Stephen Douglas Vass v. County of Henrico Police ( 2001 )


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  •                    COURT OF APPEALS OF VIRGINIA
    Present: Judges Elder, Annunziata and Senior Judge Coleman ∗
    Argued at Richmond, Virginia
    JAMES ISAAC MEDLIN, JR.
    v.   Record No. 1047-00-2
    COUNTY OF HENRICO POLICE                        OPINION BY
    JUDGE ROSEMARIE ANNUNZIATA
    STEPHEN DOUGLAS VASS                         FEBRUARY 27, 2001
    v.   Record No. 1048-00-2
    COUNTY OF HENRICO POLICE
    FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION
    Malcolm Parks (Maloney, Parks, Clarke &
    Nathanson, P.C., on briefs), for appellants.
    Ralph L. Whitt, Jr. (John T. Cornett, Jr.;
    Williams, Lynch & Whitt, on briefs), for
    appellee.
    Appellants, James Isaac Medlin, Jr. and Stephen Douglas
    Vass, Henrico County police officers, were diagnosed with heart
    disease and filed for workers' compensation benefits.     Following
    separate hearings, each was awarded compensation.   The employer
    appealed to the full commission and the full commission reversed
    both awards of the deputy commissioner and denied Medlin's and
    Vass' claims.   Medlin and Vass contend the full commission erred
    ∗
    Judge Coleman participated in the hearing and decision of
    this case prior to the effective date of his retirement on
    December 31, 2000 and thereafter by his designation as a senior
    judge pursuant to Code § 17.1-401.
    in finding that the employer had carried its burden of proving
    in each case, by a preponderance of the evidence, that Medlin's
    and Vass' work was not a proximate cause of their heart disease. 1
    The employer responds that the commission properly found
    the employer rebutted the Code § 65.2-402 presumption and that
    Medlin and Vass both failed to prove, "by clear and convincing
    evidence," that their heart disease arose out of and in the
    course of their employment.    See Code § 65.2-401.
    For the following reasons, we reverse and remand both
    cases.
    I.
    BACKGROUND
    Medlin v. County of Henrico Police
    Medlin, age fifty-three, began work as a police officer for
    the County of Henrico on October 30, 1974 and continued to be
    employed in that position at all times relevant to this case.
    1
    Medlin and Vass each particularize their claim of
    evidentiary insufficiency, contending the commission erred: (1)
    in finding that because certain medical witnesses testified that
    Medlin's and Vass' employment contributed to the "development,
    acceleration, or aggravation" of their disease, that Medlin's
    and Vass' heart disease pre-existed their employment; (2) in
    interpreting a physician's "inability to exclude work" as a
    causal factor to mean that this statement implied nothing more
    than a lack of knowledge or an admission that Medlin's and Vass'
    work was only a "possible" cause of their disease; (3) in
    discrediting the testimony of a medical expert on the basis that
    he used the term "risk factor" rather than "cause"; and (4) in
    focusing on "semantics" rather than rendering a plain and fair
    interpretation of the evidence. Because we reverse both cases
    on more general grounds, we decline to address each claimed
    - 2 -
    As required by his employer, he underwent a physical examination
    in 1976.    At that time Medlin was found to be free of heart
    disease and hypertension.
    In the course of his twenty-four-year career as a law
    enforcement officer with the County, Medlin held "street duty"
    positions for nineteen of those years and had administrative
    assignments for the remaining five years.    Medlin described the
    numerous physically demanding and dangerous activities that his
    job required, and stated that he found these activities to be
    stressful. 2
    On May 2, 1997, Medlin consulted his family physician, Dr.
    Donald B. Longest, after experiencing some chest "tightness" and
    shortness of breath while taking a walk.    Dr. Longest ordered a
    cardiac stress test and referred Medlin to a cardiologist.
    Significant coronary artery blockages were found, and Medlin
    underwent three-vessel coronary artery bypass grafting on May 5,
    1997.    Medlin was incapacitated from work from May 2, 1997 until
    he was cleared to resume his police work on January 21, 1998.
    One of Medlin's treating cardiologists, Dr. Robert M.
    Bennett, noted after his initial consultation with Medlin that
    he had several "cardiac risk factors," including high
    error except those requiring resolution on remand.
