Opinion ID: 871065
Heading Depth: 3
Heading Rank: 3

Heading: Events Following Ms. Spiller's Termination of Benefits

Text: Post-cancellation, Ms. Spiller repeatedly sought reinstatement of benefits. The relationship between Ms. Spiller and Ms. Mottern became increasingly hostile as Ms. Spiller worked toward her reinstatement. The District Court cites several areas in the record demonstrating the animosity between Ms. Spiller and Ms. Mottern:  Ms. Spiller Deposition: I yelled at [Ms. Mottern], and I seized.... And [Ms. Mottern] insisted that I had done everything wrong. I hadn't gotten her paperwork.... While I was talking to her I would get upset. She had a very like accusatory tone, you were friends ... with [Mr. Kahalekulu].... She was awful.  Ms. Mottern: Insured called me again to re-iterate our conversations from yesterday. She has sent us a picture of herself in her casket.... Stated [Mr. Kahae] has a separate address: he is staying with her since she is sick. I stated that is not what you told me yesterday.  Ms. Mottern: I called insured to request that she stop trying to reach out to [Ms. LaFica].... She states [Ms. LaFica] has been nice to her and I have been nothing but trouble to her.... States she will seize and fall and hurt herself.  Ms. Mottern: Called todaystated yesterday that she was left alone and had a grand mal seizure`if it wasn't for someone coming to give her [V]alium ... she would have died and I would be happy'.... Continued to yell at me[.]  Ms. Mottern: When I asked her how she was doing sh[e] stated `not well: still in seizure from yesterday' ... records from Dr. McQuire [sic] are on the backs of MRI reports and [Ms. Spiller's] funeral plot letter.  Ms. Mottern: Penny stated that she wants Annette LaFica back, as she understands herall her problems started when I took over.... [She] [b]egan to get very excited stating her policy is not medical necessity and she is tired of all this. I stated she is right policy is not medical necessityshe started yelling she would like to strangle me and became noticabley [sic] upset. I told her we needed to hang up now. During her deposition, Ms. Spiller testified to her contentious relationship with Ms. Mottern: on my birthday she informed me that she was pulling, basically pulling the plug on any reasonable cash flow I had to keep me and my household operational and get the supervision I needed without having to call my children back to watch me all the time. Moreover, Ms. Spiller was very upset and very anxious. She testified that her seizures were increasing. Ms. Spiller described her experience with Defendants as feeling like a death sentence. Ms. Spiller attempted suicide after her benefits termination. She stated in her deposition, I took a hundred and six pills, a combination of Keppra and Diazepam, and a piece of banana.... I though [sic] I wouldn't be a burden to anybody[.] Following her attempted suicide, Ms. Spiller sought treatment from psychiatrist Sonia Patel (Dr. Patel). On October 28, 2008, Dr. Patel wrote a letter to Ms. Mottern, stating in pertinent part: I am currently providing Penelope with psychiatric treatment. She has suffered from emotional disturbances, including decreased mood and increased anxiety, since her Long Term Care Policy was stopped.... It is of utmost importance that Penelope be given continued care for brain cancer and brain cancer treatment sequelae, which include uncontrolled seizures, loss of balance and falls, disorientation, difficulties with memory, concentration[ ] and spatial judgment. She requires no less than full time care in order to prevent injuries or possible death related to her unpredictable seizures or falls. Dr. McGuire also wrote to Ms. Mottern on November 10, 2008: Ms. Spiller has been diagnosed with brain cancer and metastatic lung disease. Due to her diagnosis, Ms. Spiller also suffers from headache, blurred vision, vertigo, tinnitus, speech and memory [loss], walking difficulty, weakness and seizure disorder.... [I]t is not medically recommended that patient be left unsupervised at any time of the day or night due to possible injuries or death. ... I've noted ... the matter of possible termination of her long term care has contributed to an increase of emotional symptoms and increase of seizure disorder within the past few months. On November 4, 2008, Ms. Spiller's daughter called Ms. Mottern and Ms. Mottern provided notification over the telephone that she denied Ms. Spiller's appeal. On November 21, 2008, Ms. Mottern wrote a letter to Ms. Spiller (again on Hartford stationery) stating: [t]he denial of benefits under your Hartford long term care policy documented in our letter to you on September 19, 2008, has been upheld. Please know that we have carefully reviewed all documentation presented to us, to render this decision. Ms. Mottern's notes explain her reasoning behind the denial: Nothing documents [Ms. Spiller's] inability to perform her activities of daily living. Have records from Dr. Thompsonwhich are the most credible; record from Dr. McQuire [sic] are on the back of MRI reports and Penny's funeral plot letter. Letter from psychiatrist stating she needs benefits. None of it is credible except the records from Dr. Thompson. Ms. Mottern also justified Ms. Spiller's denial in a November 4, 2008 NotePad report: BDA received was not conclusive as narrative did not match objective info. Unable to get another assessor to go out to see her as assessor felt threatened by comment from insured about her being part of denial and question if ever saw the movie Psycho. Info received from PCP is for year 2007 only. Have requested documents from him 3 times. Neuro Radiologist Dr. Thompson gives the most clear cut, objective assessment.... Letter from Psychiatrist was requested by insured. Therefore, I have to believe the best evidence we have obtained is from Dr. Thompson. Dr. Thompson's medical records for Ms. Spiller indicate that she experienced only a singular grand mal seizure over the preceding year and a half and that her mental status was normal, she lacked any focal deficits and she was doing well as of June 2008. After Defendants denied Ms. Spiller's appeal, she filed complaints with the New York Insurance Department and the Hawai`i Department of Commerce and Consumer Affairs, Insurance Division, and ultimately retained an attorney. MedAmerica responded to an inquiry from the Hawai`i Insurance Division on December 5, 2008, explaining (on MedAmerica stationery) its determination that Ms. Spiller did not meet the triggers of her policy; she did not need hands-on assistance with at least [two] ADLs and was not shown to be cognitively impaired[] based upon her July 28, 2008 BDA and medical records received. The Hawai`i Insurance Division responded to MedAmerica on December 17, 2008 that [t]he statements from Ms. Spiller's doctors appear to comply with the policy requirement that substantial supervision is required to protect Ms. Spiller from threats to her health and safety due to severe cognitive impairment, as well as being unable to perform at least two ADL's. Ms. Spiller's attorney, Mark Davis, wrote a letter to Ms. Mottern on January 5, 2009, demanding that she fully reinstate Ms. Spiller's benefits, reimburse her for the costs she incurred in connection with the denial of her benefits since August 2008, and threatening a bad faith suit. Also on January 5, 2009, Ms. Spiller contacted Ms. Mottern to report that she was taken to Molokaai hospital for another seizure. Ms. Spiller's fourth BDA was performed on January 9, 2009. This BDA indicated that Ms. Spiller was chronically ill, requiring assistance with all ADLs[] and was a threat to her own safety. Defendants restored Ms. Spiller's long term care benefits on January 23, 2009 and notified her that `in good faith the approval period begins on 9/1/08,' i.e., retroactively. Ms. Spiller continued to receive her contractual benefits until her death on September 10, 2010.