Case Name: GLEN COAL COMPANY and Old Republic Insurance Company, Petitioners, v. Jess SEALS and Director, Office of Workers' Compensation Programs, United States Department of Labor, Respondents
Court: United States Court of Appeals for the Sixth Circuit
Jurisdiction: United States
Decision Date: 1998-06-24
Citations: 147 F.3d 502
Docket Number: No. 96-4121
Parties: GLEN COAL COMPANY and Old Republic Insurance Company, Petitioners, v. Jess SEALS and Director, Office of Workers’ Compensation Programs, United States Department of Labor, Respondents.
Judges: Before: BOGGS and MOORE, Circuit Judges; and DOWD, District Judge.
Reporter: Federal Reporter 3d Series
Volume: 147
Pages: 502–522

Head Matter:
GLEN COAL COMPANY and Old Republic Insurance Company, Petitioners, v. Jess SEALS and Director, Office of Workers’ Compensation Programs, United States Department of Labor, Respondents.
No. 96-4121.
United States Court of Appeals, Sixth Circuit.
Argued Dec. 1, 1997.
Decided June 24, 1998.
Laura Metcoff Klaus (briefed), Mark E. Solomons (argued and briefed), Arter & Had-den, Washington, DC, for Petitioners.
Harold Ronnie Montgomery, Jonesville, VA, Christian P. Barber, Gary K. Stearman (argued and briefed), U.S. Department of Labor, Office of the Solicitor, Washington, DC, for Respondents.
Before: BOGGS and MOORE, Circuit Judges; and DOWD, District Judge.
The Honorable David D. Dowd, Jr., United States District Judge for the Northern District of Ohio, sitting by designation.

Opinion:
DOWD, D. J., delivered the opinion of the court. BOGGS, J. (pp. 515-17), delivered a separate opinion concurring in the judgment. MOORE, J. (pp. 517-22), delivered a separate opinion concurring in part and dissenting in part.
OPINION
DOWD, District Judge.
INTRODUCTION
Petitioners Glen Coal Company and its insurer Old Republic Insurance Company (collectively "Petitioners") appeal an award of benefits under the Black Lung Benefits Act. 30 U.S.C. § 901-945. An administrative law judge ("ALJ") of the United States Department of Labor ("DOL") ordered Petitioners to pay certain medical bills of Respondent Jess Seals ("Seals"), holding that Petitioners had failed to rebut a presumption established in the Fourth Circuit that Seals' medical bills were related to his pneumoconi-osis (Black Lung disease of respiratory system). This award was subsequently affirmed by the Benefits Review Board. An appeal was noticed to the United States Court of Appeals for the Fourth Circuit, but it was then determined that Seals had incurred his injury from his work in coal mines in Kentucky. Accordingly, the Fourth Circuit granted Petitioners' motion to transfer the appeal to this Court in accordance with 28 U.S.C. § 1631.
On appeal, Petitioners argue for a remand to the ALJ on the grounds that the Fourth Circuit presumption applied below is inconsistent with the law of the Sixth Circuit because the presumption impermissibly reallocates the burden of proof in a manner that conflicts with § 7(c) of the Administrative Procedure Act ("APA"). 5 U.S.C. § 556(d). Specifically, Petitioners argue that under § 7(c) of the APA, the burden should be on Seals, the claimant, to prove that the medical bills are related to his pneumoconiosis. Seals and co-Respondent Director, Office of Workers' Compensation Programs, United States Department of Labor ("Director") (collectively "Respondents"), on the other hand, argue that the presumption merely reallocates the burden of production, and therefore does not violate § 7(c) of the APA.
These arguments require us to examine whether the Fourth Circuit presumption is consistent with Sixth Circuit law. This is a two step process: (1) does the presumption violate § 7(c) of the APA, in which case it is an impermissible presumption; and (2) if it does not violate § 7(c) of the APA, does it otherwise conflict with the law of this Circuit concerning Black Lung Benefits Act issues?
After careful review of the matter, and for the reasons set forth below, we hold that the judicial presumption created by the Fourth Circuit and applied by the ALJ is inconsistent with the law of the Sixth Circuit. While we find that the presumption does not violate § 7(c) of the APA, we find that it nonetheless runs afoul of the purposes of the Black Lung-Benefits Act. As a result, we VACATE the decision awarding benefits to Seals, and REMAND to the ALJ for a determination of Petitioners' liability for the medical bills here in dispute under the legal standard stated herein for the Sixth Circuit.
Before addressing the substantive issues on appeal, an overview of the structure of the Black Lung Benefits Act is instructive.
OVERVIEW OF THE BLACK LUNG BENEFITS ACT
The Black Lung Benefits Act was enacted to "provide benefits . to coal miners who are totally disabled due to pneumoconiosis and to the surviving dependents of miners whose death was due to such disease." 30 U.S.C. § 901(a). Under the Act, pneumoco-niosis is defined as "a chronic dust disease of the lung and its sequelae, including respiratory and pulmonary impairments, arising out of coal mine employment." 30 U.S.C. § 902(a).
Part B of the Black Lung Benefits Act provides for monthly cash benefits to the claimant, but no health care benefits. 30 U.S.C. § 921-925. Part B claims are paid by the federal government and do not involve the mine operators or the DOL.
