Matthews v. Pennsylvania Life Insurance

606 F. App'x 460
CourtCourt of Appeals for the Tenth Circuit
DecidedApril 7, 2015
Docket14-4100
StatusUnpublished

This text of 606 F. App'x 460 (Matthews v. Pennsylvania Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Tenth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Matthews v. Pennsylvania Life Insurance, 606 F. App'x 460 (10th Cir. 2015).

Opinion

ORDER AND JUDGMENT *

TERRENCE L. O’BRIEN, Circuit Judge.

Glenn Matthews appeals from a summary judgment entered in favor of Pennsylvania Life Insurance (the insurer) on *461 his claim for benefits under an Accident Benefit Policy (the policy). 1 Because there is no genuine dispute as to any material fact and the insurer is entitled to judgment as a matter of law, we affirm.

BACKGROUND

In 2002, when he was 50 years old, Matthews “was riding a horse and was bucked off. He landed on his hip and lower back and sustained a severe hip injury which has never fully healed.” Aplee.App. at 2. Matthews was hospitalized the same day. Dr. Dunn, the physician who looked at the x-rays, said they “show abnormal widening of the pubic symphysis.” ApltApp. Vol. 1 at 98. He also noted “[b]oth SI joints seem to be somewhat wider than average as well. The appearance of the pelvis suggests that [Matthews] probably has developmental diastasis of the symphysis pubis and the AC joints may look abnormal as a result. There do appear to be some degenerative changes of the spine.” Id. Dr. Dunn stated “I cannot entirely exclude the possibility that this might be exaggerated by an acute injury but I doubt that the appearance is acute.” Id. He again acknowledged an “abnormal widening of the sym-physis pubis with widening of both SI joints,” but “suspeet[ed] that these findings are primarily chronic and developmental.” Id.

A few days later Matthews was seen by another physician, Dr. Brunsdale, who noted “the diastasis of the symphysis pubis does appear abnormal.” Id. at 100. He commented that the abnormality “could be a chronic thing” or “an acute orthopedic injury.” Id.

At the time of the accident Matthews was insured against an “Injury [that] causes Total Disability.” Id. at 53. The policy defined “Injury” as “accidental bodily injury sustained: (1) directly and independently of disease or bodily infirmity, or any other causes; and (2) while [the][p]oli-cy is in force.” Id. at 49.

As a result of the horseback riding accident, Matthews made a claim for disability benefits. The insurer paid benefits from the time of the accident through November 2003, when Matthew’s physician, Dr. Callahan, released him to return to full-time work as a construction supervisor. In 2008, he was permanently laid off due to a lack of work. In early 2009, Matthews talked to a couple of companies about work as a construction supervisor, but there were no openings. He made no further effort to find work because he “just figured it would be the same story everywhere.” Id. at 80. As Matthews’s explained the situation, I “[p]retty much” resigned myself to retire. Id.

In March 2010, Matthews circled back to the insurer and filed a second claim for disability benefits. As grounds he cited a “[b]ad back.” Id. at 344. In support of the new claim, Dr. Callahan described the disability as “continuing degenerative disease, continued pain.” Id. at 345. The insurer initially approved benefits while it gathered Matthews’s medical records and scheduled a functional capacity examination. At the beginning of the examination in August 2010, Matthews stated “the low back aching was constant and the pubic bone discomfort comes and goes.” Id. at 333. Matthews, however, was unable to complete the examination due to his hypertension, which was out of control. He was advised to seek medical treatment for that problem and return at a future date. In the meantime, the insurer wrote to Matthews in early December advising it would discontinue benefits in mid-February 2011. In particular, it referenced Dr. Callahan’s *462 notes from September 22, 2009 (Matthews’s first back-related medical appointment since 2004) stating “your medical records reflect that you have ‘multiple level degenerative disc disease and degenerative arthritis.’ ” Id. at 141. As such, the insurer determined the disability was not the result of an “Injury” as defined in the policy because it did not arise “directly and independently of disease or bodily infirmity, or any other causes.” In other words, although Matthews may have suffered a pelvic injury (pelvic symphysis diastasis) in the horseback riding accident, his disabling back pain did not arise directly from that injury and was not independent of all other causes.

In July 2011, Matthews filed for Social Security disability insurance benefits in which he listed the following impairments: (1) pelvic injury; (2) bad back; (3) depression; (4) high blood pressure; (5) degenerative discs; and (6) arthritis. Ultimately the agency found two severe impairments: “degenerative disk disease in the lumbar area of the spine and pelvic symphysis diastasis.” ApltApp. Vol. 2 at 541. In February 2012, the agency concluded in light of Matthews’s “age, education, work experience, and residual functional capacity, there are no jobs that exist in significant numbers in the national economy that [he] can perform,” and accordingly he was disabled and entitled to benefits. Id. at 543.

In September 2012 Matthews filed suit seeking benefits under the policy. According to the complaint, the “hip injury [suffered in the horseback riding accident] is the most predominating condition that affects [his] total disability and has had a major impact upon his ability to function.” Aplee. App. at 2. He acknowledged the existence of “degenerative disc disease,” but alleged the “disease, but for his hip injury, would not be relevant.” Id.

When asked during discovery to describe the medical symptoms preventing him from working, Matthews said: “Split pelvis, degenerative disc[ ] disease.” Aplt. App. Vol. 2 at 379. According to Dali, Matthews’s own medical expert; pubic diastasis (pelvic symphysis diastasis) was the only accident-related injury suffered by Matthews and his degenerative disc disease, low back pain, and osteoarthritis of the hip were all non-accident related. Dali stated there was no “objective medical evidence [as to the] impact or synergistic effects ... the accident-related diagnoses had on Matthews’ non-accident related diagnoses.” ApltApp. Vol. 1 at 137.

The insurer’s medical expert, Dr. Ballard, opined “[t]here are multiple causes for [Matthews’s] work restrictions [including] [t]he accident-related pubic diastasis with secondary sacroiliac joint dysfunction, and also [t]he lumbar degenerative changes in his back which are not secondary to the accident in question.” Aplee. App. at 28.

When asked to comment on Ballard’s report, Dali submitted a frank rebuttal. In it he does “not have a lot to say inasmuch as Dr. Ballard’s comments are fairly consistent with mine. We both agree that the pain leading to [Matthews’s] functional limitations and restrictions is multifactorial.” ApltApp. Vol. 2 at 547.

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606 F. App'x 460, Counsel Stack Legal Research, https://law.counselstack.com/opinion/matthews-v-pennsylvania-life-insurance-ca10-2015.