    2
    Examples of the activities that Medlin found to be
    stressful included chasing suspects, extracting people from auto
    crashes, dealing with hostage situations, enduring gunfire,
    taking the life of a suspect, and having officers under his
    supervision die in the line of duty.
    - 3 -
    cholesterol, hypertension, and a family history which included a
    father who had died of a heart attack at age forty-one or
    forty-two, a brother who had bypass surgery at age forty-six,
    and a mother who had bypass surgery at age seventy-nine.    Dr.
    Bennett and Dr. Bradford Matthews, another one of Medlin's
    treating cardiologists, answered interrogatory-type questions in
    which they indicated that they could not exclude Medlin's
    work-related stress "as a contributing factor in the
    development, acceleration and/or aggravation" of his heart
    disease.   Both doctors concluded that Medlin's heart disease was
    "multi-factorial" and that it was "more probable than not" that
    Medlin's employment contributed in some degree to his disease.
    Cardiologist Dr. Richard A. Schwartz examined Medlin on
    January 8, 1998 and reviewed his medical records.   Dr. Schwartz
    concluded that Medlin had several risk factors, including family
    history, high cholesterol and occupational stress, and that "it
    is more probable than not that Officer Medlin's work was a
    contributing factor in the development of his heart disease."
    Dr. Schwartz also submitted a supplemental report to which he
    appended a chapter in a medical textbook published in 1998,
    which linked stress to cardiovascular disease.
    On December 3, 1997, Dr. Michael Hess examined Medlin at
    the request of the employer.   Dr. Hess met briefly with Medlin
    but did not discuss with him the details of his employment.    In
    - 4 -
    his deposition, Dr. Hess conceded that he knew nothing about the
    dangers or physical and emotional demands of Medlin's job.
    Rather, Dr. Hess concluded that, as a general matter, there is
    no link between stress and heart disease.   Specifically, he
    stated, "[t]here is no evidence in the literature that stress or
    work-related factors play any primary cause in the development
    of coronary artery disease.   Further there is absolutely no
    evidence that employment as a police officer is a factor in
    causing the coronary artery disease."    Dr. Hess admitted that he
    could not identify any authority that disproved the connection
    between law enforcement work and hypertension but, rather, based
    his opinion on what he perceived to be a lack of affirmative
    proof of a connection.   Dr. Hess concluded that Medlin's heart
    disease was caused by family history, high cholesterol, and
    hypertension.    However, he also stated that "emotional stress on
    the job can contribute to hypertension or aggravate
    hypertension."   Dr. Hess conceded that Medlin was free of heart
    disease and hypertension when he began his employment with the
    County and that Medlin's earliest elevated blood pressure
    measurement was taken in 1990.
    Dr. Mark Bladergroen, who performed the bypass surgery on
    Medlin, answered the same interrogatory-type questions answered
    by Drs. Bennett and Matthews.    Dr. Bladergroen indicated that he
    could exclude Medlin's work as a contributory factor in his
    disease but then stated that the cause of Medlin's disease was
    - 5 -
    multi-factorial and that it was "unknown" whether it was more
    probable than not that the demands and stresses of Medlin's work
    as a police officer contributed to his heart disease.
    Vass v. County of Henrico Police
    Vass, age fifty-one, began his employment as a police
    officer for Henrico County in 1974, and has worked in that
    capacity ever since.   In 1976, Vass' employer required him to
    undergo a physical examination.    He was found to be free of
    heart disease and hypertension at that time.
    In the course of his career as a law enforcement officer
    for the County, Vass held a "uniform," or "front-line" position
    for the first eight years.   During that period, he was
    concurrently assigned to the County's tactical squad, commonly
    known as the "SWAT" team.    Since 1982, Vass has been assigned to
    the Investigative Section.   Vass described numerous physically
    demanding and dangerous activities that his job required and
    stated that he found these activities to be stressful. 3
    In February, 1997, Vass experienced back pain and two
    episodes of shortness of breath.   On February 11, 1997, he
    visited his family physician, Dr. Richard Overmeyer, who
    referred Vass to a cardiologist, Dr. Charles M. Zacharias.      Dr.
    3
    Examples of the activities that Vass found to be stressful
    included performing undercover work, being on-call
    round-the-clock, witnessing horrific crimes and death scenes,
    conveying news of persons' deaths to their families, chasing,
    detaining and disarming suspects, and being shot at.