Part C of the Black Lung Benefits Act, on the other hand, establishes an employer-funded federal workers compensation program to provide benefits, in cooperation with the states, for total disability or death due to pneumoconiosis, and is administered by the DOL. 30 U.S.C. § 931-945. Medical benefit entitlements under Part C of the Black Lung Benefits Act are governed generally by 20 C.F.R. § 725.701-725.707. The procedure for determining entitlement has been held to be a two-stage procedure. See Lute v. Split Vein Coal Company, No. 84-2087 BLA, O.W.C.P. No. [ XXX-XX-XXXX ], 1987 WL 107347, *2 (Ben.Rev.Bd. March 20, 1987). The first stage is the liability phase, which involves the determination of whether the miner is totally disabled from pneumoconiosis, thereby making the employer/operator responsible; and the second stage is the determination of the employer/operator's liability for individual medical bills. See Lute, supra, at *2.
The first stage is governed by 20 C.F.R. § 727.203, which states that a miner is entitled to an "interim presumption" of total disability due to pneumoconiosis resulting from coal mine work if the miner worked in a coal mine for over 10 years and the miner can offer certain listed medical evidence. Following the miner's offering of this evidence, the miner is entitled to the statutory "interim presumption" that he is totally disabled from pneumoconiosis. Then, the employer can rebut this presumption in one of four listed ways. Alternatively, the employer could concede that the miner is totally disabled, but argue that some malady other than or in addition to a respiratory ailment is responsible for the disability, employing one of the listed rebuttal methods. Cal-Glo Coal Company v. Yeager, 104 F.3d 827, 831 (6th Cir.1997).
After the decision has been made that the miner is totally disabled from pneumoconio-sis, the employer/operator is liable for the medical bills incurred in treatment. See Lute, supra, at *2. The analysis then moves to the second stage. With liability settled, the question becomes whether the individual bills are related to the miner's pneumoconio-sis. The procedure for disputes concerning medical benefits is found in 20 C.F.R. § 725.707. This section, unlike the section concerning the initial determination of liability, does not set out any statutory presumptions. Rather, it merely states that if the dispute cannot be resolved by the district director, then it proceeds to the Office of Administrative Law Judges. 20. C.F.R. § 725.707(b).
BACKGROUND FACTS
Seals was a miner for approximately seventeen years. He stopped working in 1972, at the age of 42, following a back injury. Additionally, Seals smoked a pack of cigarettes a day for approximately 35 years.
Within a year- of stopping work, Seals was awarded benefits from the Social Security Administration under Part B of the Black Lung Benefits Act. 30 U.S.C. § 921-925. This award is not at issue in this case because, as explained above, Part B claims are paid by the federal government and do not involve the mine operators or the DOL.
On June 27, 1979, Seals filed a claim for health benefits under Part C of the Black Lung Benefits Act. See 30 U.S.C. § 931— 945. These benefits are at issue in this case.
The Old Republic Insurance Company ("Old Republic"), the black lung insurance carrier for the Glen Coal-Company ("Glen Coal"), was notified of Seals' claim sometime in 1984. Old Republic agreed without further proceedings to pay the cost of black lung related health care provided to Seals. In fact, the parties entered into an agreement stating that Seals "meets the standard of total disability under the. Black Lung Benefits Act (30 U.S.C. 901 et seq.). The above coal mine operator [ (Glen Coal) ] further agrees to pay medical benefits and to reimburse the Black Lung Disability Trust Fund for any medical benefit payments made." Subsequently, on June 11, 1984, the DOL deputy commissioner issued an uncontested award of benefits to Seals providing as follows:
The responsible operator [ (Glen Coal) ] shall provide to the claimant [ (Seals) ] all reasonable and necessary medical benefits required for the treatment'of his pneumo-coniosis condition, including the reasonable costs of transportation to obtain such treatment, beginning, June 27, 1979 and continuing, in accordance with the provisions and limitations of the Act. The DOL also informed Old Republic that no bills had been submitted in the period from June 1979 to June 1984 for treating Seals' pneumoconiosis.
The Longshore and Harborworkers' Compensation Act ("LHWCA") requires a health care provider who begins to treat a compensation beneficiary to give notice to the employer and to provide certain reports outlining the course of treatment to be followed. 33 U.S.C. § 907(d). Petitioners here, however, claim that after accepting liability to pay the cost of treating Seals' pneumoconiosis, Petitioners never received a first report from a treating physician, and, in fact, did not receive any information from any physician at all.
Nonetheless, beginning in 1985, Old Republic began receiving bills for prescription antibiotics and bronchodilators for Seals. No information was provided to show that the infection being treated was caused by pneumoconiosis, and for that reason, Old Republic declined to pay the bills. Old Republic wrote several letters to the pharmacist who sent the bills, stating that Old Republic was not responsible for payment for the antibiotics since they could not be for treatment of pneumoconiosis, which is "not infectious in nature."
In 1987, Seals submitted the unpaid bills to the DOL. Dr. Cander, the DOL's medical consultant, reviewed the medical bills. On April 25, 1988, Dr. Cander concluded that under the Federal Black Lung Act, the use of bronchodilators was reimbursable, but the antibiotic therapy was not. Therefore, it was Dr. Cander's recommendation that Glen Coal pay for the bronchodilator treatments, but not the antibiotic therapy.
