In Stein, M.D. v. Paul Revere Life Ins. Co., No. 21-3546, 2023 WL 2539004 (E.D. Pa. Mar. 16, 2023), Pennsylvania Eastern District Judge Juan R. Sanchez granted summary judgment to Plaintiff and awarded retroactive benefits finding that Paul Revere had improperly classified Plaintiff’s repetitive stress injury as an illness under the group long-term disability (“LTD”) policy.
Plaintiff was a medical doctor specializing in interventional radiology for over thirty years. The LTD policy provided for payment of disability income benefits for losses due to injury or sickness of up to $6,000 per month. The policy also included a lifetime payment of benefits rider for a disability that begins before age 65. Under this rider, Plaintiff was entitled to the full monthly disability benefit for life in case of an injury but to only 10% of the benefit for a sickness after an initial 30-month period.
In 2009, Plaintiff began experiencing sciatic and lower back pain, stiffness, and mobility problems. He did not seek treatment until December 2011, when his primary care physician, Dr. Klinzing, diagnosed him with spinal stenosis, lumbar osteoarthritis and lumbar spondylosis. Dr. Klinzing eventually advised Plaintiff to stop working effective May 25, 2018, concluding that Plaintiff could no longer wear lead shields at work, was disabled, and needed spinal surgery.
Plaintiff was 64 years old when he stopped working and applied for LTD benefits. In preparing his claim forms, Plaintiff did not complete the “injury/accident” portion of the form, but instead completed the section for “sickness.” When asked to indicate whether his condition was related to his occupation, whether he had filed a worker’s compensation claim, and whether he intended to file a worker’s compensation claim, Plaintiff checked the boxes for “no.” Paul Revere approved the claim on August 7, 2018, due to sickness, and deemed him to be totally disabled from May 26, 2018, forward.
Plaintiff never returned to work. Because Paul Revere had awarded benefits due to sickness, it determined that Plaintiff’s LTD benefit after the initial 30-month period was limited to 10% thereafter based on the Lifetime Total Disability Rider. Plaintiff appealed demanding that Paul Revere re-classify his total disability as due to an “injury,” and pay him the full benefit due. In support of this re-classification request, Plaintiff submitted a letter from his physician stating that his condition was aggravated by wearing a lead apron which he is required to do in his field as an Interventional Radiologist and was consistent with a repetitive stress injury, as opposed to an illness or disease. Paul Revere denied Plaintiff’s request after paper reviews from two physicians both concluded the radiologic findings and diagnoses were “consistent with degenerative disease affecting the lumbar spine rather than injury to the lumbar spine.” On appeal, Paul Revere obtained a third paper review which concurred, and upheld its decision again. The subject lawsuit ensued.
With no binding Third Circuit authority the Court utilized the test outlined by the First Circuit in Wickman v. Northwestern National Insurance Co., 908 F.2d 1077 (1st Cir. 1990) to determine the meaning of an “accidental bodily injury”. The Wickman decision outlined a two-step inquiry: (1) the fact-finder should attempt to ascertain whether the insured expected an injury similar to that suffered; and if the insured did not expect such an injury, the fact-finder must then ask whether that expectation was reasonable. (2) If the evidence is insufficient to determine an insured’s subjective expectation, the fact-finder should then engage in an objective analysis of a reasonable person’s expectations – i.e. whether a reasonable person, with background and characteristics similar to the insured, would have viewed the injury as highly likely to occur as a result of the insured’s intentional conduct. If so, then the injury suffered is not an accident.
Applying this test, the Court concluded that Plaintiff had been disabled as the result of an “accidental bodily injury.” It reasoned that Plaintiff had no subjective expectation about developing stenosis, degenerative spondylolisthesis or osteoarthritis from practicing interventional radiology. Moreover, the reasonable person in Plaintiff’s position would not, nor should not, have known or expected to develop these conditions. Moreover, the evidence strongly suggested that the connection between wearing heavy leaded aprons for lengthy radiological procedures had only become apparent in recent years. The Court concluded it was clear that Plaintiff suffered from a physical condition brought on by repetitive stress injuries as outlined by his physicians.
As this case demonstrates, an insurer’s improper interpretation of policy terms can affect your award of benefits. If your insurer has denied, terminated or otherwise limited your disability claim, contact us for assistance.
*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.
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