    - 6 -
    Zacharias diagnosed Vass with coronary artery disease and
    performed a heart catheterization and coronary angioplasty.
    Vass returned to work on March 17, 1997.
    Vass' medical records indicate that in February, 1997, he
    had several "risk factors," including high blood pressure, high
    cholesterol, a history of cigarette smoking, and heart disease
    suffered by two of his family members, an uncle and a cousin.
    Vass' family physician, Dr. Overmeyer, answered
    interrogatory-type questions in which he indicated that he could
    not exclude Vass' work-related stress "as a contributing factor
    in the development, acceleration and/or aggravation" of his
    heart disease.   Dr. Overmeyer concluded that Vass' heart disease
    was "multi-factorial" and that it was "more probable than not"
    that Vass' employment contributed in some degree to his disease.
    Vass' cardiologist, Dr. Zacharias, answered the same
    interrogatory-type questions answered by Dr. Overmeyer.    Dr.
    Zacharias indicated that Vass' disease was "multifactorial" and
    that he could not exclude Vass' work as a contributing factor in
    his disease.   However, Dr. Zacharias answered "no" to the
    question whether it was more probable than not that the demands
    and stresses of Vass' work as a police officer contributed to
    his heart disease.
    Dr. Richard A. Schwartz reviewed Vass' medical records but
    did not examine Vass.   Dr. Schwartz concluded that "it is
    probable that officer Vass' occupational risk factor was
    - 7 -
    contributory in that insofar as any risk factor is contributory
    to the development of coronary artery disease" and that "[Vass']
    occupational stress can be considered a contributing factor."
    Drs. Michael Hess and Stuart Seides reviewed Vass' medical
    records at the request of the employer but neither examined
    Vass.    Both doctors concluded that, as a general matter, there
    is no link between stress and heart disease.    Specifically, Dr.
    Hess stated in his deposition, "I do not believe that stress
    leads to the development of coronary artery disease," and he
    agreed with the statement that "there is no persuasive evidence
    that stress, in whatever form, contributes to the development of
    coronary artery disease."    Dr. Seides stated in his deposition
    that "a person's occupation as a police officer . . . cannot in
    any reasonable way be linked with the development of coronary
    artery disease."    Dr. Seides admitted that his opinion that
    Vass' work did not contribute to his disease was based on what
    Dr. Seides perceived to be a lack of affirmative proof of such a
    causal connection.
    II.
    ANALYSIS
    A.
    Code § 65.2-402 Presumption – Prima Facie Case
    In this matter of first impression before the Virginia
    appellate courts, we address the question of whether testimony
    which only generally refutes the existence of a causal
    - 8 -
    relationship between work-related stress and heart disease
    rebuts the statutory presumption established under Code
    § 65.2-402(B).   We hold that testimony of this nature is not
    probative on the issue.
    Code § 65.2-402(B) provides the following presumption in
    certain workers' compensation cases:
    Hypertension or heart disease causing the
    death of, or any health condition or
    impairment resulting in total or partial
    disability of [various specified law
    enforcement personnel] shall be presumed to
    be occupational diseases, suffered in the
    line of duty, that are covered by this title
    unless such presumption is overcome by a
    preponderance of competent evidence to the
    contrary.
    The statute requires that in order for the presumption to apply,
    the employee must have undergone a pre-employment physical
    examination, if requested by the employer, and must have been
    found to be free of hypertension or heart disease at the time of
    that examination.   Code § 65.2-402(D).
    Medlin proved that the presumption applied to him.   He was
    a member of the Henrico County Police Department at all times
    relevant to this claim.   Although Medlin began his employment
    with the County in 1974, he was not asked to undergo a physical
    examination until 1976.   At the time of the examination, he was
    found to be free of heart disease and hypertension.   Finally,
    Medlin was diagnosed with heart disease in May, 1998 and was
    also found to be suffering from hypertension at that time.
    - 9 -
    Likewise, Vass proved the presumption applied to him.    Vass
    has been employed by the Henrico County Police Department since
    1974.    In 1976, he was found to be free of heart disease and
    hypertension following a physical examination conducted at the
    direction of his employer.    Finally, Vass was diagnosed with
    hypertension and heart disease in February, 1997.