On August 10, 1988, the DOL adopted Dr. Cander's conclusion and ordered Glen Coal to pay for the bronchodilator treatment. Old Republic again refused, stating that the record contained no justification for bronchodilator therapy, and that Seals' most recent x-ray had been negative for clinical pneumoco-niosis.
Due to the fact that the dispute continued, the DOL forwarded the case to the Office of Administrative Law Judges on May 18, 1989. Administrative Law Judge Clement J. Ki-chuk ("the ALJ") heard this case on November 6, 1991. On June 2, 1992, the ALJ issued his decision, ordering Petitioners to pay for both the bronchodilators and the antibiotics, with a total amount owed of approximately $1,900.
The ALJ began his decision by setting out the two ways in which the first stage determination of total disability by pneumoconiosis may be reached:
[a] mine operator is responsible for a claimant's pneumoconiosis if either 1) it is determined in an adjudication that the miner is totally disabled due to pneumoco-niosis, and is, therefore, entitled to benefits under the Act or 2) the mine operator voluntarily agrees to pay the cost of such treatment by conceding the claimant's general eligibility. Doris Coal Company v. Director, OWCP, 938 F.2d 492, 15 BLR 2-135, 138 (4th Cir.1991); Lute v. Split Vein Coal Company, 11 BLR 1-82, 1-84 (1987).
The ALJ then held that Glen Coal was liable for the treatment of Seals' pneumoconiosis due to the prior agreement. Therefore, the only issue for adjudication by the ALJ was the second stage issue of whether Seals had established that the medical bills at issue were for the treatment of his pneumoconio-sis.
The ALJ then noted that under the Act, Seals was required to establish that the medical bills were necessary to treat his pneumo-coniosis, but held that Seals did not need to make any preliminary evidentiary offering, citing the rationale of the Fourth Circuit case of Doris Coal Company v. Director, OWCP, 938 F.2d 492 (4th Cir.1991). Instead, adopting that Fourth Circuit decision, the ALJ concluded that Seals was entitled to the so-called "Doris Coal presumption" that the bills were related to his pneumoconiosis, and therefore Petitioner's bore the burden of rebutting this presumption by showing the bills were not related to Seals' pneumoconiosis.
Explaining the Doris Coal decision and the reasons for its applicability in the instant case, the ALJ focused on the Doris Coal court's distinction between "clinical" or "medical" pneumoconiosis and "legal" pneu-moconiosis:
The Act defines pneumoconiosis as a "chronic dust disease of lung . arising out of coal mine employment." 30 U.S.C. § 902(b). As we recognized in Hobbs v. Clinchfield Coal Co., 917 F.2d 790, 791 n. 1 (4th Cir.1990), "clinical" or "medical" pneu-moconiosis must be distinguished from "legal" pneumoconiosis. Medical pneumoco-niosis is "the lung disease caused by the fibrotic reaction of the lung tissue to inhaled dust ." Id. Legal pneumoconiosis., [sic] however, is much broader and "refers to all lung diseases which meet the statutory or regulatory definition of being any lung disease which is significantly related to, or substantially aggravated by, dust exposure in coal mine." Id.
Id. at 496. The Doris Coal Court then applied the broader legal definition of pneumo-i coniosis to the miner's burden, and in so doing created the presumption that is at issue on this appeal:
Based on this broad definition, a miner meets his burden of showing that his medical expenses were necessary to treat pneu-moconiosis if his treatment relates to any pulmonary condition resulting from or substantially aggravated by the miner's pneu-moconiosis. Since most pulmonary disorders are going to be related or at least aggravated by the presence of pneumo-coniosis, 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, making the employer liable for the medical costs.
Id. at 496-97 (emphasis added).
After reviewing the rationale of the Doris Coal court, the ALJ held that because the parties here had agreed that Seals was totally disabled from pneumoconiosis, as defined under the Act, they had agreed to the broader definition of "legal" pneumoconiosis, and therefore the Doris Coal presumption applied. Seals was therefore entitled to the presumption that the "disabling pulmonary disorder" for which he received treatment was caused or at least aggravated by his pneumoconiosis: As such, Glen Coal was responsible for the medical costs. The ALJ concluded that the presumption was proper because "[t]o hold otherwise would, in effect, require [Seals] to prove again that his respiratory ailment.is related to his coal mine employment, thus, placing an undeserved burden upon [Seals] and on the black lung benefits system. See Doris Coal Company, 15 BLR at 140 [938 F.2d 492]." Glen Coal was then afforded the opportunity to rebut this presumption.
The ALJ then made specific findings of fact with respect to four doctors' reports to determine whether they were sufficient to rebut the presumption that the bills were related to Seals' pneumoconiosis. Drs. McQuillan and Kanwal concluded that the medical treatments at issue were related to Seals' pneumoconiosis. Dr. McQuillan based his findings on a review of the treatment and office notes of- Seals' physician; Dr. Kanwal based his opinion on two examinations of Seals in 1990, and ffis review of the prior medical records of Seals. The ALJ found that the other two doctors (Drs. Dah-han and Branscomb), on the other hand, concluded that the medical treatments at issue were not related to Seals' pneumoconio-sis. Dr. Dahhan examined Seals on three occasions in 1989 and 1990, and both he and Dr. Branscomb concluded that the prescribed medications were for chronic bronchitis and bronchospasm resulting from Seals' smoking history. Moreover, Dr. Dah-han concluded that there was not enough evidence to diagnose pneumoconiosis.
