Paulson v. Paul Revere Life Ins. Co.

Decision Date16 June 2004
Docket NumberNo. 4:03-CV-90234.,4:03-CV-90234.
Citation323 F.Supp.2d 919
PartiesThomas PAULSON, Plaintiff, v. THE PAUL REVERE LIFE INS. CO., Defendant.
CourtU.S. District Court — Southern District of Iowa

R. Ronald Pogge, Thomas P. Murphy, Hopkins & Huebner, Des Moines, IA, for Plaintiff.

Michael W. Thrall, Nyemaster Goode Voigts West Hansell & O'Brien PC, Des Moines, IA, for Defendant.

MEMORANDUM OPINION AND ORDER ON CROSS MOTIONS FOR SUMMARY JUDGMENT

PRATT, District Judge.

Plaintiff filed a Complaint in the above-captioned matter on April 30, 2003, alleging that Defendant wrongfully denied him long term disability benefits pursuant to the Employee Retirement Income Security Act ("ERISA"). Currently pending before the Court are Plaintiff's Motion for Summary Judgment (Clerk's No. 13); Defendant's Motion for Summary Judgment (Clerk's No. 23); and Defendant's Motion to Strike (Clerk's No. 33). The parties have filed briefs, resistances, and replies to the motions and have agreed to submit the case on cross motions for summary judgment. See Clerk's No. 9. A brief telephone hearing was held on May 12, 2004 and the matter is fully submitted.

I. FACTUAL BACKGROUND

At the time of the injury Plaintiff claims is the cause of his disability, Plaintiff was working as manager of Embers Restaurant in Des Moines, Iowa. Plaintiff reports that he generally worked approximately eighty hours per week and was frequently required to work twenty-four hour shifts and cover for employees who were absent. On January 1, 1999, Plaintiff slipped and fell while carrying a tub of dishes at Embers. He struck the back of his head on the floor and drove himself to the hospital to have his injury evaluated. Iowa Lutheran Hospital treated Plaintiff at the emergency room. The treating doctor noted that Plaintiff claimed not to have lost consciousness, but had a headache and some pressure behind his eyes. Plaintiff did not experience any dizziness or nausea from the fall and did not have visual disturbances at the time he was seen in the emergency room. Plaintiff did report seeing "bright lights" immediately after the fall, however, he admits that this may have been the result of his position after falling, i.e., lying on his back on the floor looking up toward the ceiling lights. An emergency room physician diagnosed Plaintiff with a "head injury" and discharged him with instructions to take Advil, follow standard head injury precautions, and follow up with his family physician if needed. Joint App. at 87-88.

On February 18, 1999, Plaintiff was called into the restaurant to work. Upset by the call, Plaintiff scratched his own face until it bled. On the way to the restaurant, Plaintiff drove his car into a snowbank. Once at the restaurant, Plaintiff hit the wall with his fist and fractured his fifth right metacarpal. The treatment notes from Iowa Lutheran Hospital reflect that Plaintiff "[was] having a stressful time with his job at this time and tonight he was stressed out about his job situation ...." Id. at 85. The treating physician noted that Plaintiff's past medical history was, "Remarkable for a similar episode of explosive temper a few years ago. There is no prior history of depression, suicidal ideation or suicide attempts." Id. Plaintiff's fracture was treated and he was advised to follow up with his family physician, both for his fracture and to get a referral "to a specialist who would help him in controlling his temper." Id. at 84. February 18, 1999 was the last day that Plaintiff actually performed work at Embers, though he remained on the payroll, and was thus still formally employed, until March 28, 1999.

On February 22, 1999, Plaintiff sought counseling with Ed Ashby, a licensed mental health counselor. Ashby diagnosed Plaintiff with depression and noted that treatment would consist of cognitive and behavioral therapy. Ashby also recommended that Plaintiff be placed on an antidepressant. Plaintiff's family physician, Dr. Rick Wilkens, M.D., prescribed Prozac for Plaintiff on April 14, 1999 and Ashby and Plaintiff continued their therapy sessions.