    After the claimant establishes that he is entitled to the
    presumption, the burden shifts to the employer to refute the
    presumption.     Fairfax County Fire and Rescue Dept. v. Mitchell,
    
    14 Va. App. 1033
    , 1035, 
    421 S.E.2d 668
    , 670 (1992).    The
    employer must prove, by a preponderance of the evidence, two
    factors:    (1) a non-work-related cause for the heart disease;
    and (2) that work was not a cause of the claimant's heart
    disease.     Bass v. City of Richmond Police Dept., 
    258 Va. 103
    ,
    112-13, 
    515 S.E.2d 557
    , 561-62 (1999).
    Medlin conceded that, in addition to work-related causes,
    there were non-work-related causes that contributed to his heart
    disease.    Vass likewise conceded that both work-related and
    non-work-related causes contributed to his heart disease.
    Therefore, because a non-work-related cause was established, the
    remaining question is whether the employer proved, by a
    preponderance of competent evidence, that the work that Medlin
    and Vass performed as police officers did not contribute to
    their heart disease.
    - 10 -
    In finding that the employer had proved Medlin's work was
    not a cause of his heart disease, the commission relied, in
    part, on the testimony of Dr. Hess.     Dr. Hess concluded that, as
    a general matter, occupational stress does not cause heart
    disease.    In Vass' case, the commission relied, in part, on the
    testimonies of Drs. Hess and Seides in finding the employer had
    proved Vass' work was not a cause of his heart disease.    Both
    doctors testified that, as a general matter, occupational stress
    is not linked to the development of heart disease.    We find that
    because of the legislatively created presumption to the
    contrary, Dr. Hess' and Dr. Seides' opinions regarding the
    relationship between occupational stress and heart disease were
    of no probative value to the issues in these cases.     See Page v.
    City of Richmond, 
    218 Va. 844
    , 847, 
    241 S.E.2d 775
    , 777 (1978). 4
    Code § 65.2-402 "has long been recognized as a remedial
    statute, enacted by the legislature to overcome the difficulty
    4
    In Page the Supreme Court held:
    [T]he doctor not only failed to give his
    opinion as to the cause of [the employee's]
    disabling disease, but he also failed to
    state affirmatively that the evidence
    disproved any causal connection between the
    disease and [the employee's] occupation as a
    fire fighter. [The employer's doctor]
    merely reported that he had found no
    evidence of such a connection. We hold that
    this evidence is insufficient to rebut the
    statutory presumption upon which [the
    employee] was entitled to rely.
    
    Page, 218 Va. at 847
    , 241 S.E.2d at 777.
    - 11 -
    that a [police officer] would otherwise have in proving
    causation."   City of Norfolk v. Lillard, 
    15 Va. App. 424
    , 430,
    
    424 S.E.2d 243
    , 247 (1992).   In enacting the statute, "[t]he
    legislature knew that the causes of . . . cardiac diseases are
    unknown and that the medical community is split regarding the
    impact of stress and work environment on these diseases."
    Fairfax County Fire and Rescue Services v. Newman, 
    222 Va. 535
    ,
    540, 
    281 S.E.2d 897
    , 900 (1981); see also Stephens v. Workmen's
    Compensation Appeals Board, 
    20 Cal. App. 3d 461
    , 465 (Cal. Ct.
    App. 1971); Robertson v. North Dakota Workers' Compensation
    Bureau, 
    616 N.W.2d 844
    , 854 (N.D. 2000); Sperbeck v. Dept. of
    Industry, Labor & Human Relations, 
    174 N.W.2d 546
    , 548 (Wis.
    1970).   By enacting the statutory presumption, the General
    Assembly resolved the split in medical opinions in favor of the
    employee and adopted the presumption that the stress of working
    as a law enforcement officer causes or contributes to the
    development of heart disease.    See 
    Stephens, 20 Cal. App. 3d at 465
    ; Linnell v. City of St. Louis Park, 
    305 N.W.2d 599
    , 601
    (Minn. 1981); Cunningham v. City of Manchester Fire Dept., 
    525 A.2d 714
    , 718 (N.H. 1987); 
    Robertson, 616 N.W.2d at 854
    .