The ALJ held that neither the opinion of Dr. Dahhan nor the opinion of Dr. Bran-scomb was sufficient to rebut the presumption that the disorder for which Seals was receiving treatment was caused or aggravated by pneumoconiosis. The ALJ found the report of Dr. Dahhan to be unpersuasive because Dr. Dahhan opined that Seals did not have pneumoconiosis despite the fact that the parties had stipulated to that fact, and the DOL had already awarded medical benefits to Seals. Therefore, the ALJ held that Dr. Dahhan's report was "contrary to the spirit of the Act in that a final determination of entitlement to medical benefits precludes raising the basic issues of entitlement."
The ALJ found Dr. Branscomb's report unpersuasive because it was conclusory in nature. Dr. Branscomb opined that the treatments were for pulmonary disorders caused by Seals' smoking rather than his pneumoconiosis. However, because Dr. Branscomb did not explain the reasons for this opinion, the ALJ was not persuaded.
The ALJ then made specific findings himself concerning whether Seals' cigarette smoking played a part in his respiratory problems.
The Court notes that pneumoconiosis is irreversible and is a progressive disease. While his symptoms secondary to cigarette smoking ordinarily would be expected to stabilize upon cessation of tobacco use, claimant's COPD advanced even after he quit smoking. The Court is not persuaded by [Petitioners'] rebuttal evidence urging that pneumoconiosis made no contribution to the claimant's lung disease manifested by COPD and chronic bronchitis as well as by other pulmonary and respiratory afflictions.
In conclusion, the ALJ ordered Petitioners to pay for both the bronehodilators and the antibiotics prescribed for Seals.
Petitioners appealed this decision to the Benefits Review Board. The Board upheld the decision of the ALJ on the grounds that it was supported by substantial evidence and there was no reversible error. Further, the Board upheld the application of the Doris Coal presumption to this case, and also upheld all of the ALJ's findings of fact with regard to the four doctors' reports. One member of the Board, however, wrote a separate concurrence to the Board's affirmance of the ALJ's order. While believing that the "court-created" presumption was contrary to the holding of the United States Supreme Court in Director, OWCP Department of Labor v. Greenwich Collieries [Ondecko], 512 U.S. 267, 114 S.Ct. 2251, 129 L.Ed.2d 221 (1994)(elaimant must prove his case by a preponderance of the evidence, in accordance with § 7(c) of the APA), the member wrote that he was concurring in the opinion because the substantial evidence supported the ALJ's award of medical benefits.
An appeal was subsequently taken to the United States Court of Appeals for the Fourth Circuit. The Fourth Circuit transferred the matter to this Court pursuant to 28 U.S.C. § 1631 upon discovery that Seals' coal mine work occurred in the Sixth Circuit, in Kentucky. Before this Court is therefore an issue of first impression of whether the Fourth Circuit Doris Coal presumption is consistent with the law of the Sixth Circuit, as governed by § 7(c) of the APA.
PROPRIETY OF APPLICATION OF THE DORIS COAL PRESUMPTION IN THE SIXTH CIRCUIT
Petitioners argue that this Court should vacate the order of the ALJ in this case and remand for proceedings under Sixth Circuit law, as governed by § 7(c) of the APA. Petitioners argue that the Fourth Circuit presumption relied upon by the ALJ is improper as a matter of law because it shifts the burden of proof to Petitioners, in conflict with § 7(c) of the APA, which states that the burden of proof is on the proponent of a rule or order (i.e. Seals in this case) unless statutorily changed. Petitioners rely on the Supreme Court decision of Director, OWCP, Department of Labor v. Greenwich Collieries [Ondecko], 512 U.S. 267, 114 S.Ct. 2251, 129 L.Ed.2d 221 (1994), which struck down a judicially created presumption in conflict with § 7(c) of the APA because it attempted to place the burden .of proof on other than the claimant.
Respondents, on the other hand, argue that the Doris Coal presumption does not violate the rule of Greenwich Collieries and is therefore consistent with § 7(c) of the APA and the law of the Sixth Circuit. Respondents argue that the Doris Coal presumption merely reallocates the burden of production, and Greenwich Collieries only prohibits a reallocation of the burden of proof.
1.Standard of Review
The court of appeals has a very narrow scope of review over decisions of the Benefits Review Board. Cah-Glo Coal Company v. Yeager, 104 F.3d 827, 830 (6th Cir.1997). The AL J hears the evidence and makes findings of fact. Director, OWCP, United States Department of Labor v. Quarto Mining Company, 901 F.2d 532 (6th Cir.1990). The Benefits Review Board then reviews the findings of fact and conclusions of law of the AL J and may set them aside "only if they are not supported by substantial evidence in the record considered as a whole or if they are not in accordance with law." Quarto, supra, at 536.
