CATHARINA M. STOECKLIN, )
vs. ) Case No. 98-3239
Respondent. )
The formal hearing in this case was held pursuant to notice by Stephen F. Dean, assigned Administrative Law Judge of the Division of Administrative Hearings, on December 11, 1998, in Tallahassee, Florida.
For Petitioner: Dr. Sara Stoecklin, Mother of Petitioner 1559 Christobal Drive
The issue in this case is whether the Petitioner is entitled to have her bills paid for medical services rendered to her by Tallahassee Memorial Regional Medical Center, on January 12, 1997, through January 16, 1997, by the State of Florida, Group Health Self Insurance Plan.
The Respondent denied payment for an insurance claim on the basis that the injuries, for which treatment was rendered, were self-inflicted. On June 29, 1998, the Petitioner filed a request for formal hearing which was forwarded to the Division of Administrative Hearings on July 16, 1998. Pursuant to notice, this cause came on for formal hearing on December 11, 1998, in Tallahassee, Florida.
At the commencement of the hearing, Respondent's Motion for Official Recognition, filed by the Department of Management Services (DMS) was granted and notice thereof given to the Petitioner. The Motion for Official Recognition requested the Administrative Law Judge to take notice of the rules of the Division of State Group Insurance (DSGI) and the case of Stalnaker v. Department of Management Service, Division of State Employees' Insurance, Final Order issued February 10, 1997,
DOAH Case No. 96-3773. At the formal hearing, the mother of the Petitioner, Dr. Sara Stoecklin, was determined at the commencement of the proceeding to be a qualified representative.
The Petitioner presented the deposition testimony of the Petitioner which was stipulated into evidence. Also received into evidence were the Petitioner's medical records, Joint Exhibit 1; the deposition of Melanie A. Ward, M. D., Joint Exhibit 3; and a copy of the state's booklet on the benefits of
the State Group Health Self Insurance Plan, Joint Exhibit 4. The Respondent introduced its working file, Respondent's Exhibit 1; a copy of Chapter 96-424, Laws of Florida, Respondent's Exhibit 2; and a curriculum vitae of its expert witness, Patrick Thomas Gerald Hennessey, Respondent's Exhibit 3. The transcript of the proceedings was prepared and filed on January 4, 1999. Both parties filed post-hearing proposed findings which were read and considered.
The Petitioner was insured under the State of Florida Employees' Group Health Self Insurance Plan (Plan) at the time of her treatment which is in question and payment therefore was denied by the Respondent. Claims were processed at the time of the Petitioner's treatment by Unisys Corporation. The Division of State Group Insurance (DSGI) administers health coverage benefits for the Plan.
The processing of the payment of claims by Unisys Corporation and now by Blue Cross/Blue Shield is based on the number of employees enrolled in the Plan. Neither Unisys or Blue Cross/Blue Shield have an economic interest in whether the claim is paid.
Prior to midnight on January 12, 1997, the Petitioner went to Tallahassee Memorial Regional Medical Center (Hospital) and was seen in the hospital's emergency room (ER).
The Petitioner gave statements regarding her complaint and her prior activities to several doctors and nurses at the hospital.
Page 71 of Joint Exhibit 1 is the Psychiatric Center Psychiatric Emergency Response Preliminary (PERP) Assessment Form filled out on January 12, 1997, at 2250 hours. Of particular note on this form is the statement by the Petitioner of an overdose of thirty 500-milligram Tylenol PM eleven hours previously. See Presenting Problems Section, aforementioned form. The form states that the Petitioner was very cooperative, was clean and neat, and was appropriately attired. Her facial expression was sad, but her posture, gait, and motor activity were unremarkable. She had logical associations. Her language was normal. Under stream of mental activity, her productivity was marked spontaneous. At the time of the review by the PERP nurse, the nurse could not conclude that the Petitioner was suicidal. The conclusion of the medical staff was summed up in the note that suicidal ideations could not be ruled out.
Page 16 of Joint Exhibit 1 is the report of the admitting physician, Dr. Broadway, who stated as follows at 0100 hours (1:00 a.m.) on January 13, 1997, (abbreviations and symbols have been written out for clarity):
Twenty-seven year old white, female presents to emergency room twenty-three hours after ingesting thirty tablets of Tylenol PM. Patient had an argument with her boyfriend and started drinking wine. She began taking Tylenol tablets one after another until she
had taken a whole bottle. Patient awoke with nausea and vomiting, didn't feel well and thought she should be checked. She denies any thoughts of suicide. Patient history:
Bi-Polar Disorder, suicide attempt at age fifteen by shooting herself in the soft tissue of neck.
