Salerno testified on behalf of Respondent.
At the conclusion of formal hearing, the undersigned raised the issue that some definitions used in the testimony and exhibits might be more fairly considered in light of the current Diagnostic and Statistical Manual. The parties stipulated that the undersigned could refer to this and similar texts for preparation of this Recommended Order. (See Findings of Fact 9 and 11).
The transcript of proceedings was filed on December 19, 1996. All timely- filed proposed findings of fact have been considered in preparation of this Recommended Order. The parties' Joint Prehearing Stipulation has been utilized as appropriate, with grammatical changes, elimination of cumulative and/or irrelevant material, and omission of the patient's name to protect her privacy.
At the time of her daughter's treatment by the North Florida Regional Medical Center Hospital emergency room, Petitioner was an insured under the State Of Florida Employees' Group Health Self-Insurance Plan (Plan).
Petitioner's daughter was treated at the emergency room on November 21, 1995, after having ingested an undetermined amount of Tylenol PM tablets for possible side effects of over-ingestion of the acetaminophen product.
The parties stipulated that the diagnoses made by the emergency room's attending physician, T. Paul Rast, D.O., who was on duty the evening of November 21, 1995, shall be regarded as truth and fact. His diagnoses were "1. Adjustment disorder with depressive symptoms; 2. Suicidal gesture versus attempt."
Medical records admitted in evidence indicate that a history was given to the emergency room staff that Petitioner's daughter had taken the Tylenol PM because she was mad after having broken up with a friend and tried to hurt herself and make everyone feel sorry for her. (Joint Exhibit 2)
There is no dispute that Petitioner's daughter intentionally and volitionally ingested approximately 20 Tylenol PM tablets (one bottle) at approximately 6:30 p.m. on November 21, 1995, or that she did so as part of her depressed state.
Petitioner's daughter's treatment at the emergency room was comprised of being lavaged clear, given charcoal and Sorbitol 50 mg. Health care was limited to the over-ingestion of the acetaminophen product.
Treatment for depression was not provided at that time in the emergency room. Petitioner's daughter was not admitted or treated as an "inpatient", but was released to her parents. However, Petitioner's daughter subsequently was treated privately for depression. That treatment for depression has been declared "covered" by the Plan's Administrator and has been paid for according to the Plan's scheduled rates.
The Florida State Legislature determines what services and supplies will, and will not, be covered under the Plan.
The Florida Employees' Group Health Self-Insurance Plan Booklet and Benefit Document (Joint Exhibit 1) is the contract of insurance in this case and provides, in pertinent part, as follows:
DEFINITIONS
48. "Mental or Nervous Disorder" means any and all disorders set forth in the diagnostic
categories of the most recently published edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, regardless of the underlying cause,
or effect, of the disorder. Examples include, but are not limited to, . . . anxiety and depression. (Itallics supplied)
COVERED HOSPITAL AND OTHER FACILITY SERVICE The following services shall be covered when
ordered by a physician and are medically necessary for the treatment of an insured as a result of a covered accident, illness or mental or nervous disorder.
8. Covered Inpatient Services; PPC: [List omitted]
COVERED MEDICAL - SURGICAL SERVICES AND SUPPLIES Payment of Covered Medical-Surgical Services and Supplies shall be subject to the limitations, exclusions or provisions of the Plan except as provided in Paragraphs C. 5. and 7.
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Ninety percent . . . of the PPC Schedule for medically necessary inpatient/outpatient services and supplies provided to an insured by a preferred patient care physician for the treatment of the
insured as a result of a covered accident, illness or mental or nervous disorder shall be paid by the Plan.
G. EXCLUSIONS:
The following services, supplies or equipment are not covered services and supplies under the Plan. The insured is solely responsible for the payment of charges for all such services, supplies or equipment excluded in this Section.
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Any services and supplies received due to the following circumstances:
(b) Resulting from an intentional
self-inflicted injury whether the insured was sane or insane.