The court of appeals' review of the Benefits Review Board is then "limited to a determination whether the outcome below is supported by substantial evidence and was reached in conformance with applicable law." York v. Benefits Review Board, 819 F.2d 134, 136 (6th Cir.1987). This circuit has stated that the court of appeals must affirm the Board's decision if the Board has not committed any legal errors or exceeded its statutory scope of review of the ALJ's factual determinations. See Pyro Mining Co. v. Slaton, 879 F.2d 187 (6th Cir.1989). Furthermore, as in the court of appeals' review of a district court decision, the court of appeals may affirm the decision of the Board on grounds other than those stated by the Board. See Old Ben Coal Co. v. Luker, 826 F.2d 688 (7th Cir.1987).
2. Statutory Burdens Applicable to the Black Lung Benefits Act
Section 7 of the APA states that "[e]x-cept as otherwise provided by statute, the proponent of a rule or order has the burden of proof." 5 U.S.C. § 556(d). The United States Supreme Court has held that this burden of proof provision applies to adjudications under the Black Lung Benefits Act. Director, OWCP, Department of Labor, v. Greenwich Collieries [Ondecko], 512 U.S. 267, 270, 114. S.Ct. 2251, 2254, 129 L.Ed.2d 221 (1994). There, the Supreme Court stated that its prohibition of certain judicially created presumptions would not overburden Black Lung claimants because Congress realized that these claims could be hard to prove, and so created certain statutory presumptions to ease claimants' burdens. Id. at 280, 114 S.Ct. 2251. In conclusion, the Court held that the Department of Labor Administrative Law Judges cannot formulate additional presumptions which allocate the burden of proof in a manner that is in conflict with the APA. Id. at 281,114 S.Ct. 2251.
3. Does the Doris Coal presumption improperly reallocate the burden of proof?
In this case, the ALJ and the Board were confronted with a situation in which the first stage of the Black Lung Benefits Act analysis had been settled by agreement. The parties had agreed that Seals was totally disabled by pneumoconiosis and that Petitioners were the responsible party. Absent this agreement, the first stage would have required Seals to prove that he was totally disabled by pneumoconiosis. 20 C.F.R. § 727.203. Here, however, because the parties agreed that Seals was totally disabled from pneumoconiosis and that Glen Coal was the responsible operator, the dispute involved the second stage determination of whether Petitioners had to pay certain of Seals' medical bills.
Faced with this situation, the ALJ followed the Fourth Circuit case of Dons Coal. The Doris Coal court recognized that in the second stage, the miner had the "burden" of proving that the bills were related to the pneumoconiosis. However, the court held that following a first stage determination of liability, the miner is entitled to a presumption that the bills are related to pneumoconi-osis, and the "burden" is therefore on the employer/earrier to rebut this presumption by showing the bills are not related to pneu-moconiosis. The Doris Coal court did not cite any ease law or statute which supported the creation of this presumption. Rather, the Doris Coal court stated that this presumption was warranted because "most pulmonary disorders are going to be related or at least aggravated by the presence of pneu-moconiosis." Doris Coal, supra, at 496-97. Furthermore, the Doris Coal court seemed to suggest that because the miner bore the "burden" of proving his pneumoconiosis in the first stage, it would be unfair, and against the spirit of the Black Lung Benefits Act, to place the "burden" on the miner in the second stage as well.
Petitioners argue that the Doris Coal presumption is contrary to the legal standards applicable to the Black Lung Benefits Act based on the Supreme Court case of Greenwich Collieries, supra. In that ease, the Supreme Court held that § 7(c) of the APA applies to the Black Lung Benefits Act, and thus places the burden of proof on the proponent of a rule or order unless otherwise stated by statute. Id. at 271, 114 S.Ct. 2251. The Court then struck down the so-called "true doubt" rule which said that when the evidence was evenly balanced, the claimant wins, holding it conflicted with § 7(c) of the APA. Id. at 281, 114 S.Ct. 2251. The Court held that this judicially created presumption "ran afoul of the APA, a statute designed 'to introduce greater uniformity of procedure and standardization of administrative practice among the diverse agencies whose customs had departed widely from each other.' " Id. at 280-81, 114 S.Ct. 2251, quoting Wong Yang Sung v. McGrath, 339 U.S. 33, 41, 70 S.Ct. 445, 94 L.Ed. 616 (1950).
Respondents argue on appeal that the Doris Coal presumption is distinguishable from the invalid "true doubt rule" because the Doris Coal presumption merely reallocates the burden of production, not the burden of proof, and therefore is valid under Greenwich Collieries. In support of this argument, Respondents cite the case of Lovilia Coal Co. v. Harvey, 109 F.3d 445 (8th Cir.1997), in which the Eighth Circuit upheld a presumption created by the Director of the Department of Labor, rejecting the argument that it violated § 7(c) of the APA. The presumption at issue in Lovilia was called the "one-element" standard, and concerned the first stage determination of entitlement of a miner who was previously denied benefits at the first stage. As discussed earlier, to be entitled to benefits at the first stage, the miner must show three elements: (1) total disability, (2) that disability was caused "at least in part by pneumoconiosis," and (3) that "disability arose out of coal mine employment." Lovilia, supra, at 451. Under the "one-element" standard, a miner arguing that a previous denial of benefits was incorrect need only show that there has been a material change in one of the three elements required for entitlement.
