Johnson v. General American Life Ins. Co.

• Decision Date: 21 December 2001
• Docket Number: No. CIV.A. 701CV00042.,CIV.A. 701CV00042.
• Citation: 178 F.Supp.2d 644
• Parties: Jerry Eugene JOHNSON, Plaintiff, v. GENERAL AMERICAN LIFE INSURANCE COMPANY; National Service Industries, Inc., Defendants.
• Court: U.S. District Court — Western District of Virginia

178 F.Supp.2d 644

Jerry Eugene JOHNSON, Plaintiff, v. GENERAL AMERICAN LIFE INSURANCE COMPANY; National Service Industries, Inc., Defendants.

No. CIV.A. 701CV00042.

United States District Court, W.D. Virginia. Roanoke Division.

December 21, 2001.

COPYRIGHT MATERIAL OMITTED

COPYRIGHT MATERIAL OMITTED

Paul Graham Beers, Glenn, Flippin, Feldman and Darby, Roanoke, VA, for Jerry Eugene Johnson.

Kevin S. Blair, Woods, Rogers & Hazlegrove, P.L.C., Roanoke, VA, for General American Life Ins. Co., National Service Industries, Inc.

MEMORANDUM OPINION

KISER, Senior District Judge.

This is a declaratory judgment action brought by plaintiff Jerry E. Johnson ("Johnson") under 28 U.S.C. §§ 2201-2202 and 29 U.S.C. § 1132 of the Employee Retirement Income Security Act ("ERISA") with regard to a long term disability benefit policy issued to him by the defendants. Johnson claims that his benefits were improperly terminated under a mental illness limitation contained therein.

The Court has jurisdiction under 28 U.S.C. § 1331 and the above statutes. A bench trial was conducted on September 10 and 11, 2001, and the parties have submitted post-trial briefs, making this matter ripe for disposition.

The issue for the Court to decide, best considered in narrow terms due to the wealth of case law on the subject, is whether, using a de novo standard of review, the Policy's Mental Illness Limitation limits benefits where a policyholder's disabling depression was caused by a physical ailment which qualified as a physical disability for a limited time. For reasons stated below, I DENY plaintiff's plea for a declaration that his disability is covered under the long term disability policy issued to him by the defendants, and all other relief requested in his Complaint.

I. Findings of Fact

The relevant facts are largely undisputed. To the extent that they are not, the following narrative represents my findings of fact.

Plaintiff Johnson worked at National Linen, a division of National Service Industries, Inc. (collectively, "National") for twenty two years before he was stricken with a heart attack in June, 1996. In September, 1996, he had triple bypass heart surgery during a lengthy hospital stay.

Johnson attempted return to work in January of 1997, but was not able to continue because of an inability to concentrate and lack of physical and emotional stamina. Plaintiff's Trial Exhibit 2 (Deposition of L. Douglas Balke, M.D. ("Balke Dep."), Dep. Ex. 5 (letter from Johnson's internist, Dr. Charles H. Hiles, dated June 23, 2000)). Johnson's inability to work is the result of the major depression which Johnson developed following his hospitalizations, and for which he has been treated unsuccessfully by Dr. Balke and others since March, 1997. Id.

Throughout the relevant period, Johnson was insured under a long term disability policy issued by General American Life Insurance Company ("General"). Pl.Ex. 16 (Policy No. LTD-800, Bates Nos. GA-0166-0195).

Relevant portions of the Policy are as follows:

Section I Definitions

...

"Sickness" means illness or disease. It will include pregnancy. The disability must begin while the employee is insured under the policy ...

"Disability" and "disabled" mean that because of injury or sickness:

1. The insured cannot perform each of the material duties of his regular occupation; and

2. after benefits have been paid for 24 months, the insured cannot perform each of the material duties of any gainful employment for which he is reasonably fitted by training, education or experience.

Section III Benefits

DISABILITY

When the Company receives proof that an insured is disabled due to sickness or injury and requires the regular attendance of a physician, the Company will pay the insured a monthly benefit.... The benefit will be paid for the period of the disability.

...

MENTAL ILLNESS LIMITATION

...

Benefits for disability due to mental illness will not exceed 24 months of monthly benefit payments....

"Mental illness" means mental, nervous or emotional diseases or disorders of any type.

Pl.Ex. 16 (Policy, Bates No. GA-0172-0173, 0176, 0185) (emphasis added).

Defendant General American Life Insurance Company ("General") approved Johnson for long term disability benefits on June 18, 1997. Defendant's Trial Exhibit 8 (General's determination letter, Bates No. GA-0003, 0004). Johnson received benefits for 24 months before General terminated his benefits under the "Mental Illness Limitation" contained in the Policy. Def. Ex. 2 (letter of March 29, 1999, advising Johnson that benefits would terminate on April 25, 1999). Johnson appealed. In its letter dated September 15, 1999, General again denied benefits based upon the opinion of Dr. Hiles that Johnson was "released from a cardiovascular perspective for return to work on a permanent basis eight hours a day." Def. Ex. 5. According to Hiles, "On a purely physical basis, [Johnson] has had a full-time work capacity from January 6, 1997, when he returned to work, until present." Id. Hiles still considered Johnson to be disabled, but General understood Hiles to state that Johnson's "disabling diagnosis" at that point was "that of Depression and not cardiovascular disease." Id. Therefore, it upheld its earlier decision to enforce the Mental Illness Limitation. General issued a final denial on January 17, 2001. Def. Ex. 6.