Plaintiff began treating with Damini Parulekar, M.D., on July 27, 1999. Plaintiff told Dr. Parulekar that he began using Prozac for depression in mid-April 1999 and responded well until early July. After that point, Plaintiff began noticed that he was overly sleepy during the day and his wife remarked on his slow responses and difficulty with decision making. Plaintiff reported having no drive, feeling sad, irritable, sluggish, worried, guilty, and that he had difficulty concentrating. Dr. Parulekar noted, "Decision-making has been troublesome for a few years, but worse since 1998." Joint App. at 76. In his notes regarding Plaintiff's temper, Dr. Parulekar wrote, "He has had a temper & denies having been violent toward others. S/T he was a calm person which changed 5-6 years ago." Id. Stressors in Plaintiff's life were listed as overworking for the last year, especially in the three months prior to January 1999; a daughter born in 1998 with Downs syndrome and accompanying medical problems; health, financial, and family problems. Id. at 75. Dr. Parulekar diagnosed Plaintiff with "Major depression, single without psychotic features." Id. at 73. He increased Plaintiff's dosage of Prozac and recommended techniques for stress management and continued therapy sessions with Ashby. Id.

It appears from this point, Plaintiff continued treatment with Dr. Parulekar and continued one-on-one therapy sessions with Ashby. Plaintiff saw Dr. Parulekar approximately once per month after his initial visit. Dr. Parulekar's progress notes reveal that the severity of Plaintiff's condition waxed and waned over the months. On Attending Physician Statements provided to Defendant, Dr. Parulekar repeatedly indicated that Plaintiff's diagnosis was "Major Depression, Single," and that the prognosis for Plaintiff was fair. Treatments listed were medications and therapy. See Joint App. at 145, 150, 288, 288, 294, 310, 313., 328, 334, 340. Ashby's findings regarding Plaintiff were similar. In Attending Physician Statements, Ashby noted that the Plaintiff had been diagnosed with depression and that his "progress toward recovery is good."

On May 7, 1999, Plaintiff signed a claim form seeking Long Term Disability Benefits. Plaintiff checked the boxes indicating that the condition was due to both an accident and a sickness. In response to the question, "Describe the injury incurred (what, how, where, date) or the nature and details of the sickness and when it began," Plaintiff replied, "The sickness is depression and it has been going on for some time." Plaintiff noted his treatment for a concussion on January 1, 1999 and stated that his condition prevented him from, "Planning, organizing, implementations, inspection and controlling. The condition mostly affects planning and organization and controlling, but it affect implementation and inspection also. I have trouble concentrating and thinking and reacting quickly. The decision making mental processes are slowed down." On May 12, 1999, Plaintiff's family physician, Dr. Rick L. Wilkens, signed an "Attending Physician Statement" identifying Defendant's primary diagnosis as Depression with a secondary diagnosis of "right hand metacarpal fracture." Defendant received these documents on June 1, 1999 and immediately began obtaining documentation in support of Plaintiff's claim.

Defendant approved Plaintiff's disability claim on October 1, 1999 under the "Other Limitations" provision of the policy. According to Defendant's letters of approval, the "Other Limitations provision covers:

[A]ny disability which is caused or contributed to by a Mental Disorder or Substance Use Disorder, benefits are payable for up to twenty-four months whether or not the employee is Hospital Confined. Your maximum benefit period under this Provision will end May 23, 2001."1

Joint App. at 96. Defendant noted that Plaintiff was working part time and applied a "Work Adjustment Benefit."

As noted, the letter addressed to Plaintiff approving benefits specifically stated that benefits would only be payable for twenty-four months and that the maximum benefit period under the provision would end on May 23, 2001. Joint. App. at 98-100. As a requirement for Plaintiff to continue receiving disability benefits, Plaintiff was required to fill out a form entitled "Supplemental Proof of Loss (Monthly Income Statement)" once a month. Additionally, Defendant required Attending Physician Statements to be submitted on a regular basis. On October 8, 1999, Plaintiff filled out Supplemental Proof of Loss forms for May, June, July, August, and September 1999. Under a heading requesting a list of factors that caused Plaintiff's earnings to be less than they were prior to disability, Plaintiff wrote on the September form, "Lack of concentration and short term memory problems, sleep problems associated with Clinical Depression." Id. at 109. On each subsequent form, Plaintiff identified the cause of reduced earnings as "Clinical Depression." Id. at 111-13. Statements signed and presented to Defendant in months subsequent to September 1999 also cited "Clinical Depression" as the cause of Plaintiff's reduced earning capacity. See id. at 152, 156, 184, 241, 287, 292. Along with each Supplemental Proof of Loss Form, Plaintiff provided copies of paystubs from his part time employment, first from Manpower, and later from United Parcel Service.

On May 26, 2000, Plaintiff was notified that his case was being closed. This apparently was the result of an Attending Physician Statement filed by Ashby which stated that Plaintiff could resume work without restriction on June 1, 2000. See Joint App. at 253. Dr. Parulekar wrote the Defendant on June 30, 2000, stating his belief that Plaintiff was still disabled and expressing his disagreement with the determination that Plaintiff's long...

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