If a claimant presents such evidence, "[a]b-sent contrary evidence clearly demonstrating that the denial of the initial claim was a mistake," an inference of material change is "compelled" and an ALJ "must then consider whether all the evidence in the record, including the evidence predating the denial of the prior claim, supports an entitlement to benefits."
Id. at 451.
The Lovilia Plaintiff contended that the Director's "one-element" standard was invalid because it violated § 7(c) of the APA, requiring that "the proponent of a rule or order has the burden of proof." Plaintiff there relied on Greenwich Collieries for the holding that a judicially created presumption in the Black Lung Benefits Act is invalid under § 7(c) if it shifts the burden of proof to the party opposing the benefits claim.
The Eighth Circuit rejected Plaintiff's argument and upheld the Director's "one-element" standard. Id. at 452. The court held that while the Director's standard did indeed create a presumption, this presumption did not violate § 7(c) because it shifted the burden of production, not the burden of proof. Id. at 452-53. The court stated that Greenwich Collieries stood for the proposition that the burden of proof could not be allocated in a manner that conflicts with § 7(c), but did not hold that burdens of production could not be shifted. Id. at 452. The Eighth Circuit held that the "one-element" standard still kept the burden of proof on the claimant to prove his entitlement by a preponderance of the evidence; the only thing it did was ease the claimant's burden of production by reducing the amount of evidence that the claimant had to come forward with in order to support his claim. Id. Even though this works to the advantage of the claimant by requiring less of a showing of evidence in order to support his claim, it does not reallocate his ultimate burden of proving his entitlement by a preponderance of the evidence. In fact, the Eighth Circuit continued, not only did the "one element" standard not violate Greenwich Collieries, it was akin to the presumptions expressly approved of by the Greenwich Collieries court:
The [Greenwich Collieries ] Court indicated that the statutory and regulatory presumptions which ease a claimant's burden of production (i.e., "a party's obligation to come forward with evidence supporting its claim") do not violate the APA.
Id.
In the instant case, Respondents urge this court of appeals to apply the reasoning of the Eighth Circuit in Lovilia and find the Doris Coal presumption to be consistent with § 7(c) of the APA because it merely reallocates the burden of production rather than impermissibly reallocating the burden of proof. This requires an analysis of the Doris Coal presumption in order to determine which burden is truly being reallocated.
The Doris Coal presumption states that if a miner proves his entitlement to benefits in stage one, the miner is entitled to a presumption in stage two that the medical bills he presents are related to his pneumoco-niosis, thus making the employer/carrier liable. The employer/carrier must then come forward with evidence to rebut this presumption and show that the bills are not related to the miner's pneumoconiosis. '
We hold that the Doris Coal presumption merely reallocates the burden of production, and does not affect the burden of proof. The effect of the Dons Coal presumption is to find that where there is a stage one determination that the claimant is totally disabled due to pneumoconiosis, then in stage two the claimant does not have to come forward with any additional evidence to prove that his medical bills are related to his pneumoconio-sis; instead, the employer/carrier must come forward with evidence demonstrating that the bills are not related to his pneumoconio-sis. Under this analysis, the only thing that changes is that the claimant's initial burden of coming forward with evidence supporting his stage two claim is eased by virtue of the determination in the first stage that he has pneumoconiosis — i.e. his burden of production is eased and placed on the employer/carrier from the outset. The presumption does not change the fact that the claimant still bears the burden of proof to show by a preponderance of the evidence that his bills are related to his pneumoconiosis, rather it allows him to satisfy his burden of production (i.e. producing evidence to support his claim) by relying on the determination in the first stage that he is disabled by pneumoconiosis. The claimant still must satisfy the trier of fact that the bills are related, but the claimant is relieved of the requirement of producing additional evidence of this relationship. He may rely on the first stage determination to show the relatedness of his condition and the medical treatment at issue.
Under this reasoning, we find the Dons Coal presumption to be valid under Greenwich Collieries because it reallocates only the burden of production, and not the ultimate burden of proof. However, despite the fact that we find the Doris Coal presumption withstands scrutiny under Greenwich Collieries, we nonetheless hold it is inconsistent with Sixth Circuit law because it does not further the purposes of the Black Lung Benefits Act.
4. The Doris Coal presumption is inconsistent with Sixth Circuit law because it does not advance the purposes of the Black Lung Benefits Act, as explained in Greenwich Collieries.
The Greenwich Collieries case discusses more than the technical differences between the burdens of proof and production. It is true that in that case the Supreme Court engaged in a long discussion of the meaning of the terms "burden of proof' and "burden of production" and then came to the conclusion that the "true doubt" rule was invalid because it was a judicially created presumption which allocated the burden of proof in a manner that conflicted with § 7(c) of the APA. But to infer the inverse and interpret Greenwich Collieries to actually encourage judicially created presumptions that merely reallocate the burden of production would, we feel, be a limited reading of the case and would lead to great confusion in the application of the Black Lung Benefits Act. In fact, Greemvich Collieries makes some important observations about the Black Lung Benefits Act, which suggest that the Black Lung Benefits Act was intended to be applied with uniformity which could be destroyed if the door is suddenly opened to the creation of judicial presumptions.