Johnson was not depressed prior to the onset of coronary disease in June, 1996. Balke Dep. Ex. 5. The opinions of Dr. Hiles-and to a lesser degree of certainty, Dr. Balke — consistently have been that Johnson's depression was caused by, or exacerbated to the point of disability by, his cardiovascular condition. Balke Dep. 9:6-16; 28:17-24; 30:1-2; 31:17-19; Dep. Ex. 2, 3 and 5; Pl.Ex. 6 (Hiles' patient progress notes dated October 31, 1996); Pl.Ex. 11 (Hiles letter to the Social Security Administration dated April 1, 1997); Pl. Ex. 18 (Hiles letter dated May 19, 1999); Def. Ex. 8 (Hiles letter dated June 23, 2000, Bates No. GA-0145-0146; Balke letter dated July 21, 2000, Bates No. GA-0147). Johnson still has coronary artery disease. Pl.Ex. 18. However, aside from the depression caused by that ailment, Johnson would be able to return to work. Def. Ex. 5. (General denial letter quoting Dr. Hiles, dated September 15, 1999).

At trial, General presented no expert testimony to the contrary. It did, however, attempt to undermine the scenario described by Johnson's doctors. Although General's argument relied, for the most part, on excluded deposition testimony,¹ it also argued that Johnson's psychiatrist, Dr. Balke, equivocated once or twice on the cause of Johnson's depression, saying that it was a reaction to Johnson's reduced responsibilities after he returned to work. Def. Bf. at 5-6 (citing (Balke Dep., 14-15, 20); Def. Ex. 7 (Balke letter of July 21, 2001, Bates. No. GA-0147)). Balke consistently claimed that Johnson's heart disease was "a significant factor" in causing his depression, but he would not go so far as bill his treatments under a code that unequivocally described the cause as physical. Balke Dep. at 25-26. General pointed out that the DSM-IV recognizes a separate diagnosis for mental disorders caused by physical conditions and that Balke did not make this diagnosis of Johnson. Balke Dep. at 22. Balke testified that Johnson's heart condition "precipitated" his depression, but he could not testify that Johnson would not have had depression if he also had not developed heart disease, due to the possibility of genetic susceptibility and other stressors. Balke Dep. at 16-17. Balke also noted that during one period following the surgery, Johnson was walking up to three miles a day, did yard work, and completed staining a large deck. Balke Dep. at 21-22.

Johnson points out, however, that Dr. Balke has repeatedly deferred to Dr. Hiles concerning the etiology of Johnson's depression, claiming that Hiles is best qualified to opine on that matter. Pl. Bf. at 5-7 (citing Balke Dep. 9:6-16, 27:1-2, 28:17-24, 31:17-19; Balke Dep. Ex. 2 (Balke letter of June 16, 1999)). General does not dispute Dr. Hiles' opinion, but in fact relied upon it as the basis for limiting Johnson's benefits. For these reasons, I adopt Dr. Hiles' opinion that until January 6, 1997, Johnson was unable to perform all regular duties of his job due to his heart condition; that after this date and to the present, Johnson has still been unable to perform all these duties; that the reason Johnson has not been able to perform all of the duties of his job since January 6, 1997 is due to depression and not due to the physical symptoms of his heart disease; and that Johnson's depression was caused, or at least exacerbated to the point of disability, by Johnson's heart condition.

II. Conclusions of Law

1. The applicable law of ERISA plan construction is that of federal common law as developed by the Fourth Circuit. However, the particular choice of law is not dispositive to this matter.

In federal district courts, the choice-of-law analysis to be applied to a given case is that of the state in which the forum court resides. Klaxon Co. v. Stentor Elec. Manufact. Co., 313 U.S. 487, 61 S.Ct. 1020, 85 L.Ed. 1477 (1941). Virginia conflict-of-law doctrine will enforce contractual forum selection clauses "unless the party challenging enforcement establishes that such provisions are unfair or unreasonable, or are affected by fraud or unequal bargaining power." Paul Business Systems, Inc. v. Canon U.S.A., Inc., 240 Va. 337, 342, 397 S.E.2d 804, 807 (1990) (citing The Bremen v. Zapata Off-Shore Co., 407 U.S. 1, 10, 92 S.Ct. 1907, 32 L.Ed.2d 513 (1972); Restatement (Second) of Conflict of Laws (1988 Revisions) § 80 (Supp.1989)). In this case, the Policy states that it is "delivered in Georgia and subject to the laws of that jurisdiction." Pl.Ex. 16 (Bates No. GA-0166). General which opposes the application of Georgia state law, does not argue that this provision is...