Gautreaux v. Massachusetts Mut. Life Ins. Co., 03-2298-GTV.
| Decision Date | 14 February 2005 |
| Docket Number | No. 03-2298-GTV.,03-2298-GTV. |
| Citation | 356 F.Supp.2d 1184 |
| Parties | Mary Helen GAUTREAUX, Plaintiff, v. MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY, Defendant. |
| Court | U.S. District Court — District of Kansas |
Roger M. Driskill, McArdle Law Firm, Independence, MO, for Plaintiff.
Adam B. Walker, Richard N. Bien, Robyn Lyn Anderson, Lathrop & Gage, LC, Kansas City, MO, for Defendant.
Plaintiff Mary Helen Gautreaux brings this action against Defendant Massachusetts Mutual Life Insurance Company, alleging that Defendant improperly denied her claim for long-term disability benefits. Defendant moved for summary judgment (Doc. 29), claiming that because Plaintiff's alleged disability is "contributed to" by a psychological or emotional disease/disorder or caused by a spinal disorder, both of which are specifically excepted by a rider to the policy, no benefits are due. Plaintiff responds that (1) she is not claiming disability as a result of a psychological disorder, and (2) a letter purportedly clarifying the portion of the rider concerning spinal disorders modified the policy's terms, making her eligible for benefits. For the following reasons, the court denies Defendant's motion (Doc. 29).
The following facts are taken from the summary judgment record and are uncontroverted. Plaintiff failed to properly respond to Defendant's list of uncontroverted facts, so all of the following facts are taken from Defendant's brief and the evidence supporting it. Immaterial facts and facts not properly supported by the record are omitted. References to testimony are from depositions, unless otherwise noted.
Plaintiff applied to Defendant for a long-term disability policy on December 1, 1998. Defendant issued a policy to Plaintiff on April 14, 1999, and Plaintiff accepted the policy on April 22, 1999 by signing a Modification of Coverage rider. Plaintiff kept the policy in force until December 14, 2000, when Defendant cancelled it at Plaintiff's request.
Under the policy, Defendant committed to "pay the Total Disability Monthly Benefit shown in the Policy Specifications [($2,000)] if the Insured is Totally Disabled." The policy defined "Total Disability" as:
The occurrence while this Policy is In Force of a condition caused by a Sickness or Injury, in which the Insured cannot perform the main duties of his/her Occupation and is not working at any other occupation for which he/she is reasonably suited by education, training or experience. The Insured must be under a Doctor's Care.
The policy contained a provision specifying that:
An authorized officer of Our company must approve any change to the provisions of this Policy. Our agents are not authorized to make changes or waive any provisions of this Policy. If the change restricts any coverage, the change request must be signed by You. All changes must be attached to the Policy.
The policy was also subject to a Modification of Coverage rider, which provided:
The insurance will not cover any disability contributed to or caused by any psychological or emotional disease or disorder including treatment, surgery and complications thereof.
The insurance will not cover any disability contributed to or caused by any injury to or disorder of the spine including its muscles, ligaments, discs or nerve roots including treatment, surgery and complications thereof.
Before accepting the policy, Plaintiff sought clarification from Defendant of the language in the rider regarding the policy's noncoverage of disabilities contributed to or caused by a spinal injury or disorder. Plaintiff testified at deposition that she objected to the rider because it "cover[ed] virtually nothing that I[had] a problem with and any future event that I would have a problem with." Roberta M. Bitzer, Director of Disability Income Claims for Defendant, responded to Plaintiff's request for clarification with a letter dated April 14, 1999, which stated:
If you were to suffer any disability contributed to or caused by any injury to or disorder of the spine, including its muscles, ligaments, discs, or nerve roots including treatment, surgery and complications thereof, for example, so severe that it resulted in a disability and, in all likelihood, would have done so even in the case of a person whose spine was completely normal, the exclusion would not apply, and the disability would be covered.
On the other hand, if you were to suffer a relatively slight injury or sustain a disorder which would have resulted in a disability because of the existing condition of the spine, but which would not have had the same result in the case of a person whose spine was completely normal, the exclusion would apply and the disability would not be covered.
While legally I cannot incorporate my letter of interpretation into your Modification of Coverage Rider or exclusion rider, this is an attempt to explain how policies issued with a Modification of Coverage Rider or exclusion rider may affect your eligibility for benefits should you become disabled in the future.
