COURT OF APPEALS OF VIRGINIA 

Present: Chief Judge Moon, Judges Willis and Fitzpatrick 

Argued at Alexandria, Virginia 

FOOD DISTRIBUTORS AND 

 CENTURY INDEMNITY COMPANY 

 OPINION BY 

v. Record No. 1206-96-4 JUDGE JOHANNA L. FITZPATRICK 

 MAY 13, 1997 

ESTATE OF KENNETH MERRILL BALL 

 FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION 

 

 Douglas Seymour (Law Offices of E. Wayne 

Powell, on brief), for appellants. 

 Kermit L. Racey (Racey & Racey, on brief), 

for appellee. 

 Food Distributors and its insurer (collectively referred to 

as "employer") contend that the Workers' Compensation Commission 

("commission") erred in finding that (1) Kenneth Merrill Ball's 

(decedent) death by suicide was causally related to his 

compensable September 5, 1989 injury by accident; and (2) Code 

§ 65.2-306(A)(1) did not bar compensation for the decedent's 

suicide. We conclude that the suicide was causally related to 

the earlier injury and that compensation was not barred. 

I. BACKGROUND 

 On September 5, 1989, decedent suffered a compensable injury 

to his left shoulder when he tripped over a phone cord in his 

employer's office. His claim was accepted by employer and he 

underwent successive surgeries to his shoulder in October 1989, 

February 1990, and October 1990. Ultimately, decedent was 

diagnosed with post-traumatic impingement syndrome and with a 
 2 

permanent thirty-three percent "impairment of the upper extremity 

or twenty percent of the whole person." Despite the three 

operations, rehabilitation, and medication, decedent remained 

incapacitated, in pain, and depressed. 

 Following the injury, due to his chronic pain, decedent was 

unable to work full time or to engage in simple, repetitive 

tasks. He also suffered from insomnia. The pain began 

immediately after his injury and continued throughout the rest of 

his life. Decedent described his pain as an aching in his left 

shoulder, accompanied by the sensation of pins and needles and 

numbness throughout his left arm and hand. Decedent's inability 

to work and to provide for his family led to low self-esteem and 

depression. He went from being an "outgoing, vibrant person" 

prior to his injury to becoming "someone who was very morose, 

moody, and at times angry." Decedent's treating orthopedic 

surgeon, Dr. Thomas W. Daugherty, referred decedent to Dr. 

Bernard J. Lewis for psychological counseling. 

 Before he was seen by Dr. Lewis, decedent's depression 

worsened, and he attempted suicide in December 1990. He was 

hospitalized at the Winchester Medical Center and treated by Dr. 

Bob Lizer. Following his release from the hospital, decedent 

began individual and group counseling with Dr. Lewis, who became 

his treating psychologist at the Chronic Pain Program of 

Psychological Health Associates, Ltd. Decedent continued 

treatment with Dr. Lewis until his death. Decedent continually 
 3 

took pain medication and antidepressants following his first 

suicide attempt. Five years later, decedent committed suicide by 

taking a drug overdose. He was fifty-six at the time of his 

death, and he is survived by his wife, Mrs. Ball, and two 

daughters. 

 Decedent's estate and widow (claimant) filed a claim for 

benefits with the commission on February 22, 1995 and requested 

death and other benefits pursuant to the Workers' Compensation 

Act. In an opinion dated April 16, 1996, the commission relied 

on Dr. Lewis' opinion regarding causation and the doctrine of 

compensable consequences to find decedent's action outside the 

scope of the bar of Code § 65.2-306(A)(1). The commission 

reviewed the history of decedent's injury, pain, depression, and 

treatment, as well as evidence presented by Dr. Lewis, Mrs. Ball, 

Dr. Daugherty, and Dr. Bruce M. Smoller. Based on this review, 

the commission determined that: 

 From this record the Deputy Commissioner 

concluded that the evidence preponderates in 

establishing a direct and proximate causal 

connection between the decedent's September 

5, 1989, industrial accident and his death on 

February 12, 1995. We agree. Dr. Lewis has 

been the treating psychologist since 1990. 

