Arkansas Blue Cross & Blue Shield, Inc. v. Doe Ex Rel. Doe

733 S.W.2d 429, 22 Ark. App. 89, 1987 Ark. App. LEXIS 2470
CourtCourt of Appeals of Arkansas
DecidedJuly 29, 1987
DocketCA 86-406
StatusPublished
Cited by17 cases

This text of 733 S.W.2d 429 (Arkansas Blue Cross & Blue Shield, Inc. v. Doe Ex Rel. Doe) is published on Counsel Stack Legal Research, covering Court of Appeals of Arkansas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Arkansas Blue Cross & Blue Shield, Inc. v. Doe Ex Rel. Doe, 733 S.W.2d 429, 22 Ark. App. 89, 1987 Ark. App. LEXIS 2470 (Ark. Ct. App. 1987).

Opinion

George K. Cracraft, Judge.

Arkansas Blue Cross and Blue Shield, Inc., appeals from a judgment of the Lee County Circuit Court, sitting as a jury, finding it liable to appellee policyholders for benefits provided for a physical condition rather than those provided for a mental one and allowing the pro se appellee an attorney’s fee. It contends that the trial court erred in finding that appellee’s daughter’s hospitalization and treatment were for a physical illness rather than a mental condition, in excluding the testimony of appellant’s actuarial manager, and, because appellee was also a witness in the case, in holding that he, as a pro se attorney, was entitled to an allowance of fees.

On February 25, 1987, we granted a joint motion to certify this case to the supreme court pursuant to Rule 29(1 )(c) and (4)(b) of the Rules of the Arkansas Supreme Court and Court of Appeals. On June 9,1987, the case was remanded to the court of appeals for decision. Accordingly, jurisdiction lies in this court. We find no error and affirm.

The appellee and his minor daughter were insured under a group health insurance policy issued by appellant to appellee’s law firm. The policy provided liberal benefits for hospitalization and medical treatment for physical illness and accidental injury, but limited coverage for medical and hospital expenses incurred as a result of mental, psychiatric, or nervous conditions. The policy did not define either mental or psychiatric condition. Appellee’s daughter was hospitalized and treated for a disorder diagnosed as bipolar affective disorder. The appellee submitted the expenses for her hospitalization and treatment but only those limited benefits provided for mental conditions were paid. Appellant contended that the child’s disorder was a mental condition for which she had received psychiatric treatment and therefore was entitled only to limited benefits. The appellee brought this action to recover full benefits provided in the policy for an illness of a physical nature.

The appellee testified that he was a practicing attorney and the father of the insured minor whose developing problem became acute in 1984. She spent a great deal of time in bed crying and developed eating and sleeping problems. She lost weight and at times was in deep depression. In those periods, she would lose interest in all those things in which other children her age were engaged. At times, she was suicidal and talked about dying. At other times, she was energetic and her sleeping and eating patterns were near normal. She was subsequently hospitalized and was seen by psychiatrists. She was prescribed medications for her condition and has improved to such an extent that she is now a different person. Her mood, weight, and eating problems have stabilized and are now normal. Her sleeping patterns, though variable, are near normal. She is attending a special school and has reasonable expectation for a normal life so long as she remains on her medication.

Dr. Thomas Harris, a treating psychiatrist, testified that those of the medical profession who dealt in mental conditions had historically categorized these illnesses by symptom rather than cause. He stated that bipolar affective disorder, referred to in the past as manic-depressive disorder, is characterized by those symptoms described by the appellee but that “I think most laymen, and actually I think most physicians and most people in psychiatry now classify illnesses by cause or origin.” Although classified according to symptoms as a mental disease by some in the profession, he stated it is in fact a physical disorder. “The medical research is now, in my opinion, overwhelming in that regard.” He stated that it was an illness of the brain and body rather than of the mind and stemmed from a chemical imbalance which responds to medication. This illness, like many others he described, manifests some behavioral or emotional disturbances, but the causes of those manifestations are physical and biological in nature as distinguished from mental.

There was evidence that, although bipolar affective disorder originates as a physical illness which requires and responds to medical treatment, psychotherapy is utilized in several ways in treatment of the disease, as was done in Jane Doe’s case. It helps the patient accept the fact of her illness and learn to cope with it. It also assists the patient in becoming accustomed to normal feelings and reactions and learning the importance of taking the prescribed medication necessary to continued recovery. It is further utilized in measuring the effect of medication on a person’s mood levels in order that proper adjustment could be made in medicine dosages.

Dr. John Leite, a clinical psychologist who treated the minor appellee, testified that “[o]f all the kids I’ve seen, [Jane Doe’s] is most clearly a biologically-based illness.” Dr. Anne Utley, a treating psychiatrist, stated that, although bipolar affective disorder is classified as a mental problem, there are physical causes for it. Dr. Dolores DiGaetano, a psychiatrist, agreed that bipolar affective disorder was caused by hormonal imbalance and that it was a biological condition. Dr. Douglas Stephens, a clinical psychologist, testified positively that bipolar affective disorder was a physical disorder resulting from metabolic imbalance. Dr. Stuart Harris, a psychiatrist, also agreed that it was a biological, physical disorder of the brain function with multiple symptomatic manifestations.

There was evidence from medical witnesses that the classification of illnesses by symptoms by those in the psychiatric field was a primitive way of classification and that the profession was moving away from that method. It was pointed out that the Arkansas Psychiatric Society at its 1986 meeting had declared “[bjipolar affective disorder is an illness whose origin is biological.”

Appellant offered evidence of its director of claims that the classification system used by Blue Cross-Blue Shield was the same as that generally used by medicare and most hospitals, physicians, and clinics in the country. Under that system, bipolar affective disorder is classified as a mental disorder. Though most of the doctors who testified in person or by deposition indicated that the psychiatric field did classify bipolar affective disorder as a mental condition, all but one of those agreed that it was so classified by symptom rather than cause.

We agree with the trial court that the issue for its determination was whether bipolar affective disorder is a physical illness or a mental or psychiatric condition within the terms of the policy. On conflicting evidence, it expressly found that “the illness of Jane Doe is a physical condition within the meaning of the Blue Cross contract” and not a mental one. Findings of fact of a circuit court sitting as a jury will not be reversed on appeal unless clearly against a preponderance of the evidence and, in making that determination, we give due regard to the superior position of the trial court to judge the credibility of the witnesses. National Investors Fire & Casualty Insurance Co. v. Chandler, 4 Ark. App. 116, 628 S.W.2d 593 (1982). We cannot conclude on the facts of this case that the finding of the trial court is clearly against a preponderance of the evidence.

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733 S.W.2d 429, 22 Ark. App. 89, 1987 Ark. App. LEXIS 2470, Counsel Stack Legal Research, https://law.counselstack.com/opinion/arkansas-blue-cross-blue-shield-inc-v-doe-ex-rel-doe-arkctapp-1987.