Harris v. Metro. Life Ins. Co.

• Decision Date: 05 February 2010
• Docket Number: No. 2009 CA 0034.,2009 CA 0034.
• Citation: 35 So.3d 266
• Parties: Jack Patrick HARRISv.METROPOLITAN LIFE INSURANCE COMPANY, New England Life Insurance Company, Diane Freeman, Katherine Sakaloglou and Charles L. McGinty.
• Court: Court of Appeal of Louisiana — District of US

35 So.3d 266

Jack Patrick HARRISv.METROPOLITAN LIFE INSURANCE COMPANY, New England Life Insurance Company, Diane Freeman, Katherine Sakaloglou and Charles L. McGinty.

No. 2009 CA 0034.

Court of Appeal of Louisiana First Circuit.

Feb. 5, 2010.

Jack Patrick Harris, Baton Rouge, LA, In Proper Person Plaintiff-Appellant.

Lauren A. Welch, Hilliard F. Kelly, III, Metairie, LA, for Defendants-Appellees Metropolitan Life Insurance Company, New England Mutual Life Insurance Company, Diane Freeman and Katherine Sakaloglou.

Before CARTER, C.J., GUIDRY, and PETTIGREW, JJ.

PETTIGREW, J.

This appeal arises out of the trial court's maintenance of defendants' dilatory exception raising the objection of prematurity. Following a thorough review of the record, we reverse and remand.

FACTS

On or about March 1, 1992, petitioner, Jack Patrick Harris (“Mr. Harris”), purchased a Professional Disability Policy issued by New England Mutual Life Insurance Company, now Metropolitan Life Insurance Company (“MLIC”), a subsidiary of Met-Life, Inc., an insurance holding company.¹ Mr. Harris, an attorney engaged in the practice of law in Louisiana since 1977, ceased practice upon the advice of his treating psychiatrist on September 15, 2005, due to mental health conditions that Mr. Harris claims became physically manifest in 2000.

Due to his alleged inability to engage in the active practice of law, Mr. Harris filed a claim for benefits with MLIC, his professional disability insurer on November 21, 2005. Said claim consisted of a Notice of Claim and a general all purpose medical authorization both executed by Mr. Harris.

On or about December 9, 2005, Mr. Harris received a package addressed to him from New England Financial, A Met-Life Affiliate (“NEF”) containing claimant instructions, and various forms, (1) an “Attending Physician's Statement”; (2) a “Claimant Statement”; (3) an “Employment Statement”; (4) a “Job Description”; and (5) an “Employee Authorization.” Mr. Harris thereafter forwarded to Dr. Dennis Raymond, his treating physician, the “Attending Physician's Statement” and completed and returned via facsimile transmission and certified mail on December 26, 2005, the remaining forms sent to him by NEF with the exception of the “Employee Authorization.” Mr. Harris explained his objections to execution of the “Employee's Authorization” in his accompanying transmittal letter. On January 11, 2006, Mr. Harris supplemented his response with a statement detailing his net income for the period January 2005 through September 15, 2005, together with copies of bank records corroborating said fees. Mr. Harris also advised NEF of his decision to petition the Louisiana Supreme Court for a medical leave of absence from the practice of law.²

On January 12, 2006, Ms. Katherine Sagaloglou, Intake Specialist, with the Disability Benefits Center of NEF wrote to Mr. Harris acknowledging receipt of the requisite Claimant's and Attending Physician's Statements and advising NEF would be unable to begin evaluation of Mr. Harris' claim without receipt of the signed “Employee's Authorization.”

Mr. Harris received correspondence dated January 20, 2006, from a Kathryn J. Roberts, Manager, with the Worcester Benefit Operations of NEF. Ms. Roberts responded to Mr. Harris' refusal to execute the “Employee Authorization” sent to him by NEF with the explanation that “the purpose of the authorization [was] to allow [NEF] to obtain medical records for [Mr. Hams'] file and to discuss [his] claim for total disability including [Mr. Hams'] current restrictions and limitations.” Ms. Roberts stated that “without such an authorization, [NEF] would never be able to secure any independent information regarding the insured for claim purposes.” Ms. Roberts also stated “[i]mplicit in [NEF's] claim processing is [NEF's] right to investigate. As part of [NEF's] claim evaluation process, [NEF] need[ed] to obtain information on 1) restrictions and limitations due to [Mr. Hams'] medical condition and 2) description and understanding of the important duties of [Mr. Hams'] occupation.”

Ms. Roberts further stated NEF was “duly compliant with all legislated Federal and State privacy laws including HIPAA [Health Insurance Portability and Accountability Act].” and that only “necessary personnel” would review Mr. Harris' file for the purpose of claim evaluation. Ms. Roberts cautioned that “[NEF] may during the life of a claim refer claimants to independent medical evaluators; and [NEF] would release copies of medical records to this entity to assist in the claim evaluation.”