Medications: Lithium, 600 milligrams daily followed [monitored] by doctor.
Generally awake and alert and no apparent distress, Cooperative. Physical exam without focal findings - essentially normal.
Anatomy/Physiology
Tylenol OD not accidental. Will start Mucomyst protocol [treatment for Tylenol overdose]. Get PREP and Psych consults.
Bi-Polar - continue regular dose of Lithium.
On page 13 of Joint Exhibit 1, the patient's history and report of physical examination made by a physician whose name is illegible and at an unknown time prior to 0200 hours (2:00 a.m.) on January 13, 1997, states as follows in pertinent part (the abbreviations and symbols have been written out for clarity):
Personal History: Twenty-seven year old White, Female presents approximately twenty-four hours after taking thirty Tylenol. She called her Psychologist, who
told her to come to the emergency room, about which time she felt "funny." She denies protracted nausea and vomiting, loss of consciousness, or change in bowel or urine.
She is a manic-depressive, presently treated with Lithium, who denies suicidal intentions. Medical History: Gun shot suicide attempt in neck at age fifteen; facial lacerations as small child.
Family History: Non-Contributory Social History alcohol abuse.
Medication: Lithium 600 milligrams daily. Allergies: No known drug allergies
Page 14, of Joint Exhibit 1, appears to be a continuation of the preceding note made on January 13, 1997, at 0200 hours (2:00 a.m.). This charting records the results of a physical examination of the Petitioner and the results of laboratory values of blood work performed on the Petitioner. At the time of her first test, the level of acetaminophen level in the Petitioner's blood was 11.1 grams per liter; however, the time the blood was drawn is not noted. The note concludes that the diagnosis and prognosis are: 1. Tylenol overdose - treat four times with Mucomyst 7.6 gram load, then 3.8 gram x 4 x 17. Monitor LFT and acetaminophen level. 2. Bi-Polar Disorder - continue Lithium four times PERP consulted.
Page 15, of Joint Exhibit 1, are the notes of the Psychiatric Consult performed by Dr. Sebastian on January 13, 1997, at an unknown hour. His notes read as follows (abbreviations and symbols have been written out for clarity):
Cate Stoecklin, twenty-seven year old, White Female, who took overdose of (?) [Dr.
Sebastian uses the question symbol mark in the note prior to the number of pills.] thirty Tylenol because her boyfriend left her. Patient says she has been feeling panicky. She came to emergency room about twenty-four hours after taking the Tylenol.
Personal History: Suicidal attempt, manic depressive illness.
Family history of suicide (grandfather).
Observations: Alert, reportedly nervous, answers relevantly, denies suicidal thoughts/plans, evasive [note that the copy cuts off portions of the right margin and the note may be "not evasive"].
Diagnosis: Mental depressive illness, symptoms of depression.
Recommendation: Transfer to Tallahassee Memorial Psychiatric. CHAST received or reviewed signed by Dr. Sebastian
The first entry in the progress notes signed by
Dr. Ward is on January 14, 1997, at 0900 hours. Dr. Ward's notes at that time read as follows (abbreviations and symbols are written out for clarity when understandable):
Subjective: Patient wants to see Dr. Kagin, her Psychologist. He is coming this morning to see the patient with me; she had nausea while taking Mucomyst last evening.
Observation: AF/vital signs stable no SI/HI today.
Cardiovascular PRRØ M lungs CTA (B) abdomen soft, mild tenderness diffusely right upper quadrant ND, liver not enlarged, no guarding or rebound
Anatomy/Physiology
Acetaminophen overdose - patient to complete seventeen dose course of Mucomyst to finish Thursday; SGOT and PT continued to rise, VAK given to counteract rising PT; acetaminophen levels falling; continue to monitor patient.
Bi-Polar Disorder, continue Lithium; level B is circled today.
H/O suicide attempt age fifteen with gun-
patient Baker Act Code 52, now although she claims this acetaminophen overdose was not suicide attempt; Dr. Sebastian recommends transfer to in-patient psychiatric facility when medically stable. Will see patient with Dr. Kagin this morning, signed Dr. Ward.
The family practice faculty note of January 14, 1997, following Dr. Ward's notes indicates agreement with the care, indicates the patient prefers eating vegetables, and requests a dietitian interview the Petitioner.
