2005 D e c i sion s O p inion s of the U nit e d S t at e s C our t of Appe al s for the Thir d C ir c uit 7-13-2005 

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____________ *J A C Q U E L I N E SH O E M A K E R , i n hercapa ci t yas E xecutr i x of the Est at e of A r nol d M . St ockt on, D ece as ed,

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____________ O n A p p ea l from the U n it ed S tat es D istri ct C o u rt f o r th e W e ste rn D istric t o f P e n n sy lv a n ia ( D. C. No. 0 1 - c v - 0 0 3 0 0 E) D istri ct Ju d g e: H o n o rab le M au ri ce B . C o h il l, Jr.

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J une 30, 2005 B e f o re : N Y G A A R D , S M IT H a n d F IS H E R , C i r cui tJudges .

( Fi l ed: J ul y13, 2005)

____________ OPI NI ON O F THE COURT

____________D r . St ockt on w as t he or i gi nal pl ai nt i ff, butdi ed af t ers um m aryj udgm entw as 1 ent er ed. A ppel l antw as t her eaf t ers ubs t i tut ed as pl ai nt i ff.

2 F IS H E R , C i r cui tJudge . J acque l i ne Shoemaker( “A ppel l ant ”) , E xecutr i x of the Est at e of D r . A r nol d M . St ockt on ( “D r . St ockt on”) , appea l s fr om the gr antof s um m aryj udgm entforthe 1 d e f e n d a n tJ o h n Ha n c o c k M u tu a l Li f e I n s u r a n c e Co mp a n y( n o w k n o wn a s UNI CARE L if e a n d H e a lth In su ra n c e C o m p a n y , o r “ U N IC A R E ” ) in th is a c tio n se e k in g d isa b ili ty i ns ur ance benef

i t s . W e w i l l aff

i r m , and foc us her ei n on the r at i onal e forourdeci s i on.

I. W e have j ur i s di ct i on pur s uantt o 28 U . S. C . § 1291. W e exe r ci s e pl enaryr evi ew of a di s tr i ctcourt ’ s gr antof s um m aryj udgm entand us e the s ame st andar d as the D i s t r i ct C our tbel ow – i . e. , s um m aryj udgm enti s pr operw her e no genui ne i s s ue of mat er i al fac t e x ists to b e re so lv e d a t trial, an d w h e re , v iew in g th e f a c ts in th e lig h t m o st f

a v o ra b le to th e n o n -m o v in g p a rt y , th e m o v in g p a rt yis e n title d to ju d g m e n t a s a m a tte r o f la w . Mar i no v. I

ndus tr i alC r at i ng C o. , 358 F. 3d 241, 247 ( 3d C i r . 2004) . Penns y l vani a l aw appl i es i n t hi s di ver s i t yact i on. A n insu red see k ing to rec o v er d isab il ityb en ef it s u n d er a n insu ran ce p o li cyb ea rs the bur den t o pr ove thathe w as di s abl ed w i t hi n t he meani ng of the pol i cyw hi l e cove r age w a s in e f f e c t. Ca ta l a n o v . P r u d e n t i a lI n s . Co . o f A m. , 28 A . 2d 349, 350 ( Pa. Super . 1942) ( ci t i ng P er lm an v. Metr opol i tan Li f e I ns . C o. , 9 A . 2d 432 ( Pa. 1939) ) . W hen the t erm s of3

th e p o lic ya re c le a r, a c o u rt m a yn o t a s s ig n a c o n tr a ry c o n s tru c tio n to th e m . Sanders v. A lleg h e ny H

o sp ita l P a rkv iew D iv . , 8 3 3 A . 2 d 1 7 9 (P a. S u p er. 20 0 3 ). II. T h e re co rd o n su m m aryjud g m en t r ev ea ls th e f o ll o w ing . O n M ay1 , 1 9 8 3 , D r. St ockt on pur chas ed a l ong- t erm di s abi l i t yi ns ur ance pol i cyfr om U N I C A R E thr ough t he A m e ric a n O p to m e tric A ss o c iatio n . T h e p o licysta ted in re lev a n t p a rt:

‘ t ot al l ydi s abl ed’ s hal l m ean the i nabi l i t yof a mem bert o per form the m at er i al and s ubs t ant i al dut i es pert ai ni ng t o hi s orheroccupa t i on or pr ofes s i on, and thats uch per s on i s notengage d i n anyoccupa t i on or pr ofes s i on forr enumer at i on orpr ofi t , exce ptw i t h r es pectt o t hos e per s ons engage d i n a Par t i al R ecove r yE m pl oym ent . Fordur at i on of anyper i od of ‘ T ot al D i s abi l i t y , ’ a mem berm us tbe underthe r egul arcar e and a t t endanc e of a doc t orot hert han hi m s el f orher s el f. D r . St ockt on had bee n t r eat i ng w i t h D r . L obacz i n N ew Y or k forvar i ous ai l m ent s s i nce 1 9 7 7 . In a let ter da ted F eb rua ry1 7 , 1 9 9 5 , D r. L o b ac z h ad stat ed “[ i] n m yo p inion , [D r. S tock ton ] i s tem p o raril yinca p ac it ated fro m fu ll -t im e e m p loym en t. ” In M arc h 1 9 9 5 , D r. St ockt on m oved t o Penns y l vani a; befor e that , he w as l as ts een byD r . L obacz on M ar ch 13, 1995. O n O c to b e r 2 9 , 1 9 9 5 , D r. S to c k to n su b m itt e d a c laim to U N IC A R E f o r d isa b ili ty b e n e f i t s . I n No v e mb e r1 9 9 5 , UNI CARE s e n tDr . Lo b a c z a n “ a t t e n d i n g p h y s i c i a n ” f o r m, w hi ch D r . L obacz ’ s offi ce r etur ned, dat ed J anuary31, 1996, i ndi cat i ng thatD r . St ockt on su f f e re d f ro m v a rio u s a ilm e n ts, a n d w a s la st e x a m in e d in M a rc h 1 9 9 5 . D r. S to c k to n p a id pol i cypr emi um s t hr ough J anuary31, 1996, w hi l e hi s cl ai m w as pendi ng. O n February9,D r . St ockt on al s o s ubm i t t ed D r . T urbes s i as an expe r ton t ot al di s abi l i t y . A s t he 2 D istric t C o u rt e x p lain e d , h o w e v e r, D r. T u rb e ss i’s e x p e rt re p o rt a d m itt e d h is in a b ili tyto form an opi ni on w i t hi n a r eas onabl e degr ee of m edi cal cert ai ntyw hetherD r . St ockt on w as di s abl ed dur i ng t he r el evantt i m e per i od. A ppel l antas s i gns no err ort o t he D i s t r i ct Co u r t ’ s c o n c l u s i o n t h a tDr . Tu rb e s s i ’ s r e p o r ts i mp l yd i d n o ts u p p o r tth e c l a i m. 4 1 9 9 6 , U N IC A R E d en ied th e c lai m fo r i n su ff ici en t sup p o rt ing m ed ical ev iden ce . D r. St ockt on ther eaf

