness or injury . . ." There is

substantial evidence in the record to support petitioner's finding that the

prosthetic device does not identify or treat Ms. Hendley's medical

condition.





Further, the Plan excludes coverage for prosthetic devices

(other than breast implants) which have non-therapeutic uses. We find

substantial evidence2 supports the finding that the prosthetic device sought

had non-therapeutic uses, and thus was excluded from coverage.





Like all the decision-makers involved in this case, we are

sympathetic to Ms. Hendley's plight, and do not doubt that the prosthetic

device she seeks would make her life less difficult. We are constrained,

however, to review petitioner's decision and ask whether it is supported by

substantial evidence, that is, is there evidence in the record upon which






1 alopecia universalis.





2. For example, the record shows coverage was sought because the

prothesis, which is more durable and more securely attached than an

ordinary wig, would make walking on windy days or swimming at a pool

"less traumatic and intimidating." We note that respondents were not

represented by counsel at the evidentiary stage of these proceedings.

p. 13


HENDLEY. et al. v. S.C. BUDGET AND CONTROL BOARD. etc.





reasonable people would reach the same result? Sierra Club v. Kiawah

Resort Associates, 318 S.C. 119, 456 S.E.2d 397 (1995). Having found

such evidence, we reverse the decision of the Court of Appeals which itself

reversed petitioner's denial of benefits.



REVERSED.

MOORE, WALLER, and BURNETT, JJ., concur. TOAL, A.J.,

dissenting in a separate opinion.





p.14


HENDLEY. et al. v. S.C. BUDGET AND CONTROL BOARD. etc.

TOAL, A.J.: The majority holds that the State Health Plan is not

obligated to pay for Mrs. Hendley's "cranial hair vacuum prosthesis" because

the prosthesis does not identify or treat Mrs. Hendley's medical condition and

has non-therapeutic uses. The majority therefore reverses the Court of

Appeals' decision in Hendley v. South Carolina State Budget and Control

Board, 325 S.C. 413, 381 S.E.2d 159 (Ct. App. 1996. I would hold that the

hair prosthesis sought by Mrs. Hendley is,covered by her health plan. I

would therefore affirm the Court of Appeals' opinion. Accordingly, I dissent.





Mrs. Hendley suffers from alopecia universalis which, as noted by the

Court of Appeals, results in the loss of all scalp and body hair, including the

eyelashes and eyebrows. Mrs. Hendley's doctor prescribed the cranial hair

vacuum prosthesis for her condition. Mrs. Hendley's health plan covers

"medical services and supplies Medically Necessary in the diagnosis or

treatment of an illness or injury . . . [including] Prosthetic Appliances

necessary for the alleviation or correction of conditions caused by trauma or

disease . . . ." (Emphasis added). The health plan further defines medically

necessary as a "service or supply that is required to identify or treat an

illness or injury . . ." The health plan excludes prosthetic devices that have

non-therapeutic uses.





Exclusions in an insurance policy are always construed most strongly

against the insurer. Boggs v. Aetna Casualty and Surety Co., 272 S.C. 460,

252 S.E.2d 565 (1979). In my view, the hair prosthesis sought by Mrs.

Hendley in this case serves the same function and purpose as other

prosthetic devices which presumably would be covered under her health plan.

Just like an artificial limb or eye, the hair prosthesis "corrects" the condition

caused by alopecia universalis in that it replaces a part of the body lost due

to the disease. Its therapeutic value in this regard is no less real than that

attributed to traditional limb prostheses.





As stated in Abernathy v. Prudential Ins. of America, 274 S.C. 388, 264

S.E.2d 836 (19SO), the term "necessary" is best construed as what is

"appropriate" for the insured's condition. Clearly, a hair prosthesis is an

appropriate treatment for an otherwise incurable disease that results in the

loss of all body hair. Admittedly, all prosthetic devices have some degree of

cosmetic or non-therapeutic value. However, this fact alone would not

exclude a prosthesis from coverage under Mrs. Hendley's health plan. Thus,

in my opinion, Mrs. Hendley's hair prosthesis is covered by her health

insurance.



p. 15