Ganson v. State, Dept. of Admin., Office of State Employees' Ins.
| Decision Date | 07 July 1989 |
| Docket Number | No. 88-1568,88-1568 |
| Citation | 554 So.2d 516,14 Fla. L. Weekly 1594 |
| Parties | 14 Fla. L. Weekly 1594 Terri J. GANSON, Appellant, v. STATE of Florida, DEPARTMENT OF ADMINISTRATION, OFFICE OF STATE EMPLOYEES' INSURANCE, Appellee. |
| Court | Florida District Court of Appeals |
Kenneth D. Kranz of Eric B. Tilton, P.A., Tallahassee, for appellant.
Augustus D. Aikens, Jr., Gen. Counsel, Dept. of Admin., Tallahassee, for appellee.
In this appeal from a final order of the Department of Administration denying a claim for health insurance benefits, appellant asserts that the Department improperly rejected the hearing officer's recommended findings of fact and arbitrarily interpreted the provisions of the State Group Health Insurance Plan in a manner contrary to its plain meaning and to established insurance law. We agree and reverse.
Appellant was treated for situational depression prior to her employment by the State in January 1986 and her enrollment in the State Group Health Insurance Plan, which is administered by the Department of Administration pursuant to section 110.123, Florida Statutes (1987), and chapter 22K-1, Florida Administrative Code. 1 Three months after enrollment in the Plan, she was hospitalized, diagnosed and treated for manic depressive illness, now known as "bipolar affective disorder." 2 The Department denied her claim for reimbursement under the Plan for the first year of enrollment on the ground that her illness was a pre-existing condition, notwithstanding that her physician (Dr. Shamis), her psychologist (Dr. Whitley) and the psychiatrist who hospitalized her and diagnosed bipolar affective disorder (Dr. Munasifi) had informed Blue Cross/Blue Shield that she had not been treated for bipolar affective disorder before April 1986.
The State Group Health Insurance Plan Benefit Document, created and maintained by the Department and approved by the legislature, defines the coverage conditions, limitations and exclusions of the Plan. The "pre-existing condition" exclusion specifies:
For any accident or illness for which an insured received diagnostic treatment or received services within three-hundred and sixty-five (365) consecutive days prior to the effective date of coverage, no payment will be allowed for services related to such accident or illness which are received during the three hundred and sixty-five (365) consecutive days subsequent to the effective date of coverage; however, covered services related to such accident or illness which are received after three hundred and sixty-five (365) consecutive days of coverage are covered by the Plan.
The Benefit Document defines "illness" as "physical sickness or disease, pregnancy, bodily injury, congenital anomaly or mental or nervous disorder."
Appellant timely requested a 120.57 hearing and in the pre-hearing stipulation the parties agreed that she is entitled to reimbursement for the amount stipulated if the condition for which services were rendered did not constitute a pre-existing condition, i.e., an "accident or illness" for which she "received diagnostic treatment or received services within three hundred and sixty-five days prior to ..." her enrollment in the plan.
At the hearing before Michael Parrish, the Department of Administrative Hearings hearing officer, appellant testified that she had been treated since 1983 by Dr. Whitley for depression caused by events in her life, but that her March 1986 depression was uncontrollable and she was suicidal. She "got hyper" at Whitley's office and Dr. Shamis referred her to Dr. Munasifi, who hospitalized her and diagnosed bipolar affective disorder. She testified that she has no family or personal history of bipolar affective disorder, never before felt manic or depressed for no reason and never before had that kind of "high". She stated that she had never before been treated with lithium, but now takes lithium twice a day and has had no more manic episodes. She still gets depressed, but it is controllable now, and she still sees Dr. Whitley once a week.
Dr. Whitley testified that he had treated appellant before March 1986 for "situational depression" which he described as temporary depressions caused by events in her life. He stated there was no identifiable stimulus for her March 1986 depression and the symptoms (intense mood swings, suicidal ideation, inability to control her thoughts) had not been exhibited before. Dr. Shamis' anti-depressant prescriptions (Mellaril and Cogentin) escalated the symptoms and were discontinued after two days.
Dr. Whitley testified that he is familiar with bipolar affective disorder to a limited extent and suspected it might be the cause of appellant's symptoms, and that the disorder is not a progression or severe case of situational depression, but is caused by a chemical imbalance. The treatment is with lithium (to correct the chemical imbalance) and counseling (to help the patient accept the fact of the condition and the continued need for lithium treatment). Before her hospitalization, Whitley's counseling had been to help appellant deal with the situation or event causing the particular depression; she had never before described manic periods or uncontrollable depression.