The parties stipulated as fact that the definition of "effect", according to Webster's Ninth New Collegiate Dictionary is: "1) to cause to come into being. 2) to bring about, often by surmounting obstacles; accomplish"; and that the definition of "effect", according to Taber's Cyclopedic Medical Dictionary, Edition 15, is, "result of an action or force".
Petitioner has proposed, and the undersigned has determined in accord with the parties' stipulation as to authoritative texts, that the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) recognizes "adjustment disorder" and "major depressive episode". Thoughts of death and attempts or gestures at suicide are recognized as sequelae of a major depressive episode. Suicide is listed as the most derious possible consequence of a major depressive episode.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and subject matter hereto pursuant to Section 120.57(1), Florida Statutes.
The emergency room treatment at issue in this cause may be characterized for our purposes here as, "pumping Petitioner's daughter's stomach and stabilizing her with antidotes so that she would not suffer the logical effects of volitionally ingesting dangerous levels of Tylenol PM."
The parties have stipulated as law that the Plan Booklet and Benefit Document, effective January 1, 1993, [see Finding of Fact 9] is the controlling contract as to the benefits owed by Respondent to Petitioner.
Petitioner has not, and cannot, claim that either she or her daughter relied on any ambiguity in obtaining emergency room treatment for the suicide gesture, believing it was covered.
Rather, Petitioner contended that the Plan Booklet is contradictory as to which treatments are covered for persons who "attempt" or "gesture" at suicide as a causal result of depression. She emphasized that Dr. Rast had diagnosed her daughter's volitional ingestion of Tylenol PM as "a suicidal gesture" rather than "a suicidal attempt", and that therefore, her daughter had no intent (in the sense of the ultimate result desired by her daughter) to injure or kill herself. Upon the foregoing theory, Petitioner reasons that all health care, including the emergency room treatment to counteract the volitional ingestion, should be paid for by the Plan. Petitioner's argument is not persuasive.
The exclusionary language of Subsection G of the Plan is both clear and controlling. If the harm that occurred was a reasonable and probable consequence of Petitioner's daughter's volitional act, the harm was "intentional" within the meaning of the exclusion.
The exclusionary language of the Plan's Subsection G provides that the Plan is not liable for the payment of medical expenses arising out of "an intentional self-inflicted injury whether the insured was sane or insane." Although research by the undersigned has not unearthed any legal decision interpreting this Plan language specifically, the same or similar language in private insurance policies has been interpreted in case law.
In the case of Charney v. Illinois Mutual Life Casualty Company, 764 F.2d 1441 (11th Cir. 1985), the United States Court of Appeals for the Eleventh Circuit dealt with a similar problem. Therein, the insurance policy contained the exclusion, "If the insured whether sane or insane, shall die by his own hand or act within 2 years after the Date of Policy, our liability under this Policy shall be limited to the premiums paid hereon." The court held:
There is no question that Dr. Charney did in fact "die by his own hand." Nor is there any doubt that he "intended" to kill himself in the sense that he knew and understood the physiolo- gical effects of injecting himself with T61 euthanasia solution. The sole issue before this Court is whether the suicide exclusionary clause does not apply because Dr. Charney's
reserpine-induced depression so diminished his mental capacity that he did not have the requisite intent to commit suicide.
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While no Florida case cited to us has discussed this particular issue, there appears to be no reason why the plain and unambiguous language of the policy should not control. Even assuming that the insured was rendered insane by reserpine, there is nothing in the contract that suggests
the cause of insanity would make any difference in the policy's coverage. The cause of Dr.
