STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

GEORGE T. LLOYD, JR., )

)

Petitioner, )

)

vs. ) CASE NO. 88-5775

) STATE OF FLORIDA, DEPARTMENT ) OF ADMINISTRATION, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, the Division of Administrative Hearings, by its duly designated Hearing Officer, William J. Kendrick, held a formal hearing in the above-styled case on April 24, 1989, in Tallahassee, Florida.

APPEARANCES

For Petitioner: George T. Lloyd, Jr., pro se

Florida Department of Revenue Harmon Cove Tower I Promenade A, Suite 8 Secaucus, New Jersey 07094

For Respondent: William A. Frieder, Esquire

Department of Administration

440 Carlton Building Tallahassee, Florida 32399-1550

PRELIMINARY STATEMENT

At issue in this proceeding is whether the expenses incurred by petitioner incident to the admission of his son to Broward General Medical Center in March 1986 resulted from an intentional self-inflicted injury, to wit: attempted suicide, and are therefore excluded from coverage under the State of Florida Employees Group Health Self Insurance Plan.

At hearing, respondent called Tylee Rowe and the petitioner as witnesses. Respondent's exhibits 1-10 were received into evidence. 1/ Petitioner called no witnesses, but offered and had admitted into evidence petitioner's exhibits 1 and 2.

The transcript of hearing was not ordered, so the parties were granted leave until May 4, 1989, to file proposed findings of fact. Respondent elected to file proposed findings, and they have been addressed in the appendix to this recommended order.

FINDINGS OF FACT

Background.

1. Petitioner, George T. Lloyd, Jr., has been employed by the State of Florida, Department of Revenue, for over 14 years, and was, at all times material hereto, a participant in the State of Florida Employees Group Health Self Insurance Plan (Plan), with family coverage.

   
   

2. On March 25, 1986, petitioner's son, George T. Lloyd, III (George), then 17 years of age and an eligible dependent under the Plan, was admitted through the emergency room to Broward General Medical Center (Hospital), Fort Lauderdale, Florida. George was placed in the Hospital's Intensive Care Unit, and remained there until his recovery and transfer to the Hospital's psychiatric floor on April 4, 1986.

   
   

3. Upon admission, George was comatose and diagnosed as having suffered a severe barbiturate drug overdose. Blood tests performed at the time demonstrated a serum barbiturate level of 145.6 UG (milligrams per milliliter) and a serum Dilantin level of 23.3 UG. At such levels, or even one-half such levels, George would have died of respiratory depression absent medical intervention.

   
   

4. On or about August 9, 1986, Blue Cross and Blue Shield of Florida, Inc., the State's administrator of the Plan, notified petitioner that the Hospital's statement for services and supplies rendered during the course of his son's admission of March 25, 1986 to April 4, 1986, totalling $17,402.95, was ineligible for payment based upon the Plan's exclusion of benefits for intentional self-inflicted injuries, to wit: attempted suicide.

   
   

5. Pertinent to this case, the Plan provides:

   
   

   VII. EXCLUSIONS

   The following exclusions shall apply under the Plan:

   * * *

   E. Any services and supplies received due to the following circumstances:

   * * *

   2. Resulting from an intentional self- inflicted injury.

   
   

6. Over the course of the next two years petitioner's claim for such expenses was reevaluated by the Plan administrator, as well as respondent, Department of Administration (Department). At the conclusion of that review, the Plan administrator concluded that the documentation available to it demonstrated that such expenses were incurred as a consequence of George's attempt to take his own life and were therefore excluded from coverage.

   
   

7. By letter of August 19, 1988, the Department notified petitioner that his claim for benefits arising from his son's hospital admission of March 25, 1986 to April 4, 1986, was denied because such expenses resulted from his son's attempt at suicide. Petitioner filed a timely protest of the Department's decision, and the matter was referred to the Division of Administrative Hearings to conduct a formal hearing.

   An Intentional Self-Inflicted Injury?

   
   

8. Petitioner's son has a history of alcohol and drug (marijuana and cocaine) abuse and emotional problems accompanied by periods of depression that predate the incident in question by a number of years.

   
   

9. His mother and father (petitioner) were divorced in 1971 when George was approximately three years of age. Thereafter, George resided in Florida with his mother until his fifth birthday, at which time he was sent out-of-state to reside with his father. George resided with his father until he was eleven years old, and then returned to live with his mother in Florida.