The Greenwich Collieries Court stated that Congress realized that these Black Lung benefits claims would be difficult to prove, and therefore created statutory presumptions to ease the claimant's burden. Greenwich Collieries, supra, at 280, 114 S.Ct. 2251. The Court then explained that the problem with the "true doubt" presumption was that it ran "afoul of the APA, a statute designed 'to introduce greater uniformity of procedure and standardization of administrative practice among the diverse agencies whose customs had departed widely from each other.' " Id. at 280-81, 114 S.Ct. 2251. The Court then stated that the concern of losing the desired uniformity would be directly implicated if each agency is free to create presumptions that would reallocate the burdens that the parties must bear. Id. at 28Í, 114 S.Ct. 2251. Therefore, the Court seemed to suggest that in order to achieve uniformity, the only presumptions that should be applied were statutory presumptions.
In the instant case, while we find that the Doris Coal presumption merely reallocates the burden of production and therefore does not violate the APA burden of proof provisions, we look further into the Greenwich Collieries opinion and conclude that the concern expressed by the Supreme Court that judicially created presumptions would destroy the desired uniformity in the Black Lung Benefits Act requires that the Sixth Circuit find the judicial presumption inconsistent with the law of this Circuit. If we were to hold otherwise, then the door will be opened to the creation of other judicial presumptions in this Circuit and thereby destroy the desired uniformity of application of the Black Lung Benefits Act. The claimants in one district might have a harder time proving their entitlement to benefits than the claimants in another district, which would run afoul of the desired uniformity of the Act.
Further, aside from the Greenwich Collieries case, the Black Lung Benefits Act itself is set up to be a two-step process: the first stage determines entitlement and the second stage determines whether the particular medical bills are related to the entitlement. The Doris Coal presumption does not respect this two-step process, but rather attempts to reshape it as one stage through the application of this judicially created presumption. This is simply at odds with the purposes of the Black Lung Benefits Act. Not only does the Act create a two-step process, but there is already a statutory presumption written into the first stage: if the miner shows certain evidence of pneumoconiosis, there is a rebuttable presumption that he is totally disabled by pneumoconiosis. 20 C.F.R. § 727.203(a). To now allow the Doris Coal presumption to work at the second stage would destroy the independence of these two stages and ignore the fact that by creating a first stage presumption but not a second stage presumption, Congress obviously intended for there to be no such presumption in the second stage.
Finally, applying the presumption in the second stage could open the door to fraud in the preparation of medical bills. If the miner no longer has to prove that his bills are related to pneumoconiosis, his doctor is no longer required to show the relation between the treatment and the pneumoconiosis. This would allow the possibility that doctors could prescribe unrelated treatment, indicate that it is related to pneumoconiosis, and fraudulently obtain payment for such treatment by way of the Doris Coal presumption. While the employer/carrier would of course still have the opportunity to rebut the presumption, the employer is not in as good a position to obtain such evidence as is the treating doctor.
For all of the foregoing reasons, we hold that the Fourth Circuit Doris Coal presumption is inconsistent with the law of the Sixth Circuit. Even though we find that it withstands scrutiny under Greenwich Collieries, it still runs afoul of the purposes of the Black Lung Benefits Act, and is for that reason inconsistent with the law of this Circuit.
5. Because the ALJ below relied on the Doris Coal presumption, which we find to be inconsistent with the law of the Sixth Circuit, the case must be remanded to the ALJ for a determination according to the proper standard governing a second stage medical bill dispute.
The ALJ's examination of the medical evidence in this case was made under the assumption that Fourth Circuit law governed. Due to the fact that we find the Fourth Circuit law to be inconsistent with the law of the Sixth Circuit, we cannot affirm the decision made below. Further, we cannot independently evaluate the ALJ's findings of fact with regard to the doctors' reports, since the ALJ's review of them was guided by the burden shifting of the Doris Coal presumption. To affirm the ALJ's decision, despite the different legal standard applied below would require impermissible appellate fact finding. Therefore, the appropriate remedy here is a remand to the ALJ for review under the appropriate standard for the Sixth Circuit.
The proper standard in a second stage dispute concerning payment of medical bills under the Black Lung Benefits Act places the burden of proof on the claimant to prove his claim by a preponderance of the evidence. The burden of production is similarly on the claimant to offer evidence that the treatment is related to his totally disabling pneumoconiosis. The operator can offer evidence that the bills are not related to pneumoconiosis, but the operator cannot offer evidence controverting the miner's pneu-moconiosis at this second stage because the determination of whether he has pneumoco-niosis is made at the first stage.
The question then becomes what constitutes being "related to" pneumoconiosis. 20 C.F.R. § 725.701(b) requires that "[a] responsible operator . shall furnish a miner entitled to benefits under this part with such [treatment] as the nature of the miner's pneumoconiosis and ancillary pulmonary conditions and disability require." (emphasis added). The Secretary argues that "ancillary" means "unrelated," and that "pneumo-coniosis and ancillary pulmonary conditions" effectively means any and all pulmonary disease. We disagree. The word "ancillary" necessarily indicates some connection and relatedness, and usually a subordinate one.
This definition could be met by simple synergy (i.e., another pulmonary disease that combines with pneumoconiosis to cause a sum of disease greater than the two parts), or by relatedness (i.e., another pulmonary disease that would be either absent or significantly less virulent but for the pneumoconio-sis). If, however, the connection is only that both diseases affect the lungs, the other condition simply is not "ancillary." Defining "ancillary" negatively, if it can be said that a condition causes a disability that would be exactly the same even if there were no pneu-moconiosis (as Dr. Branscomb said was the case for Seals), then that other condition cannot be said to be ancillary to the pneumo-coniosis.