His extensive reports over the course of his 

treatment document overwhelmingly the fact 

that the most significant stressor in the 

claimant's life was his "intractable pain" 

resulting in incapacity and depression. Dr. 

Lewis' unequivocal opinion linking the 

decedent's death to his chronic pain and 

resulting depression is supported repeatedly 

by Dr. Lewis' ongoing assessments. Dr. 

Smoller's opinion attributing the depression 

and suicide to other factors has minimal 

support in the record. 
 4 

 The employer argues that Code 

§ 65.2-306(A)(1) bars compensation for 

suicide. However, as the Deputy Commissioner 

noted, Mr. Ball's industrial accident in 1989 

was not self-inflicted. His suicide was a 

consequence of the depression resulting from 

the compensable accident. Therefore, the 

claim is not barred by this section of the 

Act. 

Employer appeals the commission's award of benefits to claimant. 

 II. DOCTRINE OF COMPENSABLE CONSEQUENCES 

 Employer argues that the commission erred in awarding 

benefits to claimant because decedent's suicide was an 

independent and willful act that barred compensation. 

Code § 65.2-306(A)(1) provides in pertinent part that "[n]o 

compensation shall be awarded to the employee or his dependents 

for an injury or death caused by: (1) The employee's willful

misconduct or intentional self-inflicted injury." (Emphasis 

added.) Employer's argument presents an issue not yet addressed 

by this Court. 

 It is undisputed that decedent's initial injury in 1989 was 

compensable. It is also undisputed that "[t]he doctrine of 

compensable consequences is well established and has been in 

existence for many years" in Virginia. Williams Industries, Inc. 

v. Wagoner, 24 Va. App. 181, 186, 480 S.E.2d 788, 790 (1997). 

This doctrine, also known as the chain of causation rule, 

provides that "'where . . . the chain of causation from the 

original industrial injury to the condition for which 

compensation is sought is direct, and not interrupted by any 
 5 

intervening cause attributable to the [employee's] own 

intentional conduct, then the subsequent [condition] should be 

compensable.'" Leadbetter, Inc. v. Penkalski, 21 Va. App. 427, 

432, 464 S.E.2d 554, 556 (1995) (quoting American Smelting & 

Refining Co. v. Industrial Comm'n, 544 P.2d 1133, 1135 (Ariz. Ct. 

App. 1976)). Moreover, 

 [o]nce an injury is compensable, the employer 

is liable for the full extent of the injury: 

 the fact that complications arise or the 

injury worsens does not alter the compensable 

nature of the injury. "When the primary 

injury is shown to have arisen out of and in 

the course of employment, every natural 

consequence that flows from the injury 

likewise arises out of the employment, unless 

it is the result of an independent 

intervening cause attributable to claimant's 

own intentional conduct." 

Imperial Trash Service v. Dotson, 18 Va. App. 600, 606-07, 445 

S.E.2d 716, 720 (1994) (quoting Morris v. Badger Powhatan/Figgie 

Int'l, Inc., 3 Va. App. 276, 283, 348 S.E.2d 876, 879 (1986)). 

"In other words, where a causal connection between the initial 

compensable injury and the subsequent injury is established, the 

doctrine of compensable consequences extends the coverage of the 

Workers' Compensation Act to the subsequent injury because the 

subsequent injury 'is treated as if it occurred in the course of 

and arising out of the employee's employment.'" American 

Filtrona Co. v. Hanford, 16 Va. App. 159, 162-63, 428 S.E.2d 511, 

513 (1993) (quoting Bartholomew Drywall Co. v. Hill, 12 Va. App. 

790, 793-94, 407 S.E.2d 1, 3 (1991)). 

 Although we have long accepted the doctrine of compensable 
 6 

consequences, we have yet to examine its application in the 

context of death by suicide. However, we are guided by the 

decisions of our sister states that have considered this issue. 

Initially, we note the West Virginia Supreme Court of Appeals' 

observation that "[m]ost [suicide] cases . . . present the same 

pattern of facts: a severe, or extremely painful, or hopelessly 

incurable injury, followed by a deranged mental state ranging 

from depression to violent lunacy, followed in turn by suicide." 

