ALJDEC decisions subject to certification as final
20F-008-ARB-RHG · Arizona State Retirement System · 2020-11-24
IN THE OFFICE OF ADMINISTRATIVE HEARINGS
Julie Wikman
APPELLANT,
v.
Arizona State Retirement System,
RESPONDENT.
No. 20F-008-ARB-RHG
ADMINISTRATIVE LAW JUDGE DECISION
HEARING: October 19, 2020 with the record held open until November 4, 2020 to allow the court reporter’s transcript to be made a part of the record.
APPEARANCES: Appellant Julie Wikman appeared on behalf of herself. Assistant Attorney General Cassie Adams appeared on behalf of Respondent Arizona State Retirement System.
ADMINISTRATIVE LAW JUDGE: Velva Moses-Thompson
_____________________________________________________________________
FINDINGS OF FACT
1. In June of 1997, Ms. Julie Wikman became a contributing member of Respondent Arizona State Retirement System (ASRS). See Exhibit 1.
2. Ms. Wikman’s effective date of disability is January 30, 2009.
See Exhibit 2.
3. On or about October 15, 2015, Segwick notified Ms. Wickman that she was required to provide verification of her disability to remain eligible for long-term disability (LTD) benefits. See Exhibit 4. At that time, Segwick was the administrator of the LTD program. The October 15, 2015 letter provided, in relevant part, as follows:
As a part of our routine verification of your continued eligibility for disability benefits, it is necessary to update the information in your file. We have enclosed a form to be completed by you, and your attending physician and returned to our office within 30 days.
Please note that the Arizona State Retirement System Long Term Disability Income Plan requires that you be under the care of a physician. Therefore in order to ensure you are compliant with this requirement, we must annually verify this information for all members.
4. Segwick sent a Disability Progress report, an Authorization For Claim and Benefits, and a Physician Statement to Ms. Wikman along with the October 15, 2015 letter. See Exhibit 4, Bates 0009, 0010, and 0012.
5. Ms. Wikman failed to complete and return the medical verification forms.
6. On or about November 17, 2015, Segwick notified Ms. Wikman that it had not received the updated medical information. Segwick provided an additional form to be completed by Ms. Wikman and her physician. See Exhibit 4, Bates 0014 to Bates 0016.
7. In or about December 18, 2015, Segwick notified Ms. Wikman that her LTD benefits would be suspended per A.R.S. section 38-797.07D if she failed to submit the requested medical verification within 15 day of December 18, 2015. See Exhibit 4, Bates 0020.
8. In January of 2016, Segwick notified Ms. Wikman that her LTD benefits would be suspended.
9. Ms. Wikman provided the verification requested and Ms. Wikman’s LTD benefits were reinstated in April of 2016.
10. In January of 2018, Broadspire notified Ms. Wickman that she was required to provide verification of her disability to remain eligible for LTD benefits.
See Exhibit 6, Bates 0045. Broadspire was the new administrator of the LTD program.
11. Broadspire provided a Disability Progress report, an Authorization For Claim and Benefits, and a Physician Statement to Ms. Wikman along with the January 2018 letter. See Exhibit 6, Bates 0047 to 0049.
12. Ms. Wikman failed to complete and return the medical verification forms.
13. In March of 2018, Broadspire notified Ms. Wikman that it would suspend her LTD benefits in the following 30 days if she failed to provide the requested medical verification. See Exhibit 6, Bates 0054.
14. Broadspire provided a Disability Progress report, the Authorization For Claim and Benefits, and the Physician Statement to Ms. Wikman along with the March 2018 letter. See Exhibit 6, Bates 0055 to 0057.
15. Ms. Wikman failed to complete and return the medical verification forms.
16. Ms. Wikman’s long term disability (LTD) benefits were terminated effective May 31, 2018 for failure to submit required documents. See Exhibit 2.
17. In June of 2018, ASRS notified Ms. Wikman that she was not eligible for health insurance because she had become ineligible for LTD benefits. See Exhibit 7.
18. Ms. Wikman subsequently requested that her LTD benefits be reinstated.
19. On or about November 18, 2018, ASRS notified Ms. Wikman that her LTD benefits were terminated because she failed to verify ongoing medical treatment.
See Exhibit 10. ASRS also notified Ms. Wikman that her benefits would be reinstated if she submitted the requested medical verification. ASRS provided a Disability Progress report, the Authorization For Claim and Benefits, and the Physician Statement to Ms. Wikman along with November 2018 letter. See id.
20. Ms. Wikman failed to provide Broadspire with verification of her ongoing treatment.
21. On or about November 30, 2018, Ms. Wikman notified ASRS that she disagreed with its decision to terminate her benefits for failure to verify ongoing medical treatment. See Exhibit 11.
22. From December of 2018 to March of 2020, ASRS repeatedly notified Ms. Wikman that her benefits were terminated for failure to verify ongoing medical treatment and that her benefits could be reinstated if she provided the requested medical verification.