A family practice note by Dr. Ward for January 15, 1997, at 0745 hours, reads as follows (abbreviations and symbols are written out for clarity):
Subjective: Patient without complaint of cough dysnia; has emesis [vomiting] with mucomyst sometimes.
Objective: temperature 101 1/2. Vital signs stable.
PE: unchanged, lungs clear Anatomy/Physiology:
Acetaminophen overdose. Continue Mucomyst - finishes seventeenth dose tonight; continue to monitor LFT's.
Baker Act Code 52- transferred to Tallahassee Memorial Psychiatric Center in morning per Dr. Sebastian.
Bi-Polar Disorder - continue Lithium.
Fever - twenty-four hours no symptoms of infection monitor closely.
Dr. Ward's family practice note of January 16, 1997, at 0740 hours reads as follows (abbreviations and symbols are written out for clarity):
Subjective: Patient without complaint of nausea and vomiting, abdominal pain, or yellow skin.
Objective: Temperature 101 PE unchanged,
Anatomy/Physiology: acetaminophen overdose, Mucomyst completed; check LFT's today and perhaps transfer to Tallahassee Memorial Psychiatric Center is patient stable medically; Patient still Baker Act Code 52.
Bi-Polar Disorder: Continue Lithium
Fever, resolving; PDB two hours probably due to acute hepaticdic damage.
The physicians' orders of January 13, 1997, at 1130 hours state:
Please change chart to Drs. Ward/Eastum.
Transfer to private room.
Arrange twenty-four hour sitter. Cannot rule out suicidal ideations.
Begin Colace, 100 milligrams two times daily.
The physician's order by Dr. Ward of January 13, 1997, at 1145 hours state:
Please consult psychiatric emergency response preliminary assessment (in patient consult)
Baker Act Code 52 patient
The nursing notes and doctor's notes regarding the patient's history are inconsistent regarding when the Petitioner took the medication. It was initially reported as having been taken eleven hours prior to admission. In some instances, the record reflects that the medication was taken twenty-four hours
prior to admission. When she took the medication is critical to the Rumack-Matthew Nomogram analysis. See Paragraph 21, below.
The Petitioner's blood was drawn sometime after her admission and prior to the time the results of the blood test were recorded in the notes at 1400 hours, on January 13, 1997. The test reveal Petitioner had an acetaminophen level of 11.1.
As part of the protocol, the Petitioner's liver function continued to be monitored over her stay in the hospital. The review of these liver functions reveals that the Petitioner suffered from acetaminophen toxicity upon presenting at the ER. Treatment was required.
Petitioner was admitted and treated at Tallahassee Memorial Hospital for an acetaminophen overdose. This treatment consisted of the Mucomyst protocol which called for the administration of Mucomyst over a two-to three-day period.
The expert called by the Respondent testified regarding his examination of the liver function tests of the Petitioner. His opinion was based upon the information obtained in the lab reports, commonly accepted facts concerning acetaminophen toxicity, and his professional experience.
Paramount to the expert's testimony regarding how much Tylenol Petitioner took was Petitioner's acetaminophen level of
11.1 at admission. The expert found, using the Rumack-Matthew
Nomogram, that the acetaminophen level of 11.1 on admission supported the taking of a large number of Tylenol PM Twenty-four hours prior to presenting. An acetaminophen level of 11.1 does not work out as toxic in a twelve hour scenario on the Nomogram.
The cautions for the use of the Rumack-Matthew Nomogram with regard to acetaminophen poisoning includes the following caution:
The graph should be used only in relation to a single acute ingestion and blood value taken within 24 hours.
The time coordinates refer to the time of ingestion.
Serum levels drawn before four hours may not represent peak levels.
The testimony of the state expert is discounted because it was based upon the evidence of the Rumack-Matthew Nomogram and the Petitioner's lab values upon admission.
The use of the Rumack-Matthew monogram is limited to a single acute dose and blood levels taken within twenty-four hours. The blood work, at best, was taken right at twenty-four hours from the alleged single ingestion or, perhaps twelve hours prior to admission, if one uses the eleven-hour statement taken down by the PERP nurse. However, a blood level of acetaminophen of 11.1, eleven hours after ingestion would not indicate a toxic dose.
In sum, the twenty-four hour period is based upon the Petitioner's history which is not precise, and further no one
knows when the blood sample was drawn.
The course of the pathology of acetaminophen toxicity based upon a single ingestion of a toxic dose is as follows:
Stage One (day one 0-24 hours): Anorexia, diaphoresis, lethargy, malaise, nausea and vomiting palor.