Hall v. State Workmen's Compensation Commissioner, 303 S.E.2d 

726, 728 (W.Va. 1983). In addressing such circumstances, other 

states generally apply one of two rules.1 

 Under the minority rule, known as the rule in Sponatski's 

Case or the "voluntary wilful choice test," the requisite mental 

derangement is defined as: 

 [A]n insanity of such violence as to cause 

the victim to take his own life through an 

uncontrollable impulse or in a delirium of 

frenzy "without conscious volition to produce 

death, having a knowledge of the physical 

consequences of the act." 

1A Arthur Larson, Workmen's Compensation Law § 36.21, at 

 

 1Two other rules have been developed, the New York rule and the 

English rule. The New York rule "is generally a chain of 

causation test but with the possible requirement of physical 

damage to the brain itself." State v. Ramsey, 839 P.2d 936, 940 

(Wyo. 1992). The English rule states that the "insanity must be 

the direct result of the injury itself or the shock produced by 

it, and not an indirect result caused by brooding over the injury 

and its consequences." Id. As these two rules are rarely, if 

ever, applied, we do not address them for the purposes of this 

opinion. 
 7 

6-162 - 163 (citation omitted) (emphasis added). Additionally, 

this rule proscribes the following behavior: 

 [W]here the resulting insanity is such as to 

cause suicide through a voluntary wilful 

choice determined by a moderately intelligent 

mental power which knows the purpose and the 

physical effect of the suicidal act, even 

though choice is dominated and ruled by a 

disorderly mind, then there is a new and 

independent agency which breaks the chain of 

causation arising from the injury. 

Id. This minority rule is steadily losing ground.2 

 The rule adopted by the majority of states is known as the 

"chain of causation" rule which provides that suicide is 

compensable if the injury produces mental derangement and the 

mental derangement produces suicide. Larson, supra § 36.00 

at 6-160. 

 This theory focuses not upon any 

particularized state of mind or mental 

disease, but upon the causal link between a 

work-related injury and ultimate death by 

suicide. The rationale . . . of the rule is 

grounded in advances in modern psychiatry and 

a recognition that volition may be negated by 

a deterioration in mental health short of 

insanity or derangement. Where a direct 

causal link can be established between a 

work-related injury and a disturbance of the 

mind which leads to suicide, compensation 

will not be barred. 

Wells v. Harrell, 714 S.W.2d 498, 501 (Ky. Ct. App. 1986). 

 

 2The Sponatski case itself was reversed legislatively, as 

Massachusetts amended its statute to provide for compensation when 

"due to the injury, the employee was of such unsoundness of mind 

as to make him irresponsible for his act of suicide." Larson, 

supra § 36.21 at 6-162 (citation omitted). 
 8 

 Applying this rationale, the Supreme Court of Oklahoma held 

that the applicable statute did not preclude payment of death 

benefits to the surviving spouse and dependents of an injured 

worker who committed suicide after incurring a work-related 

injury. See Stroer v. Georgia Pacific Corporation, 672 P.2d 1158 

(Okla. 1983).3 In Stroer, a factually similar case, decedent 

injured his shoulder. Despite surgery and extensive therapy, he 

never regained the full use of his shoulder. Approximately 

eighteen months following his injury, decedent shot himself. His 

widow, daughter, best friend, and attending physician testified 

that after the accident, decedent became unhappy, depressed, 

antisocial and unstable, and that his depression was caused by 

his inability to continue to work, earn a living, or be 

physically active. Id. at 1160. As in the instant case, the 

employer in Stroer presented the testimony of an expert witness, 

who formed his opinion based on his review of decedent's medical 

records without ever having seen the decedent. The expert opined 

that it was possible that decedent's depression was caused by 

factors other than his injury. Id. at 1160-61. 