The decision of the ALJ is VACATED and the case REMANDED to the ALJ for a determination of Petitioners' liability for the medical bills in dispute under the proper standard set forth above.
. Part C incorporated by reference substantial parts of the Longshore and Harborworkers' Compensation Act ("LHWCA"). 33 U.S.C. § 901-950 incorporated by reference into 30 U.S.C. § 932(a). See Director, Office of Workers' Compensation Programs v. Eastern Coal Corp., 561 F.2d 632 (6th Cir.1977).
The LHWCA provides that the responsible employer or its insurance carrier must pay the cost of medical care needed by the worker as a result of any occupationally related injury or disease that is otherwise compensable. 33 U.S.C. § 907 ("Section 7"). Section 7 of the LHWCA was not originally incorporated into the Black Lung Act, but was added in the Black Lung Benefits Act of 1972. Pub.L. 92-303, § 5(b)(9), 86 Stat. 156 (1972). Thereafter, a Part C beneficiary could obtain health care benefits for the treatment of pneumoconiosis. The DOL's Part C regulations allowed a Part B beneficiaiy to "refile" for Part C benefits (subject to an offset by whatever Part B benefits were payable). 38 Fed.Reg. 26,045; 20 C.F.R. § 725.102(a) (1973) (repealed). • Some Part B beneficiaries could, therefore, obtain Part C medical benefits under the 1972 Act. Most of these "refilings" would, however, have been barred by the then applicable statute of limitations. 38 Fed.Reg. 26,046; 20 C.F.R. § 725.124 (1973) (repealed).
When Congress was again considering comprehensive amendments to the Black Lung Act in the late 1970s, it added a new provision allowing all Part B miner/beneficiaries to apply for medical benefits with the DOL under Part C. Any applicable statute of limitations would be waived if the claim for medical benefits was filed within a specific period after the Part B' beneficiary was notified by the Secretary of HEW of a right to file a medical benefits claim. Pub.L. 95-239, § 11, 92 Stat. 101 (1978) (codified at 30 U.S.C. § 924(a)). Claims of this sort are commonly called "medical benefit only" or "MBO" claims. In implementing section 11 of the 1978 amendments, the DOL wrote regulations governing MBO claims, and medical benefit entitlements generally. 20 C.F.R. § 725.701-725.707 (1996).
. One of the following medical requirements must be met:
(1) A chest roentgenogram (X-ray), biopsy, or autopsy establishes the existence of pneumoco-niosis (see § 410.428 of this title);
(2) Ventilatory studies establish the presence of a chronic respiratory or pulmonary disease (which meets the requirements for duration in § 410.412(a)(2) of this title) as demonstrated by values which are equal to or less than the values specified in the following table: [table omitted];
(3) Blood gas studies which demonstrate the presence of an impairment in the transfer of oxygen from the lung alveoli to the blood as indicated by values which are equal to or less than the values specified in the following table: [table omitted];
(4) Other medical evidence, including the documented opinion of a physician exercising reasoned medical judgment, establishes the presence of a totally disabling respiratory or pulmonary impairment; (5) In the case of a deceased miner where no medical evidence is available, the affidavit of the survivor of such miner or other persons with knowledge of the miner's physical condition, demonstrates the presence of a' totally disabling respiratory or pulmonary impairment.
20 C.F.R. § 727.203(a).
. The presumption is rebutted if:
(1)The evidence establishes that the individual is, in fact, doing his usual coal mine work or comparable and gainful work (see § 410.412(a)(1) of this title); or
(2) In light of all relevant evidence it is established that the individual is able to do his usual coal mine work or comparable and gainful work (see § 410.412(a)(1) of this title); or
(3) The evidence establishes that the total disability or death of the miner did not arise in whole or in part out of coal mine employment; or
(4) The evidence establishes that the miner does not, or did not, have pneumoconiosis.
20 C.F.R. § 727.203(b).
. "[A]ny drug that causes relaxation of bronchial muscle resulting in expansion of the air passages of the bronchi." Webster's Third International Dictionary 282 (1981).
. The ALJ applied Fourth Circuit law because at the time the matter arose, Seals was living and receiving medical treatment in Virginia. However, as noted above, the injury resulted from Seals' coal mine work in Kentucky, which required the subsequent transfer of this case to this Court.
. "COPD" is an acronym for "chronic obstructive pulmonary disease," which includes asthma, chronic bronchitis, certain types of emphysema and other conditions.
. "[Obligation which rests on one of the parties to an action to persuade the trier of the facts, generally the jury, of the truth of a proposition which he has affirmatively asserted by the pleadings." Greenwich Collieries, supra, 114 S.Ct. at 2256 (quoting W. Richardson, Evidence 143 (6th ed.1944)).
. "[A] party's obligation to come forward with evidence to support its claim." Greenwich Collieries, supra, at 2255.
. See definition of "burden of proof" supra note 7.
. See definition of "burden of production" supra note 8.
. See definition of "burden of proof" supra note 7.
. Petitioners suggest that this has already happened in many instances.