    Testimony which merely refutes the premise of such a
    legislatively enacted presumption does not constitute proper
    evidence in rebuttal.   Where the General Assembly has concluded
    that there is a causal link between stress and heart disease, it
    is not for the commission or the courts to reconsider the issue,
    - 12 -
    for to do so would defeat the intentions of the legislature.     It
    thus follows that, "[i]t is impermissible for the [commission]
    to accept the opinion of a physician so disposed as the basis
    for disallowing a claim."   
    Stephens, 20 Cal. App. 3d at 467
    ;
    Swanson v. City of St. Paul, 
    526 N.W.2d 366
    , 368 (Minn. 1995);
    
    Cunningham, 525 A.2d at 718
    ; 
    Robertson, 616 N.W.2d at 854
    .
    Stated otherwise, the employer may not, in effect, "repeal" the
    statute "by seeking out a doctor whose beliefs preclude its
    possible application."   
    Stephens, 20 Cal. App. 3d at 467
    ; see
    also 
    Linnell, 305 N.W.2d at 601
    ; 
    Sperbeck, 174 N.W.2d at 289
    .
    In Sperbeck, the court noted that "[e]vidence which only attacks
    the rationale of the statute . . . does nothing more than
    question the wisdom of the legislature."    
    Sperbeck, 174 N.W.2d at 289
    .   If the majority of the medical community concludes
    there is no link between stress and heart disease, the
    employer's remedy is to go back to the General Assembly.
    
    Sperbeck, 174 N.W.2d at 289
    .    We, accordingly, hold that
    evidence that merely rebuts generally the underlying premise of
    the statute, which establishes a causal link between stress and
    heart disease, is not probative evidence for purposes of
    overcoming the presumption. 5   The commission therefore erred when
    5
    The employer argues that if we find no probative value in
    this type of evidence, then the presumption will be irrebuttable.
    We disagree. Although irrebuttable presumptions are
    unconstitutional, 
    Newman, 222 Va. at 540
    , 281 S.E.2d at 900, the
    employer can rebut the Code § 65.2-402 presumption without
    attacking the underlying legitimacy of the presumption itself.
    See, e.g., 
    Stephens, 20 Cal. App. 3d at 468
    ; Linnell, 305 N.W.2d
    - 13 -
    it relied, in part, on the testimonies of Dr. Hess and Dr.
    Seides, which did no more than refute the conclusion of the
    Virginia General Assembly.
    Because the weight the commission assigned to Dr. Hess' and
    Dr. Seides' opinions in reaching its decisions is unclear, we
    remand both cases to the commission to determine whether the
    employer has sufficiently rebutted the presumption in light of
    the remaining probative evidence in these cases.   See Virginia
    Dept. of State Police v. Talbert, 
    1 Va. App. 250
    , 253, 
    337 S.E.2d 307
    , 308 (1985) ("We do not review the weight or
    preponderance of the evidence nor the credibility of the
    witnesses, except to consider whether there exists sufficient
    credible evidence to sustain the findings.").
    B.
    Remaining Issues
    Because two issues will likely arise again on remand, we
    will address them here.   Both Medlin and Vass contend the
    commission erred, as a matter of law, in discrediting Dr.
    Schwartz's opinion because he used the term "risk factor"
    instead of "cause."
    In determining the appropriate weight to assign Dr.
    Schwartz's opinion in both cases, the commission cited our
    decision in City of Portsmouth Sheriff's Dept. v. 
    Clark, 30 Va. at 601
    ; Worden v. County of Houston, 
    356 N.W.2d 693
    , 695 (Minn.
    1984).
    - 14 -
    App. 545, 
    518 S.E.2d 342
    (1999).    In Portsmouth, we held that
    proof of a "risk factor" alone does not establish a
    non-work-related cause for a claimant's heart disease.
    
    Portsmouth, 30 Va. App. at 554
    , 518 S.E.2d at 346.      We found
    that the employer in that case had failed to prove that the
    claimant's family history risk factor actually caused his
    disease.    
    Id. Medlin contends the
    commission misapprehended Dr.
    Schwartz's use of the term "risk factor."      He argues Dr.
    Schwartz considered risk factors to be the causative factors of
    Medlin's disease.    We disagree.