William Seaton, a benefits analyst with the Office of State Employees' Insurance who has no training in psychology or psychiatry, testified that the purpose of the pre-existing condition exclusion was to "prevent adverse selection against the Plan." He testified the Plan's position was that if the insured had been treated for any "nervous or mental condition" within the year prior to enrollment, she is not covered for any nervous or mental condition for one year after enrollment. He stated that the same was not true for any physical disease, and that this is how the Plan has always been interpreted, but admitted that there was no basis in the Plan for the different exclusion interpretations for physical and mental illnesses.
The hearing officer also considered the relevant portions of the Benefit Document, the doctors' letters, the level II review (by a nurse) and the level III review (by a doctor) of the claim, 3 the letter formally denying the claim, and correspondence between the hospital and Blue Cross over whether the condition was pre-existing, including a memo from Blue Cross stating that "regardless of diagnosis, any mental and nervous condition is pre-existing on the above patient."
In a post-hearing deposition, Dr. Munasifi was accepted as an expert in the diagnosis and treatment of bipolar affective disorder and testified that before he saw her in April 1986, appellant had been treated for situational depression and major depressive episodes, but had never been diagnosed or treated for bipolar affective disorder. He stated that bipolar affective disorder is not the same condition as her prior depressions, nor is it a progressive condition, nor is it an acute form of those conditions.
Dr. Munasifi testified that bipolar affective disorder is caused by a chemical imbalance and is usually diagnosed by psychiatrists; depression is one of its manifestations, and response to the lithium confirms the diagnosis. He stated that appellant's April 1986 depression was more severe than the earlier depressions and had manic elements, and that the insurer never consulted him nor requested appellant's medical records.
In his recommended order, the hearing officer found that prior to her enrollment in the Plan, appellant had been diagnosed as having situational depression for which she had received treatment, but that she had not been diagnosed or treated for bipolar affective disorder, which "is believed to be caused by a deregulation of the chemical neurotransmitters in the brain." He found that the primary treatment for bipolar affective disorder is lithium carbonate, which is specific for this disorder and is the main difference between treatment for bipolar affective disorder and the treatment appellant received prior to her enrollment in the Plan. He noted that behavioral therapy may also be useful in the treatment of the symptoms of bipolar affective disorder, as it is in the treatment of the symptoms of other conditions which cause depression.
The hearing officer found that situational depression and bipolar affective disorder are separate and distinct conditions, that the former is not an earlier stage of the latter, and that the fact that both conditions have certain common symptoms (periods of depression) does not mean that they are the same condition. He concluded that because bipolar affective disorder is not the same condition as situational depression, it was not a pre-existing condition within the meaning of the benefit exclusion, and recommended that appellant be reimbursed in the stipulated amount. No exceptions to the recommended order were submitted by either party.
In the final order, based on the stipulations of the parties, the testimony and exhibits "and recommended findings of the hearing officer," Adis M. Vila, Secretary of the Department of Administration, found that prior to enrollment in the Plan, appellant had been treated for conditions which fall under the "broad mental or nervous disorder of depression," but that the specific characterization of bipolar affective disorder "was not and could not have been made" until her April 1986 hospitalization, because appellant's psychologist "was not trained in diagnosing the disorder" and she did not see a psychiatrist, who is generally able to diagnose bipolar affective disorder, until then. 4 Vila found that neither doctor observed any of appellant's "transient mild episodes of hyperactivity." 5 She observed that lithium carbonate is an antidepressant drug used to treat various depressive illnesses and found, based on Dr. Munasifi's testimony, that appellant's treatment with lithium carbonate did not establish that she is suffering from a "different" mental or nervous disorder. 6
Vila found...
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Department of Admin., Office of State Employees' Ins. v. Ganson
...566 So.2d 791 ... 15 Fla. L. Weekly S469 ... DEPARTMENT OF ADMINISTRATION, OFFICE OF STATE EMPLOYEES' INSURANCE, Petitioner, ... Terri J. GANSON, Respondent ... No. 75396 ... Supreme Court of Florida ... Sept. 13, 1990 ... Augustus D. Aikens, Jr., Gen. Counsel, Dept. of Admin., Tallahassee, for petitioner ... Kenneth D. Kranz of Eric B. Tilton, P.A., Tallahassee, for respondent ... GRIMES, Justice ... Pursuant to article V, section 3(b)(3), Florida Constitution, we accepted jurisdiction in Ganson v. Department ... ...