 The court disagreed. It analyzed the statute denying 

benefits for an employee's intentionally self-inflicted injury, 

and observed that "[t]he majority of jurisdictions whose workers' 

 

 3The statute allowed compensation for the work-related death of 

an employee "except where the injury is occasioned by the willful 

intention of the injured employee to bring about injury to himself 

. . . ." Id. at 1160. 
 9 

compensation statutes contain an exclusion for wilful or 

intentional injury have adopted the chain of causation test as 

the criterion for interpreting the term 'wilful', 'purposeful' or 

'intentional.'" The court then articulated the chain of 

causation rule in detail: 

 [A]n employee's death by suicide is 

compensable if the original work-related 

injuries result in the employee's becoming 

dominated by a disturbance of mind directly 

caused by his/her injury and its 

consequences, such as extreme pain and 

despair, of such severity to override normal 

or rational judgment. The act of suicide is 

not an intervening cause of death and the 

chain of causation is not broken in cases 

where the incontrovertible evidence reflects 

that, but for the injury, there would have 

been no suicide. A suicide committed under 

these circumstances cannot be held to be 

intentional even though the act itself may be 

volitional. The chain of causation rule 

places the burden on the claimant to prove by 

a preponderance of the evidence that there 

was an unbroken chain of causation between 

the compensable injury, the disturbance of 

mind, and the ultimate suicide. The direct 

causal connection between the work-related 

injury and the suicide must not be 

overpowered and nullified by influences 

originating solely outside the employment. 

Id. at 1161. Accordingly, the court affirmed the award to 

decedent's widow.4

 See also Jenkins v. Recchi America, 658 So.2d 

 

 4The jurisdictions that have adopted the chain of causation 

rule have excluded the requisite behavior from the definition of 

"willful" or "intentional" in order to allow recovery. 

Additionally, in State v. Ramsey, 839 P.2d 936 (Wyo. 1992), the 

Supreme Court of Wyoming analyzed the issue of whether a suicide 

could become a compensable event for workers' compensation 

coverage. The court employed the chain of causation test "as the 

predominating principle on this subject within the volume of 

appellate cases" and decided the suicide was compensable. The 

court began its analysis by examining the statutory provision that 
 10 

157 (Fla. 1995) (finding that suicide was not willful within the 

meaning of the statute; thus, it was compensable); Wells v. 

Harrell, 714 S.W.2d 498, 501 (Ky. Ct. App. 1986) ("[w]here a 

direct causal link can be established between a 

work-related injury and a disturbance of the mind which leads to 

suicide, compensation will not be barred"); Campbell v. Young 

Motor Co., 684 P.2d 1101, 1103 (Mont. 1984) (finding a causal 

connection; stating that "the injury and the post-injury trauma, 

mental as well as physical, may take a path anticipated by no 

one, but nonetheless [be] traceable to the injury itself"); 

Schell v. Buell ECD Co., 690 P.2d 1038, 1042 (N.M. Ct. App. 1983) 

("once causation has been established, . . . the act of suicide 

cannot then said to be wilful or intentional within the meaning 

of the statute"); Hall v. State Workmen's Compensation 

 

excluded from the definition of compensable injury "the employee's 

willful intention to injure or kill himself or another." Finding 

that "[t]he concept that ties the causal relationship, unbroken 

chain, cases together, is that the act causing death was an 

intervening act but not an intervening cause," the court adopted 

the majority rule as the "most logical and supported by the 

current weight of persuasive precedent." Id. at 940. 

 In a similar case, Globe Security Systems Co. v. Workmen's 

Compensation Appeal Board, 544 A.2d 953 (Pa. 1988), the court 

focused on the statutory language that "no compensation shall be 

paid when the . . . death is intentionally self inflicted . . . ." 

 The Supreme Court of Pennsylvania determined that the word 

"'[i]ntentionally' is a restrictive word which limits the word 

which follows it . . . . It is patently clear, on statutory 

construction alone, that it was not the legislative intent to 

render all self-inflicted deaths noncompensable, but only those 

that were intentionally self-inflicted." Id. at 956. The court 

adopted the chain of causation test rather than the Sponatski

test, finding it to be "consistent with the humanitarian purpose 

of the Pennsylvania Workmen's Compensation Act, as the law of 

[the] Commonwealth." Id. at 957. 
 11 

Commissioner, 303 S.E.2d 726 (W.Va. 1983) (employee's suicide is 

compensable provided injury sustained arose in the course of and 

resulted from covered employment). See also Jackson Mental 

Health Center v. Lambie, 898 S.W.2d 479, 482-83 (Ark. Ct. App. 