23. In April of 2020, Ms. Wikman appealed the suspension of her LTD benefits.
24. ASRS notified Ms. Wikman that a hearing would convene on June 24, 2020 at 8:00 a.m.
25. Ms. Wikman failed to appear and the matter was dismissed.
26. Ms. Wikman subsequently notified the Office of Administrative Hearings (OAH) that she called to appear for hearing at 9:00 a.m. instead of 8:00 a.m.
27. ASRS referred the matter to the OAH for an evidentiary hearing.
28. On or about September 24, 2020, the ASRS issued a Notice of Hearing that provided that the issue set for determination was:
Due to the Arizona State Retirement System (ASRS) Director’s determination that Broadspire Services Inc. (“Broadspire”), ASRS’s Long Term Disability (“LTD”) plan administrator, appropriately terminated Ms. Wikman’s LTD benefits due to Ms. Wikman’s failure to submit the requisite documentation verifying that she is meeting the LTD plan requirements to receive LTD benefits, the ASRS has requested that the Office of Administrative Hearings conduct a formal hearing October 19, 2020 at 1:00 PM at 1740 West Adams Street, Lower Level, Phoenix, Arizona 85007 to determine whether grounds exist to justify the ASRS’s appealable agency action and its application of A.R.S. §§ 38-797.07(A)(7)(b), and 38-797.07(D), as well as Rule R2-8-302(D) of the Arizona Administrative Code. “to determine whether grounds exist to justify the ASRS’s appealable agency action and its application of A.R.S. § 38-797.07(A)(1)(f).”
29. At hearing, Ms. Wikman testified on behalf of herself and submitted exhibit A. The ASRS presented the testimony of Member Advocate, Ryan Guerra, and submitted exhibits 1 through 26.
30. At hearing, Ms. Wikman asserted that she is not required under A.R.S. section 38-797.07 to submit verification of an ongoing disability. Ms. Wikman explained that she verified her disability during her initial application for LTD benefits. Ms. Wikman contended that the initial verification is sufficient to remain eligible for LTD benefits under the law.
31. ASRS contended that under A.A.C. R2-8-302(B), members must submit documentation regarding the ongoing disability to remain eligible for LTD benefits. ASRS argued that the Director’s decision was correct because Ms. Wikman failed to verify her ongoing disability.
CONCLUSIONS OF LAW
Ms. Wikman bears the burden of proof and the standard of proof on all issues in this matter is that of a preponderance of the evidence. Ariz. Admin. Code § R2-19-119.
A preponderance of the evidence is:
The greater weight of the evidence, not necessarily established by the greater number of witnesses testifying to a fact but by evidence that has the most convincing force; superior evidentiary weight that, though not sufficient to free the mind wholly from all reasonable doubt, is still sufficient to incline a fair and impartial mind to one side of the issue rather than the other.
Black’s Law Dictionary 1373 (10th ed. 2014).
The primary goal when construing statutes is to fulfill the intent of the legislature. Backus v. State of Arizona, 220 Ariz. 101, 203 P.3d 499 (2009).
An agency’s authority is limited to that which is found in its enabling legislation. Arizona State Board of Regents v. Arizona State Personnel Board, 195 Ariz. 173, 985 P.2d 1032 (1999).
The tribunal may not expand or extend a statute to include that which is not within its provisions. State ex rel. Morrison v. Anway, 87 Ariz. 206, 349 P.2d 774 (1960).
Ariz. Rev. Stat. § 38-797.07 provides, “ASRS may suspend or terminate
benefits under this article if a member fails to provide information, data, paperwork or other materials that are requested by ASRS or the insurance company or claims administrator that is selected by the board to administer the LTD program.”
Ariz. Admin. Code § R2-8-302 provides:
A. In order to claim an LTD benefit, a disabled member shall submit to the disabled member’s Employer all the completed forms prescribed by the ASRS contracted LTD claims administrator within 12 months of the date the disabled member became disabled.
B. Pursuant to A.R.S. § 38-797.07(D), in order to continue receiving an LTD benefit, a disabled member shall submit documentation regarding the disabled member’s ongoing disability and occupation as required by the ASRS contracted LTD claims administrator to determine the disabled member’s continuing eligibility for an LTD benefit.
C. Pursuant to A.R.S. § 38-797.07(11), in order to submit an application for an LTD benefit, a member must provide objective medical evidence from an Attending Physician.
D. Pursuant to A.R.S. § 38-797.07(7)(b)(i), in order to continue receiving an LTD benefit, the disabled member must be under the Direct Care of a doctor.
The preponderance of the evidence shows that Ms. Wikman failed to verify an ongoing disability and that she was under the Direct care of a Doctor.
Ms. Wikman has not shown by a preponderance of the evidence that ASRS erred when it denied her request to reinstate her LTD benefits, nor has she shown that ASRS has the legal authority to reinstate LTD benefits absent the required medical verification.
Consequently, Ms. Wikman’s appeal should be dismissed.
ORDER
IT IS ORDERED that Julie Wikman’s appeal is dismissed.
In the event of certification of the Administrative Law Judge Decision by the Director of the Office of Administrative Hearings, the effective date of the Order is five days after the date of that certification.
Done this day, November 24, 2020.
/s/ Velva Moses-Thompson
Administrative Law Judge
Transmitted electronically to:
Paul Matson, Director
Arizona State Retirement System