t erdi r ect ed U N I C A R E thr ough l ett er s dat ed February27, 1996 and F e b ru a ry 2 9 , 1 9 9 6 , to c a n c e l h is p o lic y . U N IC A R E d id s o , e f f e c tiv e J a n u a ry 3 1 , 1 9 9 6 . M anym ont hs l at er , on D ece m ber11- 12, 1996, D r . L obacz tr eat ed D r . St ockt on agai n, and s t at ed i n a l ett er : “[i ] n m yopi ni on, [D r . St ockt on] i s unabl e t o per form the mat er i al and s ubs t ant i al dut i es per t ai ni ng t o hi s pr ofes s i on, and that[he] i s notengage d i n any pr ofes s i on forr enumer at i on [s i c] orpr ofi t . ” U N I C A R E , as evi dence d byl ett er s i n t he re c o rd , co n tin u e d to p ro c e ss th e c laim a f ter its in iti a l d e n ial. D ur i ng depos i t i on, D r . St ockt on t es t i fi ed as t o hi s ow n s ym pt om s . D r . L obacz t es t i fi ed that , i n hi s m edi cal opi ni on bas ed on y ear s of tr eatm ent , D r . St ockt on w as di s abl ed as of O ct ober1995. H ow ever , on cr os s - exami nat i on, D r . L obacz admi t t ed that he di d notknow t o a r eas onabl e degr ee of m edi cal cert ai ntyw hatD r . St ockt on’ s m edi cal c o n d iti o n h a d b e e n in a n yo f th e m o n th s f

ro m S e p tem b e r 1 9 9 5 to Ja n u a ry1 9 9 6 . O n th is rec o rd, th e D istri ct C o u rtg ran ted s u m m aryjud g m en t fo r U N IC A R E , co n clud ing that D r. S to c k to n h a d f

a iled to su b m it an ye x p e rt m e d ica l tes tim o n yp ro v in g to tal d isa b ili ty betw een O ct ober1995 and J anuary1996. 2See al s o B L ACK ’ S L AW D I C TI ON ARY ( 8th ed. 2004) ( defi ni ng “perm anent 3 di s abi l i ty ” as “a di s abi l i t yt hatw i l l i ndefi ni t el ypr eventa w or kerfr om per form i ng s om e or al l of the dut i es t hathe ors he coul d do befor e an a cci dentori l l nes s , ” and “ t ot al di s abi l i ty ” as “[a ] w orker ’ s i nabi l i t yt o per form empl oym ent - r el at ed dut i es beca us e of a p h y sical or m en tal im p airm en t. ”). 5 I V. A p p ell an t assign s tw o erro rs relat ed to the p o li cylang u ag e a n d o v era ll fra m ew o rk of the D i s tr i ctC our t ’ s anal y s i s . Fi r s t , s he cont ends the D i s t r i ctC our terr ed i n appl y i ng a s t andar d for“perm anent ” di s abi l i t yi ns t ead of for“t ot al ” di s abi l i t y . A ppel l anti s corr ect thatt ot al and perm anentdi s abi l i t yar e tw o di ffe r entthi ngs u n d er this po li cy . H o w ev er, 3 w hi l e the D i s t r i ctC our tci t ed C atalano w hi ch i nvol ved a c l ai m ants eeki ng bot h t ot al and p e r ma n e n td i s a b i l i t yc o mp e n s a t i o n , a n d u s e d th e t e r m “ p e r ma n e n t l y ” i n i t s o p i n i o n , M e m. O p . at 4 , w e a re c o n v in c e d th a t th e D istric t C o u rt u n d e rsto o d th e typ e o f c laim b e f

o re it and corr ect l yapp l i ed the go verni ng l egal s t and ards. Second, A ppel l antar gues t hat , beca us e U N I C A R E cont i nued t o pr oces s the d isa b ili tyc laim a f

ter its in iti a l d e n ial, th e D istric t C o u rt e rre d in c o n c lu d in g th a t d isa b ili ty m us tbe es t abl i s hed betw een O ct ober1995 and J anuary1996 ( i . e. , the ef fec t i ve dat e of the ca ncel l at i on) . U ndert he cl earand unambi guous l anguage of the pol i cy , cover age cea s ed on the l as tdayof the mont h forw hi ch the i ns ur ed l as tpai d a pr emi um oron t he dat e w hi ch the pol i cyi s t erm i nat ed – her e, J anuary31, 1996. T hi s i s the l as tdayfor w h ich a d isa b ili tyc laim c o u ld b e a w a rd e d b e c a u se c o v e ra g e e x ists w h ile a p o licyis in e f f e c t. N o tab ly , h o w e v e r, itis n o t th e las t d a yo n w h ich th e in su re d c o u ld su b m it a c laim6

