Garred v. General American Life Ins. Co.

• Decision Date: 20 September 1991
• Docket Number: Civ. No. 89-5108.
• Parties: Sandra Kay GARRED; Barry G. Garred, Husband and Wife, Plaintiffs, v. GENERAL AMERICAN LIFE INSURANCE COMPANY, et al., Defendants.
• Court: U.S. District Court — Western District of Arkansas

774 F. Supp. 1190

Sandra Kay GARRED; Barry G. Garred, Husband and Wife, Plaintiffs, v. GENERAL AMERICAN LIFE INSURANCE COMPANY, et al., Defendants.

Civ. No. 89-5108.

United States District Court, W.D. Arkansas, Fayetteville Division.

September 20, 1991.

James M. Roy, Roy & Lambert, Charles L. Harwell, Cypert, Crouch, Clark & Harwell, Springdale, Ark., for plaintiffs.

Sidney P. Davis, Davis, Cox & Wright, Fayetteville, Ark., for defendants.

MEMORANDUM OPINION

H. FRANKLIN WATERS, Chief Judge.

This is an action under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001 et seq. This case originated in the Circuit Court of Washington County, Arkansas. The action was removed to this court on September 9, 1989. Plaintiffs' motion to remand was denied by opinion dated November 1, 1989. See Garred v. General American Life Ins. Co., 723 F.Supp. 1325 (W.D.Ark.1989). On November 11, 1989, a stay was entered to allow the plaintiffs to exhaust their administrative remedies. The action was reopened on May 1, 1991, and plaintiffs were granted leave to file an amended complaint.

In their complaint plaintiffs, Barry G. and Sandra Kay Garred, seek payment of medical bills under a group insurance policy covering the employees of Continental Ozark, Inc. Barry Garred was a full-time employee of Continental Ozark, Inc. Sandra Garred as a spouse of an employee was covered by the group insurance policy.

The defendants are the General American Life Insurance Company, T.L.A. Group Insurance Trust, Plan B, and the Lewer Agency, Inc. The General American Life Insurance Company, is the insurance company that issued policy number MCP-2900-S to the trustees of the TLA Group Insurance Trust Fund. The TLA Group Insurance Trust Fund Plan B, is a trust created by the Lewer Agency that Continental Ozark, Inc. joined in order to fulfill its obligations under its employee welfare benefit plan. The Lewer Agency administers claims under the policy of insurance issued by General American Life Insurance Company.

The court has before it the administrative record which the parties have stipulated constitutes the entire record before the plan administrator at the time an ERISA review of plaintiffs' claim was conducted. Additionally, the court has before it the briefs of the parties. Plaintiffs have filed a motion to strike certain portions of the supplemental record provided by the defendants. Certain of the objections have been mooted by the provision of a certified copy of the master insurance policy. The plaintiffs' remaining objections deal with the handwritten responses of Dr. Robert J. Corday to defendants' inquiries regarding Ms. Garred's condition. The objections by and large go to the weight to be given these materials and not to the inclusion of these materials in the record. ERISA contemplates a review of all materials taken into consideration by the claims administrator in reaching its decision. Thus, the materials will be considered. The issue is now before the court for a de novo review conducted pursuant to Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). See also Lakey v. Remington Arms Co., 874 F.2d 541, 543 (8th Cir.1989).

Background

Ms. Garred at all times relevant to this litigation was a participant and covered individual under the employee welfare benefit plan at issue herein. The parties agree that Ms. Garred was eligible for medical insurance benefits.

Between September 11, 1988, and July 18, 1990, Ms. Garred incurred approximately $39,524.71 in medical expenses due to hospitalizations and related medical treatments stemming from depression and reactive psychosis. Ms. Garred made a claim for payment through the defendants. Defendants denied the claims initially and on review on the basis of three exclusions in the policy.

In this regard, the policy provides:

Major Medical Expense Benefits are not payable for:

* * * * * *

9) intentionally self-inflicted injury;

* * * * * *

15) psychological testing, counseling and group therapy;

* * * * * *

22) treatment of nervous and mental condition;

Master Policy at 8E-8F. These exclusions are not further explained in the policy.

Resolution of the issues before the court requires a review and discussion of the facts relevant to Ms. Garred's illness and medical treatment. The record before the court largely consists of the medical records of the various treating and consulting physicians as well as affidavits, correspondence from, and the deposition testimony of the doctors.