   
   

10. In the summer of 1984, George was abusing alcohol and drugs, and experiencing difficulties in school. At that time, his mother again sent George to live with his father in the apparent hope that he could assist George in addressing these problems.

    
    

11. The petitioner secured group counseling for George in an attempt to assist him. George continued, however, to use alcohol and drugs, and within four months, dropped out of school and ran away. Approximately four or five months later, George reappeared and returned to Fort Lauderdale to live with his mother and stepfather.

    
    

12. Following his return, George did little of a constructive nature, and what jobs he was able to secure as a tenth grade dropout were menial in nature and of a minimal wage. Variously he worked as a bag boy, mowed lawns, and washed cars.

    
    

13. On March 25, 1986, George was unemployed, and had just concluded an argument with his stepfather concerning his unemployment and failure to follow any constructive pursuit. Depressed at his circumstances, George ingested phenobarbital and Dilantin, drugs that had been prescribed for his stepfather, with the intention of taking his own life. But for the medical intervention previously discussed, George's attempt would have proven successful.

    
    

14. At the time he ingested the drugs, George was not under the influence of alcohol or any other drug, and was of sufficient age and maturity to appreciate the consequences of his actions. Both the nature of the drugs he took and the vast quantity he ingested indicate an intentional attempt to take his own life rather than an accidental overdose during "recreational" use. Here, the drugs he took were not "recreational" drugs, they produce no "high," and the dosage, as heretofore noted, was massive. Considering these factors, George's admission that he attempted suicide, and the totality of the circumstances, compels the conclusion that he did consciously attempt to take his own life, and that what depression he suffered did not deprive him of the ability to appreciate the consequences of his actions.

    
    

    CONCLUSIONS OF LAW

    
    

15. The Division of Administrative Hearings has jurisdiction over the parties to, and the subject matter of, these proceedings.

    
    

16. Where, as here, proof is made of a loss within the contract of insurance, the burden is on the insurer to establish, by a preponderance of the evidence, that the loss arose from a cause that is excepted from the policy. See: Mason v. Life & Casualty, Insurance Company, 41 So.2d 153 (Fla. 1949), Stonewall Insurance Company v. Emerald Fisheries, Inc., 388 So.2d 1089 (Fla. 3d

DCA 1980), and Hudson v. Prudential Property and Casualty Insurance Company, 450 So.2d 565 (Fla. 2d Dist. 1984). Here, the Department has meet its burden of proof by demonstrating that the claim in question arose as a consequence of an intentional self-inflicted injury.

RECOMMENDATION

Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that a final order be entered dismissing, with prejudice, the

petition for administrative review.

DONE and ENTERED this 16th day of May 1989, in Tallahassee, Leon County, Florida.

WILLIAM J. KENDRICK

Hearing Officer

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 16th day of May, 1989.

ENDNOTE

1/ With the parties' concurrence, the record remained open for 10 days for respondent to file, as an exhibit, the complete benefit document. That document was duly filed, marked respondent's exhibit 10, and received into evidence.

APPENDIX TO RECOMMENDED ORDER, CASE NO. 88-5775

1. Addressed in paragraphs 1 and 2. 2.-4. Addressed in paragraphs 2 and 3.

5.-6. Not relevant or necessary to the result reached. 7.-14. To the extent relevant or necessary to the result

reached addressed in paragraphs 13 and 14.

15,17-19, 21 and 22. To the extent relevant or necessary to the result reached, addressed in paragraphs 13 and 14.

16. Addressed in paragraph 11.

20. Addressed in paragraphs 13 and 14.

23.-30. To the extent relevant addressed in paragraphs 13 and 14, otherwise rejected as comment on the evidence, not relevant or not necessary to the result reached.

31 and 32. To the extent pertinent, addressed in paragraph 5.

33. Addressed in paragraphs 13 and 14.

34 and 35. Not relevant.

COPIES FURNISHED:

George T. Lloyd, Jr.

Florida Department of Revenue Harmon Cove Tower I Promenade A, Suite 8 Secaucus, New Jersey 07094

William A. Frieder, Esquire Department of Administration

440 Carlton Building Tallahassee, Florida 32399-1550

Augustus D. Aikens, Jr., Esquire General Counsel

Department of Administration

435 Carlton Building

T allahassee, Florida 32399-1550

Adis Vila, Secretary Department of Administration

435 Carlton Building Tallahassee, Florida 32399-1550

Docket for Case No: 88-005775

Orders for Case No: 88-005775