Charles King v. Pennsylvania Life Insurance Co

470 F. App'x 439
CourtCourt of Appeals for the Sixth Circuit
DecidedMarch 23, 2012
Docket10-1672
StatusUnpublished
Cited by6 cases

This text of 470 F. App'x 439 (Charles King v. Pennsylvania Life Insurance Co) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Charles King v. Pennsylvania Life Insurance Co, 470 F. App'x 439 (6th Cir. 2012).

Opinion

PER CURIAM.

Plaintiff-Appellant Dr. Charles E. King appeals from the district court order granting the summary-judgment motion brought by Defendant-Appellee Pennsylvania Life Insurance Co. (“Penn Life”) and dismissing King’s complaint. King alleges that Penn Life (as successor-in-interest to Massachusetts Indemnity and Life Insurance Company, or “Mass Life”) improperly terminated payments owed to him under a disability insurance policy because his stroke-induced disability was caused by “accidental bodily injury” and not “sickness.” Penn Life maintains that King’s benefits terminated when he turned 65 because his disability was caused by sickness. Because we find that there are genuine issues of material fact in dispute, we REVERSE the district court’s judgment and REMAND the case for further proceedings consistent with this opinion.

I.

This case is an insurance-coverage dispute. At the time of the events that undergird this lawsuit, Dr. King was a practicing osteopathic surgeon residing in the Flint, Michigan area. On November 23, 1976, when King was 35 years old, Mass Life issued to King a disability-income insurance policy that would provide him with coverage “in the event of disability which results from accidental bodily injury sustained while this policy is in force or in the event of disability which results from sickness which first manifests itself while this policy is in force.” (emphases added). King had to describe his medical history on the insurance application, and on the family history portion, King listed that his father died of a stroke at age 48. Under the policy, the term “total disability” means “complete inability to engage in the Insured’s regular occupation.” The policy *440 does not define the terms “accidental bodily injury” or “sickness.” Under the policy, in the event King became disabled he would receive monthly benefits for a certain period of time, the length of which depended on the cause of his disability. If his disability was the result of “accidental bodily injury,” he would receive benefits for the rest of his life; if his disability resulted from “sickness,” however, he would only receive benefits until he turned 65 years old. The actual cause of King’s disability is at the heart of this case.

On December 8, 1977, King “fell in the snow” while he was skiing in Alta, Utah with his friend and fellow physician, Dr. John L. Schriner. Dr. Schriner examined King on the ski slope after he fell and noted that King “did not seem to be injured.” King reportedly “noted some numbness in [his] right upper extremities” that lasted for 15-20 minutes after he fell. The next day, on December 9, 1977, King suffered a stroke (in medical parlance, a cerebral vascular accident) while riding up the chair lift. He was brought to a local hospital and was examined by Dr. Wayne M. Hebertson, who noted that King had developed a “marked paralysis involving the right face, arm, and leg.” Dr. Hebert-son’s report states that a “CT scan was done revealing a small lesion in the region of the left insula.” The report concluded that King had suffered “Acute intracerebral bleeding on the left, cause undetermined.”

After several days in the hospital, King returned home to Michigan and was examined by Dr. Gary W. Roat on December 22, 1977, who determined that King had suffered an “intracerebral hemorrhage” and was totally disabled as a result. There is some dispute surrounding the physician’s report from this examination. The form for the report included spaces marked “Due to sickness?” and “Due to accident?” that could be filled out. Dr. Roat wrote “see above” [referring to his diagnosis description] in the spaced marked “Due to sickness?” The space marked “Due to accident?” has a line drawn through it. It is not clear who drew a line through the “accident” section. King maintains that a representative from Mass life drew the line before giving it to Dr. Roat, while Penn Life assumes that Dr. Roat drew the line himself.

This physician’s report was attached to King’s “Statement of Claim” form, which he filled out and submitted to Mass Life on January 6, 1978 so that he could collect disability benefits. That form contains two sections particularly relevant here: one to be completed “IF DISABILITY DUE TO SICKNESS ” and another to be completed “IF DISABILITY DUE TO ACCIDENTA (emphases in original). The former section on the form (the sickness section) is filled out, with “Sickness” typed in as the “Nature of illness” and “12/9/77” listed as the “Date of first symptoms.” The latter section (the accident section) is crossed out by hand and is blank. King maintains that a representative of Mass Life crossed out the “accident” section before King received the form and filled it out.

After receiving King’s Statement of Claim, Mass Life began paying a monthly disability benefit of $2,500 because King was totally disabled. (Eventually, King was able to resume the practice of medicine as a radiologist, but he was never able to perform surgery because of his limited use of his right hand.) In July 1978 King wrote to Mass Life to provide an update on his disability and the prospects of resuming his “regular occupation” as a surgeon. In that letter, King stated:

As you know, I am receiving disability benefits from your company since suffering a stroke in December of 1977. *441 Previous to my illness, I was a practicing general surgeon, performing major surgical procedures five to seven days . per week. For six months following my illness, I was unable to do any type of work....

After it started paying benefits, Mass Life conducted further investigation into King’s disability. Mass Life agent Jack Rayner visited King on November 2, 1978, and sent a report to Mass Life representative Mick Orend on November 10 noting that King had fallen in the snow the day before his stroke was diagnosed, that King had “felt some discomfort in his arm and shoulder” after he fell, and that Dr. Schriner “was the only physician involved prior to the hospital [in Utah].” Rayner also noted that an angiogram (presumably conducted at the hospital in Utah) “showed an A.V. [arteriovenous] malformation.” 1 Following up on Rayner’s report, Mass Life asked Dr. Schriner for a narrative description of his observations while skiing with King on December 8 and 9, 1977, and Dr. Schriner responded with a letter dated March 12, 1979. That letter referred to King’s “injuries” suffered in connection with an “accident,” stating, “Prior to his injury he was assumed to be in excellent health and he and I had been skiing for at least one to two days prior to the accident.” In a subsequent memorandum to the file dated April 16, 1979, Orend wrote the following:

. Larry Cattani [another Mass Life official] & I discussed this file. We agreed that even if there were a question of accident vs. sickness — which there doesn’t appear to be — that question is not particularly pressing, since benefits are payable for sickness to age 65 for qualifying claims (2006 in this case).

Larry suggested [another doctor] review the case re: when and if we need an IME.

Around the same time, Mass Life agents met with King to get his authorization to access the ski-patrol reports for its investigation.

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