Charney's insanity, if he was insane, is simply irrelevant. The following cases have held that a suicide "sane or insane" clause is to be given
effect irrespective of the insured's mental state. Bigelow v. Berkshire Life Ins. Co., 93 U.S. 284, 287, 23 L.Ed. 918 (1876); Clarke v. Equitable Life
Assur. Soc., 118 Fed. 374, 378 (4th Cir. 1902); Johnson v. Metropolitan Life Ins. Co., 404 F.2d 1202, 1204 (3d Cir. 1968); Ann Arbor Trust Company
v. North American Co. for Life & Health Ins., 527 F.2d 526 (6th Cir. 1975), cert. denied, 425 U.S. 993, 96 S.Ct. 2206, 48 L.Ed.2d 818 (1976).
Also, in the case of C.M. Life Insurance Company v. Ortega, 562 So.2d 702 (Fla. 3d DCA 1990), the Florida Third District Court of Appeal denied a claim under a life insurance policy that contained an exclusion for suicide while sane or insane. The insured had fired a fatal shot into his head while playing Russian roulette. The court opined:
. . . the insured was depressed and despondent. He knew the gun was loaded. The shooting was the result of a conscious decision to play a
game with death. We conclude that where the harm which befalls the insured is a reasonable and probable consequence of his volitional act, the harm cannot be deemed unintentional.
The court went on to paraphrase Justice Cardozo's dissent in Landress v. Phoenix Mutual Life Insurance Company, 291 U.S. 491, 501, 54 S.Ct. 461, 464, 78
L.Ed. 934 (1934), as adopted by the majority in Gulf Life Insurance Company v. Nash, 97 So.2d 4 (Fla.
1957), at page 9, ". . . if there is no accident in the means, there is none in the result."
The cases cited stand for the principle that severe depression does not convert the act of volitionally ingesting too much Tylenol PM, whether characterized as a suicide "gesture" or "attempt", into an unintentional act, legally speaking.
Petitioner's daughter's action in ingesting the acetaminophen product was not a general health condition, and she knew what she was doing when she did it. Petitioner's daughter's volitional act was not what is normally thought of as an "accident" or "mistake" as might be the case of someone who ingests too much of a dangerous drug believing it to be a different, safer drug or believing it to be a lesser dose, or even believing it to be a non-lethal dose.
Petitioner's daughter's volitional act in taking the Tylenol PM was clearly an intentional self-inflicted injury.
The words of the Plan contract, "whether the insured was sane or insane" must have some practical meaning, especially in view of the fact that they are contained in the same clause with the word "intentional." Indeed, these words are intended to modify the phrase "intentional self-inflicted injury." Since the clause provides that an act can be intentional when the insured is insane, it necessarily follows that the act can be intentional when the insured is depressed. If the intent of the exclusion was to require the insured to be solely responsible for the payment of charges for all services, supplies or equipment resulting from an intentional self-inflicted injury, whether the insured was sane or insane, clearly it does not matter whether the intentional self-inflicted act was performed by Petitioner's daughter when she was sane, or when she was insane, or when she was merely depressed, especially if depression is recognized by the diagnosticmanual incorporated by reference into the Plan contract and that diagnostic manual classifies depression as a psychiatric disorder.
Further, Petitioner has not proven that the other Plan clauses upon which she relies are contradictory of the clear exclusion listed in Subsection G of the Plan. Each of the clauses she has cited relates to "covered accident, illness or mental or nervous disorder." The express language at Subsection G clearly excludes from coverage all "self-inflicted injuries", whether they are suicidal attempts or gestures. Also, whether the ingestion of the pills was an "effect" of depression does not bar the application of the exclusion for self- inflicted injuries. While other "effects" of depression might be covered under the Plan, and the Plan has paid and has continued to pay for treatment of her daughter's depression, the Florida Legislature has determined that in no circumstance shall intentional self-inflicted injuries be covered.
Petitioner's interpretation of the respective clauses would render any self-inflicted injury "covered", provided any psychiatric diagnosis could be procured. This result would be contrary to the clear intent of the Legislature, expressed in the clear language of the Plan contract, that self-inflicted injuries should not be a drain on State expenses. The State Plan is, after all, a contract, and the intent of the parties, as expressed in the document, should control.