    We cannot say, as a matter of law, that Dr. Schwartz's
    report clearly establishes his intent to equate the two terms,
    or that he gave a clearly-stated opinion that Medlin's
    occupational stress was a risk factor that, in fact, caused his
    heart disease. 6   Dr. Schwartz states, as a general proposition,
    6
    In his report, Dr. Schwartz stated:
    Mr. Medlin's coronary artery disease is
    clearly multifactorial. Included in these
    factors is occupational stress, in this
    case, police work. . . . There is no way to
    exclude work-related stress as a risk factor
    in the development of coronary artery
    disease nor is there any way of including or
    eliminating any other risk factor. These
    are correlative findings. It is more
    probable than not that Officer Medlin's work
    was a contributing factor in the development
    of his heart disease insofar as any risk
    factors, including family history, cigarette
    - 15 -
    that no risk factor may be excluded in the development of
    coronary artery disease and that they are all correlative. 7
    However, he does not opine which if any of the risk factors was
    causally related to Medlin's disease.    See Portsmouth, 30 Va.
    App. at 
    554, 518 S.E.2d at 346
    .    Furthermore, although he states
    that Medlin's work "is more probable than not . . . a
    contributing factor in the development of his heart disease,"
    the import of the opinion is ambiguous given his caveat that it
    applies only "insofar as any risk factors . . . can be considered
    as contributory factors . . . ."   When Dr. Schwartz's opinion is
    viewed in relation to the testimony given by Dr. Hess, we cannot
    smoking, hypertension, etc., can be
    considered as contributory
    factors. . . . All risk factors, including
    occupational stress, are correlative.
    7
    Dr. Schwartz's use of the term "correlative" is ambiguous
    and does not compel a finding that he used the term "risk
    factor" interchangeably with the term "cause." The terms
    "correlate," "correlated," and "correlative" have various
    meanings. For example, "correlate" may mean: "either of two
    things so related that one directly implies or is complementary
    to the other," "to bear reciprocal or mutual relations," or
    "relate as necessary or invariable accompaniments with or
    without the implication of causality." Webster's Third New
    International Dictionary 511 (1993) (emphasis added).
    "Correlated" may mean: "closely, systematically, or
    reciprocally related," or "related as a universal accompaniment
    whether causally connected or not." 
    Id. (emphasis added). Finally,
    the term "correlative" could mean "naturally related,"
    or "having, indicating, or involving a reciprocal relation."
    
    Id. Thus, use of
    the term "correlative," itself, does not
    necessarily indicate a causal relationship between two items.
    Furthermore, in using the term "correlative," Dr. Schwartz does
    not indicate whether he is referring to the relationship between
    various risk factors or to the relationship between a given risk
    factor and Medlin's heart disease.
    - 16 -
    conclude that the commission erred in giving Dr. Schwartz's
    opinion less weight.    Dr. Hess stated that there were three risk
    factors in Medlin's case that actually "caused" his disease:       his
    family history, hypertension and high cholesterol.    The
    resolution of the factual dispute which the two conflicting
    opinions gave rise to was within the province of the commission.
    See Metro Machine Corp. v. Lamb, 
    33 Va. App. 187
    , 195, 
    532 S.E.2d 337
    , 340 (2000) ("[T]he resolution of medical opinion is
    a question of fact."); Ogden Aviation Services v. Saghy, 32 Va.
    App. 89, 101, 
    526 S.E.2d 756
    , 762 (2000); Dollar General Store
    v. Cridlin, 
    22 Va. App. 171
    , 176, 
    468 S.E.2d 152
    , 154 (1996)
    ("We will not substitute our judgment for that of the trier of
    fact . . . .").
    In Vass' case, however, we find that the commission erred
    in its application of our holding in Portsmouth.     Contrary to
    the commission's conclusion that "Dr. Schwartz speaks only of
    'risk factors,'" the record shows that in Vass' case, Dr.
    Schwartz opined that Vass' occupational stress was a risk factor
    that "can be considered a contributing factor" in the
    development of his disability. 8   Because it erroneously applied
    8
    In one report Dr. Schwartz stated:
    Precise etiologic cause of coronary artery
    disease is not known. It is a
    multifactorial process that has associated
    with it certain well known risk factors. One
    of these risk factors is clearly occupational
    stress and the duties of a police officer
    would certainly fulfill that criteria.