1995) (allowing compensation for suicide caused by stress rather 

than by physical injury). 

 Additionally, the commission has followed this rationale in 

deciding suicide cases. See, e.g., Confer v. Arban & Carosi, 

Inc., 63 O.I.C. 66 (1984) (a case in which the issues were 

whether decedent's suicide was statutorily barred and whether the 

suicide was caused by decedent's initial injury.)5 In Confer, 

the commission adopted the majority rule: 

 [T]he appropriate test to be adopted in 

Virginia is that designated as the 

chain-of-causation rule, wherein where the 

injury and its consequences directly result 

in the worker's loss of normal judgment and 

domination by a disturbance of the mind 

causing the suicide, his suicide is 

compensable, with a suicide committed by the 

worker suffering from this degree of 

disturbance not to be considered "willful" or 

an "intentional" injury even though the 

action is volitional since the suicide 

relates back to the original injury rather 

than existing independently of the injury. 

Id. at 80. Additionally, the commission explained as follows: 

 [W]e agree with the basic tenet behind those 

cases adhering to the chain of causation, 

that recent psychiatric advances point to the 

 

 5This case was decided under Code § 65.1-38, which read that 

"[n]o compensation shall be allowed for an injury or death: (1) 

Due to the employee's willful misconduct, including intentional 

self-inflicted injury . . . ." 
 12 

fact that the consequences of an accidental 

injury can be so devastating that they 

influence the employee's mind to the point 

that the employee understands the 

consequences of the act of destruction but 

the employee is unable to resist the impulse 

to take his own life. Under such 

circumstances we do not find that the act is 

independent of the accident nor that it is 

willful within the meaning of [the statute]. 

Id. at 80-81. 

 "'It is well settled that where the construction of a 

statute has been uniform for many years in administrative 

practice, and has been acquiesced in by the General Assembly, 

such construction is entitled to great weight . . . .'" Holly 

Farms v. Carter, 15 Va. App. 29, 42-43, 422 S.E.2d 165, 172 

(1992) (quoting Dan River Mills, Inc. v. Unemployment Comm'n, 195 

Va. 997, 1002, 81 S.E.2d 620, 623 (1954)). The commission 

consistently has affirmed its adoption of the chain of causation 

rule in suicide cases. See, e.g., Ball v. Food Distributors, VWC 

File No. 1447752 (April 16, 1996); Stone v. Formex, Inc., VWC 

File No. 1652559 (May 15, 1996); Wheeler v. Pomalco Corporation, 

VWC File No. 1529329 (October 7, 1992); Confer v. Arban & Carosi, 

Inc., 63 O.I.C. 66 (1984). Accordingly, we find both the 

commission's construction of the statute and the rationale of the 

majority rule compelling. 

III. FINDING OF CAUSATION 

 Lastly, employer argues that the commission relied on less 

than credible evidence in finding that decedent's suicide was a 

compensable consequence of his original industrial accident. 
 13 

Specifically, employer contends that the commission improperly 

relied on Dr. Lewis' opinion and disregarded the opinion of Dr. 

Smoller. Additionally, employer asserts that the evidence failed 

to substantiate that decedent suffered a "loss of normal judgment 

and domination by a disturbance of the mind." 

 On appeal, we view the evidence in the light most favorable 

to the prevailing party below. R.G. Moore Bldg. Corp. v. 

Mullins, 10 Va. App. 211, 212, 390 S.E.2d 788, 788 (1990). We 

will not disturb the factual determination of causation if 

credible evidence supports the finding, even if the record 

contains evidence to the contrary. Ingersoll-Rand Co. v. Musick, 

7 Va. App. 684, 688, 376 S.E.2d 814, 817 (1989); Wagner Enters., 

Inc. v. Brooks, 12 Va. App. 890, 894, 407 S.E.2d 32, 35 (1991). 