o r o n w h ic h U N IC A R E c o u ld p ro c e s s a c la im f o r d is a b ility th a t p re d a te s a c a n c e lla tio n . T h e D istric t C o u rt m e re lyc o n c lu d e d th a t D r. S to c k to n c o u ld n o t re c o v e r f o r a n yd isa b ili ty o c c u rr in g a f

te r J a n u a ry 3 1 , 1 9 9 6 , n o t th a t h e c o u ld n o t s u b m it a v a lid c la im a f te r t h a t d a te . W e p erc eive n o erro r. A ppel l antal s o ar gues t hr ee poi nt s r el at ed t o appl i cat i on of the s um m aryj udgm ent stan d ard o n this reco rd. F ir st, sh e c o n tend s tha t, u n d er C oo per v. Metropo l i tan L i

f e Ins. C o. , 186 A . 125 ( Pa. 1935) , a pl ai nt i ff a s s ert i ng a cl ai m t o benef i t s i s compet entt o t es t i fy as t o hi s ow n s ym pt om s . T hi s i s t rue, and D r . St ockt on di d s o t es t i fy . H ow ever , s t at e l aw a ls o re q u ir e s a p la in tif

f to p ro v id e v a lid e x p e rt m e d ic a l te s tim o n yto p ro v e d is a b ility, s ee id . at 1 2 8 , an d th is is w h e re D r. S to c k to n ’s c laim f a ils. D r. S to c k to n ’s te stim o n ya lo n e is in su f f icie n t to a v o id su m m a ryju d g m e n t. Second, A ppel l antcont ends t hat , underFeder al R ul e of Evi dence 703, the D i s tr i ct C o u rt e rre d in c o n c lu d in g th a t D r. L o b a c z c o u ld n o t re n d e r a n o p in io n o f to tal d isa b ili ty abs enta phy s i cal exami nat i on dur i ng the cl ai m ed per i od of di s abi l i t y . T he pr obl em her e, how ever , w as nots ol el yt hatD r . L obacz di d notphy s i cal l yexami ne D r . St ockt on i n the r el evantt i m e fr ame, butt hathe admi t t ed an i nabi l i t yt o det erm i ne t o a r eas onabl e degr ee o f m e d ic a l c e rt a in ty w h e th e r D r. S to c k to n w a s to ta lly d is a b le d a t th a t tim e . See Redland Socce rC l ub, I

nc. v. D ept . of

the Army of

the U ni t ed Stat es , 5 5 F . 3 d 2 0 4 , 2 0 8 -20 9 (3d C ir . 1991) ( i n s t at i ng a medi cal opi ni on, phy s i ci an mustexpr es s the opi ni on w i t h “a7

re a s o n a b le d e g re e o f

m e d ic a l c e rt a in ty”) . T

h is w as th e b asis o n w h ich th e D istri ct C o u rt r e j e c t e d Dr . Lo b a c z ’ s t e s t i mo n ya s c o mp e t e n tme d i c a l e v i d e n c e i n s u p p o r to f th e c l a i m. Fi nal l y , A ppel l antar gues t hats um m aryj udgm entw as i m pr operbeca us e i tr emai ns a di s put ed i s s ue of mat er i al fac tw hetherD r . St ockt on w as t ot al l ydi s abl ed dur i ng the re lev a n t ti m e p e rio d . T h is a rg u m e n t d e p e n d s o n a re a d in g o f D r. L o b a c z ’s te stim o n yth a t fai l s t o acknow l edge hi s i nabi l i t yt o s peak t o a r eas onabl e degr ee of m edi cal cert ai ntyon the ul t i m at e i s s ue. W e r ej ectt hi s r eadi ng and, thus fi nd no genui ne i s s ue of mat er i al fac t p re c lu d in g su m m a ryju d g m e n t. A ccor di ngl y , w e w i l l aff i r m the entr yof s um m aryj udgm enti n favorof UN I CA RE.