Beginning in July of 1987, Ms. Garred began to evidence symptoms of major depression that resulted in the need for treatment and counseling. Dr. James H. Arkins, Ms. Garred's treating physician, noted on December 18, 1987, that plaintiff had been "undergoing severe endogenous depression since July." It was further noted that plaintiff was "having some suicidal ideation" and was undergoing counseling.

Dr. George Cole notes she was diagnosed with endometriosis "as well as severe PMS with associated depression." Letter from Dr. Cole to Dr. Arkins dated January 26, 1988. Ms. Garred underwent a hysterectomy early in 1988. On September 11, 1988, plaintiff was briefly admitted to Charter Vista Hospital. The primary diagnosis was listed as schizophreniform disorder. The history of present illness stated:

The patient's husband relates to staff that approximately 1½ weeks ago Sandra became withdrawn, showing preoccupied behavior and increasingly poor sleep pattern. The night prior to admission she became uncommunicative with the family, appeared to be agitated and was found in bed praying fervently. She did this all night along. She was speaking in broken sentences. She had not slept at all in the 24 hours prior to admission. Note is made that she had a poor eating pattern for the last week or two and has lost five pounds.

The husband did relate that there had been a similar episode of preoccupation and depression a few months prior to her hysterectomy in April, 1988. She was treated with Desyrel and apparently is continuing on this medication. He notes that she has had multiple `life stresses' including a son with a kidney disease. He is now age 12 and he may need a transplant. There is a 10 year old daughter that had been born prematurely.

The patient apparently has been quite deeply involved in her religion and recently a bible study leader has convinced her not to take her hormones or her antidepressants. There was a referral then to some internal conflict over this bible study.

Ms. Garred was discharged from Charter with arrangements made for her to seek alternate care.

On September 12, 1988, plaintiff was admitted to the Springdale Memorial Hospital Psychiatric Unit for "a brief reactive psychosis." Springdale Memorial Hospital Discharge Summary for discharge on 9/20/ 88. The personal history and physical examination taken at Springdale Hospital contains the following remarks regarding Mrs. Garred's history:

According to the composite history, Mrs. Jarred has been under considerable stress for the (sic) eight-to-ten years. She had a premature child about nine or ten years ago. The infant was in Neonatal Care in Tulsa for a prolonged period of time. The child now is doing well. She was in for a recent strept (sic) throat. She has a son who has diabetes insipidus and there is a possibility of need for dialysis and/or a kidney transplant. This has developed over the past six months to a year which has been a stress for her. She is described as having a lot of abdominal pain and discomfort and premenstrual syndrome or monilial irregularities leading up to a hysterectomy in April or May of this year. Prior to that time, she is described by Dr. Arkins and her husband as being depressed and at times having suicidal ideation. She was treated with Desyrel which seemed to help. Also during this time period, she and her husband were foster parents for a premature child that was later adopted out by their minister. There seems to be some concern or transference with that child and her premature daughter. She apparently was doing fairly (sic) up until the last week or two when she developed an apparent acute psychotic break. This may have been precipitated by a man in Little Rock who is saying the coming Christ is due today. She became more and more informed in this, one more religious ideation and some guilt over the weekend.

Springdale Memorial Hospital Personal History and Physical Examination, Dr. E.C. Jones, M.D., admission date 9/12/88.

The mental status examination reveals the following comments were made by Dr. Jones:

MENTAL STATUS EXAMINATION shows a well-developed, well-nourished, attractive white female lying in bed, speaking in the room with motion, talking about being with God and being with Christ. There is some concern that she is suicidal and wanting to kill herself according to the husband. He feels she believes she is in heaven at this time. Dr. Arkins thought she was probably suicidal when he saw her Sunday at Charter Vista Hospital. Religious delusions are present. It is not clear whether any auditory or visual hallucinations are present.

The discharge diagnosis from this hospitalization was stated as a "brief reactive psychosis."

Ms. Garred underwent a psychological evaluation at the Ozark Guidance Center (OGC). The OGC personnel summarized their findings as follows:

Mrs. Garred is a 32 year old Caucasian, married woman with two children. Both of her children are in poor health, especially her son who is facing a kidney transplant in the next few years. She had been under extraordinary (sic) stress in the past year, which resulted in a psychotic episode with delusions and auditory hallucinations.

Under ordinary circumstances, Mrs. Garred has adequate resources to deal with stress. In fact, she has been doing fairly well in the past ten years dealing with two frail children and managing a household. Under high levels of stress, however,

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