    - 17 -
    our holding in Portsmouth, the commission did not consider what
    weight, if any, it would accord Dr. Schwartz's opinion, as it is
    required to do.     Hungerford Mechanical Corp. v. Hobson, 11 Va.
    App. 675, 677, 
    401 S.E.2d 213
    , 215 (1991) ("Medical evidence is
    not necessarily conclusive, but is subject to the commission's
    consideration and weighing.").    On remand, the commission will
    have to reconsider Dr. Schwartz's opinion, together with all the
    remaining evidence in this case, in light of this holding.
    Medlin next contends the commission erred, as a matter of
    law, in concluding that because Drs. Bennett and Matthews stated
    that Medlin's work was a contributing factor in "the
    development, acceleration and/or aggravation" of Medlin's heart
    Importantly, the effect of various risk
    factors cannot be apportioned among them when
    multiple factors exist. Therefore, it is
    probable that officer Vass' occupational risk
    factor was contributory in that insofar as
    any risk factor is contributory to the
    development of coronary artery
    disease. . . . [O]n the other hand the way
    in which risk factors operate is still open
    to debate.
    In a second report Dr. Schwartz stated:
    [M]ore probably than not, Mr. Vass'
    occupation as a law enforcement officer was
    a risk factor. As in the case of other risk
    factors, there is a correlative "cause" in
    the development of heart disease. Finally,
    insofar as his heart disease was a cause of
    Mr. Vass' temporary disability from
    employment, his occupational stress can be
    considered a contributing factor.
    (Emphasis added).
    - 18 -
    disease, that the disease must have pre-existed his employment.
    Vass makes the same contention with respect to the commission's
    treatment of Dr. Overmeyer's opinion.   We agree with both Medlin
    and Vass.
    In both opinions, the commission cited Ashland Oil Co. v.
    Bean, 
    225 Va. 1
    , 
    300 S.E.2d 739
    (1983), for the proposition that
    "[i]f work merely aggravates a disease, then the disease must
    have pre-existed the employment.   Work, then, could not have
    been the originating cause of the disease, and the aggravation
    would not be compensable as an occupational disease."   While the
    Virginia Supreme Court held in Ashland Oil that an employee
    cannot recover "for aggravation of ordinary diseases of life,"
    
    id. at 3, 300
    S.E.2d at 740, the evidence in that case showed
    that the employee had a bunion before she began working and that
    her job merely aggravated the pre-existing condition.    
    Id. at 2, 300
    S.E.2d at 739.   The Court concluded that "it was not an
    occupational disease, and only disabilities resulting from
    occupational diseases are compensable."    Id. at 
    3, 300 S.E.2d at 740
    .
    Here, the uncontroverted evidence showed that Medlin and
    Vass began their employment in 1974 and were found to be free of
    heart disease and hypertension in 1976, following a physical
    examination conducted at the direction of the County.
    Therefore, Medlin's and Vass' conditions did not pre-exist their
    employment.   In addition, the Code § 65.2-402 presumption
    - 19 -
    provides that if the employee can prove he was free of heart
    disease or hypertension at the beginning of his employment, his
    disease will be presumed to be an occupational disease.
    Therefore, we find the commission erred, as a matter of law, in
    misinterpreting Ashland Oil, and in concluding that Medlin's and
    Vass' disease pre-existed their employment.
    Because we find the commission improperly considered Dr.
    Hess' and Dr. Seides' opinions in reaching its decisions, we
    remand both cases to the commission for reconsideration of the
    remaining evidence. 9
    Reversed and remanded.
    9
    Because we remand for reconsideration of the issue of
    whether the employer rebutted the Code § 65.2-402 presumption,
    we need not consider the employer's contention that Medlin and
    Vass failed to establish an ordinary disease of life claim. Cf.
    Augusta County Sheriff's Dept. v. Overbey, 
    254 Va. 522
    , 527, 
    492 S.E.2d 631
    , 634 (1997) (if employer rebuts presumption, burden
    shifts to employee to "'establish[] by clear and convincing
    evidence, to a reasonable medical certainty,' that his heart
    disease arose out of and in the course of his employment"
    (quoting Code § 65.2-401 (amended 1997))).
    - 20 -