Stage Two (day two 24-48 hours): Stage One symptoms disappear; hepaticdic necrosis begins; abdominal pain and tenderness occur, enlarged liver, elevated AST, ALT, bilirubin, and PT.
Stage Three (days three-four 48-96 hours): Stage One symptoms reappear; hepaticdic necrosis peaks with jaundice, encephalopathy, acute renal failure, bleeding, and hypoglycemia.
Stage Four (after day four 96 hours +): A resolution of symptoms and hepatic dysfunction.
The patient either dies or gets better in stage four.
Had Petitioner taken a massive dose twenty-four hours prior to presenting, she would have developed physical symptoms on January 13, 1997, and her blood and liver values would have been normal on admission.
Petitioner had acetaminophen blood level of 11.1 on admission, as stated above. The acetaminophen level of 11.1 is not per se toxic unless it is the residual reading after a prior massive dose as determined by reference to the Nomogram.
The only scenario which explains acetaminophen toxicity upon presenting with the late on-set of observed physical symptoms and the Petitioner's acetaminophen blood levels on admission is the history given by Petitioner.
The facts do not support a single massive dose, but a slower, although excessive, dosage rate. However, this latter scenario, in the absence of other supporting evidence, cannot be concluded to show an intent to harm oneself. There is no such credible evidence. The patient notes are inconsistent.
The deposition of Dr. Melanie Ward, at page 9, reflects that the only physical symptom of acetaminophen overdose which she observed was tenderness in the right upper quadrant in the area of her liver. This was at 0900 hours on January 14, 1997, fifty-seven hours after the supposed overdose.
On page 11 of Dr. Ward's deposition, she states that she could not say 100% whether the Petitioner really intended to hurt herself; however, they had to take the episode seriously even though the Petitioner stated she was not intending to hurt herself.
Dr. Ward explains on pages 16 and 17 of her deposition, the terms PT and PTT. PT is the Prothrombin Time and activated
Partial Thromboplastin Time. The doctor explains that these are liver function tests in the general sense and that an elevated PT tends to suggest that the liver is not working as well as it should.
On Page 18 of Dr. Ward's deposition, she states that the Petitioner's PT values are elevated on the first test, explaining that normal value should be no higher than 12.5 and that the first value was 14.5. The doctor indicates that it then went up to 17.3 and then started trending downward.
On page 21 of her deposition, Dr. Ward indicates that the Petitioner's liver enzyme tests were elevated upon admission. On page 27 of the medical records, the SGPT shows a very significant rise.
On page 74 of the transcript of Dr. Ward's testimony in the hearing, the doctor indicates that the elevated enzyme readings are consistent with the Petitioner ingesting excessive amounts of acetaminophen. However, Dr. Ward states that she cannot determine how many Tylenol would have been necessary to create the toxicity.
Petitioner testified by deposition. The Petitioner had had some difficulty sleeping because of breaking up with her boyfriend, and had been taking Tylenol PM, as a sleeping aid, for several days prior to her hospitalization. She reported this at the ER and that she had exceeded the maximum recommended dosage
with this medication. In the twenty-four hours preceding her hospitalization, the Petitioner reported further difficulty sleeping, and taking increasing doses of acetaminophen in order to sleep while drinking the remainder of a bottle of wine which she had in her apartment. When she awoke from sleeping around 2100 hours on January 12, 1997, she was nauseated and was vomiting. Feeling poorly, she called her psychologist fearing that she was suffering from a Lithium-induced problem; however, when the psychologist learned that the Petitioner had been taking acetaminophen in combination with alcohol, he recommended that the Petitioner seek emergency treatment. It was under these circumstances that the Petitioner presented herself for treatment at the emergency room.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and the subject matter in this cause. This Recommended Order is entered pursuant to Section 120.57(1), Florida Statutes.
The Petitioner is a member of the State of Florida Employees' Group Health Self Insurance Program. The Petitioner presented herself for treatment in the emergency room of Tallahassee Memorial Hospital. The Petitioner indicated that she had been drinking and had taken an excessive number of
Tylenol PM. It is the scenario of Petitioner taking a single massive dose of acetaminophen that gives rise to the suggestion
Petitioner intended to harm herself. The hospital diagnosed an acute acetaminophen overdose, and treated the Petitioner accordingly.
Subsequently, the administrators of the state's group health insurance program denied payment for the treatment Petitioner received. Generally, employees are entitled to have their health care covered under the insurance plan, and the plan has the burden to show that payment is excluded under the terms of the plan.
