Yingling v. UNUM Life Insurance Co. of America

959 F. Supp. 251, 1997 U.S. Dist. LEXIS 5768, 1997 WL 202928
CourtDistrict Court, M.D. Pennsylvania
DecidedApril 25, 1997
DocketCiv. A. 1:CV-96-1812
StatusPublished
Cited by1 cases

This text of 959 F. Supp. 251 (Yingling v. UNUM Life Insurance Co. of America) 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.

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Yingling v. UNUM Life Insurance Co. of America, 959 F. Supp. 251, 1997 U.S. Dist. LEXIS 5768, 1997 WL 202928 (M.D. Pa. 1997).

Opinion

MEMORANDUM

CALDWELL, District Judge.

I. Introduction.

In this diversity action controlled by Pennsylvania law, the defendant, UNUM Life Insurance Company of America, has filed a motion under Fed.R.CivJP. 12(b)(6) to dismiss the plaintiffs amended complaint. The plaintiff, Ronald E. Yingling, seeks to recover disability benefits under the policy UNUM issued to his employer.

The motion argues that the action is barred by the insurance policy’s contractual period of limitations. The plaintiffs opposition to the motion requires us to decide, among other things, whether the defendant waived the limitations period by leading the plaintiff on and whether a purported ambiguity in the policy language dealing with the submission of claims renders the plaintiffs lawsuit timely.

Because the motion relied on matters outside the amended complaint, by order, dated April 2, 1997, we converted it to one for summary judgment. We therefore apply the well established standard for deciding motions under Fed.R.Civ.P. 56 to the motion, see Davis v. Portline Transportes Maritime Internacional, 16 F.3d 532, 536 n. 3 (3d Cir.1994), and present the following undisputed facts in the light most favorable to the plaintiff.

II. Background.

According to the amended complaint, the plaintiff worked as a business manager and board secretary with the Spring Grove Area School District in Spring Grove, Pennsylvania. The School District had a group long-term disability policy with UNUM. The policy contained the following three-year limitation on when suit could be brought to enforce rights under it:

H. LEGAL PROCEEDINGS
A claimant or the claimant’s authorized representative cannot start any legal action:
I. ...
2. more than 3 years after the time proof of claim is required.
(UNUM policy, Section VI, captioned “General Policy Provisions” at pages L-GPP-2 and 3, attached as exhibit A to the amended complaint). In turn, the policy had the following provision on submission of a proof of claim:
F. NOTICE AND PROOF OF CLAIM 1. Notice
a. Written notice of claim must be given to the Company within 30 days of the date disability starts, if that is possible. If that is not possible, the Company must be notified as soon as its is reasonably possible to do so.
*253 b.When the Company has the written notice of claim, the Company will send the insured its forms. If the forms are not received within 15 days after written notice of claim is sent, the insured can send the Company written proof of claim without waiting for the form.
2. Proof
a. Proof of claim must be given to the Company. This must be done no later than 90 days after the end of the elimination period.
b. If it is not possible to give proof within these time limits, it must be given as soon as reasonably possible. But proof of claim may not be given later than one year after the time proof is otherwise required.
c. Proof of continued disability and regular attendance of a physician must be given to the Company within 30 days of the request for the proof.
d. The proof must cover:
i. the date disability started;
ii. the cause of disability;
iii. how serious the disability is.

(UNUM policy, Section VI, captioned “General Policy Provisions” at page L-GPP-2). The elimination period is defined as “a period of consecutive days of disability for which no benefit is payable” as shown in the policy specifications. (UNUM policy at page L-DEF-1). The policy specifications set a period of 90 days for the elimination period. (UNUM policy at page L-PS-1).

The plaintiff avers that he was exposed to various chemicals in October 1989 dining a School District renovation project. (Amended complaint, ¶¶ 9 and 11). As a result, he alleges he became “hypersensitized to common chemicals, foods, and environmental allergens” which have caused him “to experience severe bodily symptoms and reactions to minimal chemical exposures.” (Id. at ¶ 10). The plaintiff became disabled on December 5,1990, and was forced to stop working on that date, (id. at ¶. 13), although he unsuccessfully attempted to return to work part-time for a two-week period beginning April 16,1991. (Id. at ¶ 14).

Thereafter, the parties exchanged numerous letters about coverage for the plaintiff. We provide the following chronology but, aside from July 19, 1991, the date of the plaintiffs application for benefits, several dates are important to the resolution of the defendant’s motion: October 20, 1993, the date of an UNUM letter finally denying coverage and advising the plaintiff he had 60 days to appeal; February 17, 1994, the date the appeal was denied; June 17, 1994, the date the plaintiff inquired about further administrative rights and the deadline for filing a lawsuit; and August 2, 1994,- the date the defendant responded that all administrative rights had been “technically” exhausted and informed the plaintiff that suit could be brought within three years after a proof of claim was required.

As noted, on or about July 19, 1991, plaintiff submitted an application for benefits on standard UNUM forms, claiming total disability arising from his work-related exposure to chemicals. (Amended complaint, ¶ 37; plaintiffs original complaint, exhibit B; defendant’s exhibit B). The application listed December 5, 1990, as the starting date of disability and that the plaintiff had unsuccessfully attempted to return to work part-time from April 16, 1991, to May 10, 1991.

On or about February 18, 1992, UNUM notified plaintiff that there was no evidence of a physical disability but that he was being approved for disability based on psychological grounds. UNUM also informed him that, in accord with policy language limiting coverage for mental illness, he would be receiving only 24 months of disability coverage ending on October 21, 1993, and that he would have to submit periodic reports on his condition. The letter additionally stated: “If you disagree with this determination, please submit further evidence that would support your physical condition and we will evaluate it.” (Plaintiffs original complaint, exhibit C; defendant’s exhibit C).

On or about February 27, 1992, the plaintiff wrote the defendant informing, the company that he was accepting the benefits under protest' and that he would submit the *254

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959 F. Supp. 251, 1997 U.S. Dist. LEXIS 5768, 1997 WL 202928, Counsel Stack Legal Research, https://law.counselstack.com/opinion/yingling-v-unum-life-insurance-co-of-america-pamd-1997.