Additionally, "[q]uestions raised by conflicting medical opinions 

will be decided by the commission," Penley v. Island Creek Coal 

Co., 8 Va. App. 310, 318, 381 S.E.2d 231, 236 (1989); and "when 

an attending physician is positive in his diagnosis . . . , great 

weight will be given by the courts to his opinion." Pilot 

Freight Carriers, Inc. v. Reeves, 1 Va. App. 435, 439, 339 S.E.2d 

570, 572 (1986). 

 In the instant case, the record demonstrates that the 

commission reviewed substantial medical and other evidence to 

conclude that decedent's suicide was causally connected to his 

original compensable injury. The commission considered the 

testimony of decedent's widow, Mrs. Ball, and reviewed records 
 14 

kept by decedent's treating orthopedic surgeon, Dr. Daugherty. 

Included in Dr. Daugherty's records is his final diagnosis of 

decedent's condition as a "thirty-three percent impairment of the 

upper extremity, or twenty percent of the whole person." Dr. 

Daugherty's records also reflect his opinion that "Mr. Ball has a 

post traumatic reactive depression leading to hospitalization 

. . . [which] is directly and causally related to the injury 

which he sustained and for which he has been under the care of 

Winchester Surgical Clinic physicians . . . ." 

 Additional medical records were made part of the record in 

this case. Dr. Lizer, decedent's treating physician at 

Winchester Medical Center, described decedent's depression as 

follows: "[T]his patient reported increasing depression over the 

past year. He had multiple stressors. Most significantly, he 

had had a shoulder injury resulting in a significant period of 

disability." Included in Dr. Lewis' medical records and 

correspondence is his opinion regarding decedent's depression. 

Dr. Lewis opined that "Mr. Ball's current condition is clearly 

and directly related to his left shoulder and subsequent surgery 

. . . . The psychological factors we are dealing with are 

directly related to the pain and the depression which frequently 

accompanies this [condition]." Following decedent's suicide, Dr. 

Lewis wrote: 

 [I]n my opinion, Mr. Ball's suicide is 

directly related to the chronic pain he 

struggled with in both shoulders. . . . 

[T]his pain resulted in considerable 

depression and several periods of suicidal 
 15 

ideation as the only way out of his pain and 

depression . . . . 

 [H]is death is clearly a direct result 

of the chronic pain and depression associated 

with his original work related injury. 

 At employer's request, a psychiatrist, Dr. Smoller, reviewed 

decedent's records, interviewed decedent's widow, and issued an 

opinion regarding the cause of decedent's suicide. The 

commission summarized Dr. Smoller's findings as follows: 

 Dr. Bruce M. Smoller, M.D., psychiatrist, 

. . . concluded that "shoulder injuries of 

this type do not ordinarily cause depression 

which would end in suicide." He surmised 

that a number of factors had a bearing on the 

suicide, including a possible biological 

component, loss of position in the family 

business, personality factors, and marital 

problems. Dr. Smoller stated these other 

factors were as important as or more 

important that the chronic pain. 

In weighing the testimony of Dr. Lewis and Dr. Smoller, the 

commission specifically found: 

 Dr. Lewis has been the treating psychologist 

since 1990. His extensive reports over the 

course of his treatment document 

overwhelmingly the fact that the most 

significant stressor in the claimant's life 

was his "intractable pain" resulting in 

incapacity and depression. Dr. Lewis' 

unequivocal opinion linking the decedent's 

death to his chronic pain and resulting 

depression is supported repeatedly by Dr. 

Lewis' ongoing assessments. Dr. Smoller's 

opinion attributing the depression and 

suicide to other factors has minimal support 

in the record. 

 Viewing the evidence in the light most favorable to 

claimant, we find that credible evidence supports the 
 16 

commission's determination that decedent's death was causally 

related to his earlier compensable injury and that Code 

§ 65.2-306(A)(1) does not bar recovery under these circumstances. 

 Affirmed.