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