Section G of joint Exhibit 4, provides:
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.
* * *
5. (a). 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 Respondent argues that the aforementioned provision of the State of Florida Employees' Group Health Insurance Plan excludes payment of the services rendered by Tallahassee Memorial Hospital to the Petitioner. The DSGI argues that intentional means voluntary, deliberate, and non-accidental, with results
that a reasonable person can predict. DSGI argues that the Petitioner intentionally took the Tylenol PM. Therefore, the resulting acetaminophen poisoning was not accidental.
This construction is strained. The DSGI would interpret "intentional" to modify injury, when intentional modifies self-inflicted under the rules of grammar. Had the drafters intended the result DSGI asserts, a comma would be placed between intentional and self-inflicted.
A plain reading of the terms of the Plan would exclude payment for charges for such services, supplies or equipment necessary to treat an injury which the insured intended to inflict upon his or herself. In this case, the Department must show the Petitioner took the overdose of Tylenol PM with the specific intent of harming herself, not merely an intention to take the Tylenol PM.
If DGSI's argument were adopted, the state could exclude payment for services rendered to an individual with HIV/AIDS who "intended" to use intravenous drugs or engage in unsafe sex. Similarly, the state could deny payment for treatment of emphysema in smokers and heart disease in persons who are obese. This was not the intent of the legislature in putting forth this exclusion. Legislative intent was to exclude payment for services rendered for an injury which the individual intended to inflict on himself.
The Respondent must show, as stated above, that the Petitioner intended to injure herself when she took the Tylenol. There is no direct evidence of such an intent, and the Petitioner denied such an intent on admission. The only competent evidence of an intent to harm herself are the patient notes which indicate generally that the patient took thirty Tylenol PM twenty-four hours earlier because her boyfriend left her. These same notes report the patient denied suicidal intent.
An intent to harm herself could be inferred from a showing she took, at one time or a very short time, an excessively large number of Tylenol.
The Petitioner's testimony, as recorded in her deposition, reflects that she took a large number of Tylenol PM, over a twenty-four hour period preceding her admission to the hospital. However, she states that she did not take them all at one time.
The medical evidence in terms of the physical findings are inconsistent with the Petitioner having taken thirty Tylenol within a short time, twenty-four hours before presenting herself for treatment, and the level of acetaminophen in her blood at the time of her admission is inconsistent with having taken a large amount of Tylenol eleven hours before admission as recorded in the PERP report.
The lab values indicate that the Petitioner was already suffering from impaired liver function upon her admission, which
is inconsistent with the scenario of having taken thirty Tylenol twenty-four hours previously. The lab values and physical findings are more consistent with the scenario in which the Petitioner took larger than recommended dosages of Tylenol PM, over a longer period of time, thereby impairing her liver function and bringing on acetaminophen toxicity. The Petitioner did not have physical symptoms until thirty-three hours after admission and fifty-seven hours after the alleged single dose of thirty Tylenol PM. This is consistent with Petitioner's statement of taking increasing doses of the medicine to induce sleep, and not to harm herself.
The taking of the large number of acetaminophen over a longer period of time does not support the inference that she took a large number of pills at one time in order to hurt herself. Acetaminophen poisoning by long-term overdose is a frequent, accidental occurrence. The objective evidence is more supportive of Petitioner's explanation of the overdose, than the scenario suggested by the Respondent.
The burden is upon the Respondent to show that the Petitioner acted with an intent to hurt herself. The Respondent has not shown by the weight of the evidence that the Petitioner acted with an intent to hurt herself. Based on the foregoing, the Respondent had an obligation to pay the medical expenses which are not excluded, and the medical expenses of the Petitioner should not be excluded.
Based upon the foregoing Findings of Fact and Conclusions of Law set forth herein, it is
That the Plan pay the medical bills of the Petitioner. DONE AND ENTERED this 26th day of February, 1999, in
Tallahassee, Leon County, Florida.
STEPHEN F. DEAN
Filed with the Clerk of the Division of Administrative Hearings this 26th day of February, 1999.
Dr. Sara Stoecklin 1559 Christobal Drive
Joan Van Arsdall, Esquire Department of Management Services 4050 Esplanade Way, Suite 260
Paul A. Rowell, General Counsel Department of Management Services 4050 Esplanade Way
Thomas D. McGurk, Secretary Department of Management Services 4050 Esplanade Way
15 days from the date of this recommended order. Any exceptions to this recommended order should be filed with the agency that will issue the final order in this case.