Between 1971 and 1979, Plaintiff underwent surgeries for discectomy at C5-6, L5-S1, and L4-5. She also had cervical fusion at C5-6 and a laminectomy at L5-S1. Between 1980 and 1988, Plaintiff "used chiropractic manipulation and physical therapy for pain relief." In January 1988, she complained of "severe right lower back discomfort with radiation of pain along the anterior right thigh to the knee," and was admitted to St. Joseph's Health Center. Plaintiff's treating physician during her hospitalization noted:
The patient has a long past history of back problems and has had at least 3 previous back surgeries including 2 lumbar discectomies and laminectomies — L5, S1 and L4,L5 as well as C5,C6 discectomy and fusion. Apparently no injury precipitated any of these problems and she knew of no injury precipitating the current episode.
In approximately 1996, Plaintiff was diagnosed with major depression. She has taken Prozac for her depression since 1996.
Also in 1996, Plaintiff was seen by Ann K. Smith, M.D., for back pain that occurred after she mowed her lawn. Dr. Smith noted that Plaintiff had a "chronic history of back problems [and] after her 3rd back surgery spent a couple of years being `a chronic back pain patient,'" and that "about every 6 to 9 months [Plaintiff] suffers an extreme episode of back pain with severe back spasm." Between September 1996 and August 1998, Plaintiff visited several doctors, took medication, and underwent physical therapy for her back on an intermittent basis.
On August 4, 1999, Plaintiff saw Dr. Stanley Sharp for complaints of "severe back pain." Dr. Sharp noted that Plaintiff could not "walk or lie down without pain" and that Plaintiff had "multiple similar episodes in [the] past of acute back pain managed as in the plan below." On August 12, 1999, Plaintiff reported to Dr. Thomas Joseph that she had fallen, injuring her ankle, knee, and arm. Plaintiff reported to Dr. Sharp's office that, on or about August 17, 1999, she fell, hurting her ankle and back. On August 20, 1999, Plaintiff reported to Dr. Joseph that she had fallen again, and that she had also run her car into a curb.
On or about August 31, 1999, Plaintiff fell down between three and five stairs in her home. Plaintiff applied ice to her ankle as a result of the fall, although she later stated that she had injured both her left ankle and her lower back. Plaintiff later reported that she experienced moderate ankle swelling and a stiff neck the day after the fall, and that her ankle was swollen and sore during the next week.
On September 8, 1999, Plaintiff contacted Dr. Sharp's office to request refills of her back medication. She stated that she had been in a car accident, but did not mention the August 31 fall. She saw Dr. Sharp on September 14, 1999, and his notes from the visit state that Plaintiff had been in a motor vehicle accident, but do not mention the August 31 fall.
Plaintiff did not receive medical treatment for injuries that allegedly resulted from the August 31 accident until September 20, 1999, when Dr. Brian Healy examined her. He noted that Plaintiff Dr. Healy had Plaintiff wear a "Cam walker," which was painful to Plaintiff and was later replaced by a short leg cast on the ankle. Plaintiff's last day of work was October 15, 1999.
Over the following seven months, Plaintiff saw numerous doctors for back pain, and was hospitalized for "uncontrollable low back pain" in February 2000. On May 24, 2000, Plaintiff underwent spinal-fusion surgery and pedicle-screw fixation of the L4-5 and L5-S1, with anterior cage array variety at L4-5.
In a letter dated December 26, 2000, Dr. Daniel Downs stated that Plaintiff's May spinal fusion was successful, but that Plaintiff was "not going to be employable because of her chronic pain syndrome and mechanical back instability." Dr. Downs diagnosed Plaintiff with "chronic pain syndrome status post lumbar fusion status post cardiac risks post pulmonary embolus." He stated:
[Plaintiff's] continued physical and mental limitations are based on back pain radicular leg pain, and chronic pain syndrome that has developed with increasing severity over the last several months.
. . . .
[Plaintiff] cannot sit for a long period of time because of her mechanical back and neurogenic leg pain exacerbated by her severe chronic pain symptoms.
In a "Physician's Residual Functional Capacity" form Dr. Downs also completed in December 2000, Dr. Downs indicated...
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