Davies v. Paul Revere Life Insurance

147 F. Supp. 2d 347, 2001 U.S. Dist. LEXIS 7940, 2001 WL 681321
CourtDistrict Court, M.D. Pennsylvania
DecidedJune 13, 2001
DocketNo. 3:CV-99-0370
StatusPublished
Cited by1 cases

This text of 147 F. Supp. 2d 347 (Davies v. Paul Revere Life Insurance) is published on Counsel Stack Legal Research, covering District Court, M.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Davies v. Paul Revere Life Insurance, 147 F. Supp. 2d 347, 2001 U.S. Dist. LEXIS 7940, 2001 WL 681321 (M.D. Pa. 2001).

Opinion

MEMORANDUM

VANASKIE, Chief Judge.

The principal issue presented in the above-captioned matter on cross-motions for summary judgment is whether The Paul Revere Life Insurance Company (“PRLIC”) abused its discretion in determining that plaintiff Alan R. Davies was not entitled to benefits under a long term disability insurance policy governed by the Employee Retirement Income Security Act, 29 U.S.C. §§ 1001, et seq. Because a combination of factors — including, in particular, the inherent conflict of interest in PRLIC not only administering the ERISA-governed disability plan, but also funding plan benefits — warrants more stringent scrutiny on the “sliding scale” of abuse of discretion review established in Pinto v. Reliance Standard Life Ins. Co., 214 F.3d 377 (3d Cir.2000), and PRLIC’s denial of benefits does not survive close examination of its processes and rationale, PRLIC’s summary judgment motion will be denied. Furthermore, because the record demonstrates that Mr. Davies’ uncontrolled hypertension rendered him “unable to perform the important duties of his own occupation on a Full-time or part-time basis,” — the test for eligibility for benefits under the plan — Davies’ summary judgment motion will be granted.

I.BACKGROUND

On May 1, 1997, Davies applied to PRLIC for benefits under a group long term disability insurance policy issued by PRLIC to Davies’ employer, Sterling Commodities Corp. The policy issued and administered by PRLIC provides for payment of benefits in the event a covered employee:

1. is unable to perform the important duties of his own occupation on a Full-time or part-time basis because of an Injury or Sickness that started while insured under this Policy; and
2. does not work at all; and
3. is under Doctor’s Care.

Appendix to Defendant’s Summary Judgment Motion at PRL000394.1

There is no dispute that Davies satisfied the second and third requirements for dis7 ability benefits — he did not work at all and he was under a doctor’s care. The focus of PRLIC’s decision was on his ability to perform the important duties of his own occupation on a full or part-time basis.

The record reveals that Davies sustained damage to an aortic valve as a result of rheumatic fever in 1961, when he was 11 years old. (App. at PRL00006.) Davies claims that since suffering from [350]*350rheumatic fever he has had blood pressure problems, with very high systolic and very low diastolic readings; (Id.) In January of 1986, at age 35, Davies underwent a surgical replacement of his aortic valve with a porcine valve. At that time, Davies had been working in the commodities trading business for approximately 12 years. (Id.) Davies temporarily left the commodities business following the 1986 surgery, returning in January 1990 because “I had been feeling very well, and my blood pressure was normal after that first surgery, for the first time in my adult life.” (Id.) In June of 1994, the porcine valve was replaced with a St. Jude’s valve. Davies returned to work as a commodities trader in September of 1994. (Id.) In his application for disability benefits, Davies reported:

After my second surgery, my blood pressure did not return to the normal levels it had been after the first surgery. I have had high readings at virtually every checkup since, although the valve itself is functioning normally. I have been on various medications since the second surgery to control my blood pressure, starting with Vasotec and La-noxin. I have experienced a variety of symptoms at work, including light-head-edness, dizziness, headache, tingling in the fingers, pain in the left arm, tightness and pain in the chest and back, and stabbing pain in the lower back. Also, flashing lights in my eyes, leading to headaches.
These symptoms have become increasingly frequent and severe over the last year. I became concerned with how I was feeling on the trading floor and began to have my blood pressure checked by the registered nurse on duty at the trading floor. The first time I had it checked I was shocked that it was so high, around 200/105. The nurse was concerned, asked me if I was on medication, and recommended immediately calling my doctor. This was repeated about once a week for the next few weeks, with no appreciable change, and I saw my doctor in late February 1997. We tried various medications, but my pressure at work remained very high. My doctor told me to take a medical leave on March 28, and I have not returned to work since. My blood pressure seems to be under better control away from work, although it is still not as normal as I would like. Unfortunately, I believed that if I were to return to work, my pressure would immediately go back up to dangerously high levels.

(App. at PRL000006-7.) Confirming Davies’ account of high blood pressure while at work were reports of the “floor nurse,” which were as follows:

Date Reading

March 5,1997 174/100

March 12, 1997 186/106

March 13, 1997 176/100

March 19, 1997 180/106

March 25, 1997 186/104

March 26, 1997 176/100

(App.PRL000073.)

Accompanying the application for disability benefits was an April 22,1997 letter from Davies’ attending physician, Don W. Henderson, M.D., F.A.C.P. Dr. Henderson indicated that, while anti-hypertensive medication proved effective outside the work environment, Davies’ blood pressure was essentially uncontrolled when he was working as a commodities broker. Dr. Henderson concluded:

[Davies] prognosis is guarded. His blood pressures do clearly go out of control at work. I mentioned to him that he should strongly consider discontinuing his present employment.

(App. at PRL000015.)

By letter dated August 1, 1997, PRLIC informed Davies’ counsel that the applica[351]*351tion for long term disability benefits was denied. The denial letter suggested that consideration of Davies’ claim had been impaired as a result of the refusal of Davies’ counsel to allow a field claim representative to interview Dr. Henderson. As to the medical records that were obtained, PRLIC explained:

We have reviewed the medical records from Dr. Henderson and Dr. Bernardi. Volatile or lobile [sic] hypertension should be controlled with appropriate medication. Dr. Bernardi, Mr. Davies’ cardiologist, did not need to see him for six months following his February 20, 1997 visit. The office notes during that visit state that Mr. Davies was experiencing no chest pain, no shortness of breath, no syncope. He has had no growth limiting symptoms. Dr. Henderson states that Mr. Davies has significant improvement when he is taking his medications.
* * *
Based on the medical documentation that we have obtained, we find no evidence of a continued impairment that would have rendered Mr. Davies totally disabled from performing the important duties of his occupation as a floor trader.

(App. at PRL000038-39.)

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Bluebook (online)
147 F. Supp. 2d 347, 2001 U.S. Dist. LEXIS 7940, 2001 WL 681321, Counsel Stack Legal Research, https://law.counselstack.com/opinion/davies-v-paul-revere-life-insurance-pamd-2001.