At the conclusion of her correspondence, Ms. Roberts quoted Section 9.4 of the MLIC policy captioned “Written Proof of Loss.” Ms. Roberts claimed Mr. Harris' continued refusal to execute the Employee Authorization would effectively limit NEF's right to investigate and fail to comply with Mr. Harris' obligation to provide NEF with a “complete proof of loss.”

Mr. Harris allegedly placed a telephone call to MLIC upon receipt of Ms. Robert's correspondence, and his call was later returned by Diane Freeman, who purportedly advised Mr. Harris that she was an employee of MLIC and authorized to speak to him regarding his claim. Ms. Freeman allegedly advised Mr. Harris that MLIC's rationale for insisting that he execute the “Employee Authorization” was simply to conform to federal HIPAA standards. Accordingly, Mr. Harris proposed, and Ms. Freeman allegedly accepted, an alternative solution whereby Mr. Harris agreed to prepare or obtain HIPAA compliant authorizations that would be acceptable to all health care providers and forward the executed originals to Ms. Freeman in order that MLIC might obtain all medical records, medical opinions, and medical reports relating to Mr. Harris' past and current treatment.

In furtherance thereof, on January 27, 2006, Mr. Harris forwarded to Ms. Freeman via facsimile transmission and regular mail a copy of his eight-page evaluation by the Amen Clinic, and an original “Authorization to Exchange Information” required by the Amen Clinic to release Mr. Harris' medical files. Also enclosed therewith was a copy of a HIPAA compliant medical authorization addressed to Dr. Dennis Raymond authorizing the release of all medical records requested, including psychotherapy notes if required.³ Mr. Harris concluded this correspondence by stating that it was his belief that he had complied with his obligation under the provisions of the MLIC policy to provide complete and satisfactory proof of loss. Mr. Harris wrote to Ms. Freeman again on February 10, 2006, and enclosed additional documentation to update his claim information. Said documentation consisted of a February 8, 2006 order from the Louisiana Supreme Court transferring Mr. Harris to “Disability Inactive Status” effective immediately. Also enclosed was a copy of an IRS Form 1099 reflecting Mr. Harris' total compensation and net income for 2005, through September 15, 2006[sic].

Ms. Freeman wrote to Mr. Harris on February 8, 2006,⁴ and acknowledged receipt of “all portions of [Mr. Hams'] disability claim forms, excluding a current HIPAA signed authorization.” Ms. Freeman explained that using September 16, 2005, as the as the start date of Mr. Harris' disability, Mr. Harris' “first disability benefit consideration would have occurred on January 15, 2006; however, [NEF] need[ed] additional information before a claim determination can be made.” “To determine if [Mr. Harris met] the policy definition of disability,” Ms. Freeman advised NEF needed to verify (1) any restrictions and limitations Mr. Harris may have; (2) the duties Mr. Harris was performing in the occupation(s) in which he was engaged at the time the disability began; and (3) how said restrictions and limitations affect the performance of said duties.

In determining any restrictions or limitations Mr. Harris may have, Ms. Freeman advised NEF had requested and received Mr. Harris' records from Dr. Dennis Raymond and the Amen Clinic in Newport Beach, California. To assist NEF in evaluating Mr. Harris' claim, Ms. Freeman advised NEF needed to know the duties Mr. Harris performed in his regular occupation prior to the onset of his disability and those duties he can no longer perform. Ms. Freeman stated NEF expected to make a decision on Mr. Harris' claim “within 60 days, provided we have all of the information needed to determine our liability.” In furtherance thereof, Ms. Freeman requested that Mr. Harris provide NEF with: (1) Billings, diaries, court appearances and court records from 2003 to the present; (2) Complete copies of business and personal tax returns with all schedules and attachments, years 2003, 2004, and 2005 when available; (3) Claimant's Supplemental Statement completed in full, by March 10, 2006; and (4) Signed and dated HIPAA authorization, form 1198-02-NEF-AUTH (9/04). Ms. Freeman stated that as soon as the foregoing information was received, Mr. Harris' claim would receive NEF's “immediate attention.” Ms. Freeman wrote to Mr. Harris again on March 15, 2006,⁵ acknowledging NEF's receipt of the supreme court's order transferring Mr. Harris to disability inactive status, and stated that NEF was awaiting the documentation Ms. Freeman requested from Mr. Harris in her February 8, 2006 correspondence. Ms. Freeman further stated that based upon NEF's initial review of the clinical records received from Dr. Dennis Raymond and the Amen Clinic, it was determined an Independent Medical Exam (“IME”) was required to clarify Mr. Harris' “psychiatric diagnoses and any resulting restrictions or limitations due to [Mr Hams'] condition(s).” Ms. Freeman requested that Mr. Harris respond within 14 days and provide NEF with dates when he would not be available for an IME.

Ms. Freeman wrote to Mr. Harris a third time on April 11, 2006,⁶ seeking a response to NEF's previous requests for information relevant to Mr. Harris' claim. Ms. Freeman advised that her attempts on this date to...