Hurley v. First UNUM Life Insurance

24 A.D.3d 509, 808 N.Y.S.2d 247

This text of 24 A.D.3d 509 (Hurley v. First UNUM Life Insurance) is published on Counsel Stack Legal Research, covering Appellate Division of the Supreme Court of the State of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hurley v. First UNUM Life Insurance, 24 A.D.3d 509, 808 N.Y.S.2d 247 (N.Y. Ct. App. 2005).

Opinions

In an action, inter alia, for a judgment declaring that the plaintiff is totally disabled and that the defendant is obligated to pay the plaintiff benefits pursuant to a policy of disability insurance, the plaintiff appeals, as limited by her brief, from so much of a judgment of the Supreme Court, Nassau County (O’Connell, J.), entered March 20, 2003, as, after a nonjury trial, and upon an order of the same court dated March 30, 2001, as amended June 14, 2001, and September 11, 2002, which, among other things, determined that the plaintiff breached her duty of cooperation under the disability insurance policy by refusing to submit to a medical test requested by the defendant, and granted that branch of the defendant’s cross motion which was to dismiss the complaint, is in favor of the defendant and against her dismissing the complaint, and the defendant cross-appeals from so much of the same judgment as, upon the order, directed that the dismissal of the complaint be “without prejudice,” and directed reimbursement of certain premiums paid by the plaintiff.

Ordered that the judgment is reversed insofar as appealed from, on the law, that branch of the cross motion which was to dismiss the complaint is denied, the order is vacated, and the [510]*510matter is remitted to the Supreme Court, Nassau County, for the entry of an amended judgment declaring that the plaintiff is disabled and the defendant is obligated to pay to the plaintiff disability benefits in accordance with the terms of the subject policy of insurance; and it is further,

Ordered that the cross appeal is dismissed as academic in light of the determination of the appeal; and it is further,

Ordered that one bill of costs is awarded to the plaintiff.

The plaintiff, a dental hygienist, purchased an “own occupation” policy of disability insurance from the defendant, First UNUM Life Insurance Company, in 1991. In or about September 1994 the plaintiff was diagnosed as suffering from carpal tunnel syndrome. She made a claim under the policy and the defendant required that she undergo a medical examination by a physician it selected. The examination included an electromyelograph study (hereinafter EMG), the result of which was negative. After considering the report of its examining physician, which reached the conclusion that the plaintiff was suffering from pronator teres syndrome, either in addition to or rather than carpal tunnel syndrome, the defendant determined that the plaintiff was totally disabled and commenced paying benefits pursuant to the policy. Each month thereafter, the plaintiff duly submitted a statement by her treating physician, Dr. Peter Stein, attesting to the continuation of the condition that resulted in the finding of a disability, as required by the policy, and the defendant paid the benefits due pursuant to the policy.

In early 1997 the defendant’s claims examiner reviewed the plaintiffs file and found it questionable that the plaintiff was totally disabled as a result of her work as a dental hygienist, but was able to care for the child to which she had given birth subsequent to the onset of her disability. There was no medical evidence in the file, or produced subsequently, to support the reasonableness of this concern. The claims examiner ordered a medical review of the plaintiff’s file and, as a result of that review, a physician employed by the defendant suggested to the plaintiff’s physician that the plaintiff undergo an additional EMG. Although the plaintiffs physician initially agreed to that suggestion, and took steps to implement it, he subsequently discussed the matter with the plaintiff and they “decided that it probably wouldn’t change anything, repeating EMGs.” The plaintiff admitted that she initially agreed to submit to the EMG, but later changed her mind. A progress report by the plaintiffs physician dated May 12, 1997, indicated that “[d]ue to the complexity of her problems and bilateral nerve compressions and the limited guarantee of improvement by surgery, further invasive testing (EMG’s) will be deferred at present.”

[511]*511In a telephone conversation on June 3, 1997, the claims examiner advised the plaintiff that in order for benefits to continue she would have to undergo the EMG. The substance of that conversation was confirmed by letter of the same date from the claims examiner to the plaintiff, which stated, in relevant part: “As discussed today, no further benefits can be extended until an EMG test is performed and the results are received and reviewed by this office. Based on all the information in the file and a telephone conversation between Dr. Stein and our medical consultant, we find that there is a lack of significant clinical and objective findings to support the degree of impairment you claim exists.”

The plaintiff then obtained an attorney. By letter dated June 17, 1997, to the plaintiffs attorney, the claims examiner stated: “As discussed with Ms. Hurley and yourself, we feel we have a deniable claim at this time. However, we are willing to keep the file open pending the result of an EMG. After your review of the enclosed information, please advise as to whether Ms. Hurley will be having an EMG or not.” This was followed by a letter dated July 9, 1997, to the plaintiff’s attorney, in which the claims examiner stated: “As previously discussed with yourself and Ms. Hurley, we have not received any indication that Ms. Hurley will be having an EMG. Therefore, this claim has been closed.” The letter then summarized the basis for the defendant’s determination:

“As you are aware, we have completed a comprehensive review of all the medical records of Dr. Peter Stein. We then arranged for one of our staff physicians to review Ms. Hurley’s medical records and to speak to Dr. Stein regarding Ms. Hurley’s condition. Our staff physician and Dr. Stein . . . agreed to strongly suggest to Ms. Hurley that she undergo these studies. Even though we felt we had enough information in this file to close this claim for lack of significant clinical and objective findings to support the degree of impairment Ms. Hurley claims exists, we were willing to keep the file open until the EMG studies were done.
“Since there is insufficient medical information to support Ms. Hurley’s claimed inability to work, we are unable to extend further benefits and have closed this claim.”

The plaintiff thereafter continued to refuse to undergo the EMG and ultimately instituted this action, inter alia, for a judgment declaring that she is totally disabled and that the defendant is obligated to pay benefits pursuant to the policy of disability insurance. The defendant denied that the plaintiff is totally disabled and defended on the additional ground that the [512]*512plaintiff failed to submit to the examination, as required by the terms of the policy. Following a nonjury trial, the Supreme Court determined that the plaintiffs failure to submit to the testing constituted a breach of her duty to cooperate under the policy and, inter alia, dismissed the complaint without prejudice on that basis. The Supreme Court declined to address the issue of the plaintiffs disability on the ground that it was not necessary to reach that issue in light of its determination. This appeal and cross-appeal ensued.

Under the terms of the policy of disability insurance at issue here, the plaintiff was obligated to submit to a medical examination that was reasonably requested by the defendant at any time during the pendency of a claim.

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Bluebook (online)
24 A.D.3d 509, 808 N.Y.S.2d 247, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hurley-v-first-unum-life-insurance-nyappdiv-2005.