United States District Court, Southern District of New York
January 13, 2003
FIRST UNUM LIFE INS. CO., DEFENDANTS.
The opinion of the court was delivered by: John S. Martin, Jr., United States District Judge
OPINION & ORDER
Plaintiff Louis R. Napoli, a bond trader, has not worked since November 29, 1996, when he suffered a heart attack at work and had emergency by-pass surgery. After a period in which he received payments from the Defendant under a disability insurance contract, Defendant notified Plaintiff that they were terminating his benefits because it had determined that he was not permanently disabled. Plaintiff then commenced this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., seeking to compel Defendant to continue paying him under his disability contract. Defendant now moves for summary judgment on the ground that the administrative record supports its determination that Plaintiff is not permanently disabled. Plaintiff has cross-moved to supplement the record and for a jury trial. Plaintiff's motion for a jury trial is denied, but its motion to supplement the record is granted in part. Having reviewed the record as supplemented, the Defendant's motion for summary judgment is granted.
In an action such as this, to review the denial of benefits under ERISA, the Court is to conduct a nonjury de novo review of the plan administrator's determination. DeFelice v. American Int'l Life Assurance Co. of New York, 112 F.3d 61, 64 (2d Cir. 1997). Plaintiff is not entitled to a jury trial. Id. at 64; Tischmann v. ITT/Sheraton Corp., 145 F.3d 561, 568 (2d Cir.), cert. denied, 119 S.Ct. 406 (1998); Sullivan v. LTV Aerospace & Defense Co., 82 F.3d 1251, 1258 (2d Cir. 1996).
Where the administrator is also the party who will pay the benefits, the court has the discretion to admit additional evidence that was not part of the record before the administrator. DeFelice, supra, 112 F.3d at 65. In this case, Plaintiff seeks to conduct discovery and to have a trial at which he can offer additional evidence.
Having examined the record, the Court, in the exercise of its discretion, denies the application for discovery and for a trial for the taking of additional testimony. However, the Court will consider the affidavit of Dr. Frelich for the additional information it contains concerning Plaintiff's condition.
The insurance policy at issue here provides:
Disability and disabled mean that because of injury or
sickness you cannot perform each of the material
duties of your regular occupation.
There is no question that Plaintiff has the physical ability to perform each of the material duties of his regular occupation. The issue is what degree of risk of future damage to one's health will render one totally disabled to perform his or her regular occupation. Plaintiff contends that he is disabled because there is some risk that, if he returns to work, the stress of his work may cause another serious heart attack. While not denying that Plaintiff may face some risk of future heart problems, if he returns to work, Defendant contends that the risk is so insubstantial that it does not preclude Plaintiff from returning to work.
In the Affidavit submitted by Plaintiff, Dr. Frelich states: "Mr. Napoli's Coronary Artery Disease is not curable, is a permanent condition and the avoidance of excessive stress from his occupation as a government bond broker could prevent a further heart attack." The affidavit also states: "the extreme stress of Mr. Napoli's occupation could progress his Coronary Artery Disease and could again exacerbate his heart condition, causing another heart attack."
For its part, Defendant notes that after Dr. Frelich was contacted by a physician employed by the Defendant in August, 1997, while the claim was under review, he signed as accurate a memo memorializing his conversation, which stated:
You believe that Mr. Napoli should not engage in any
activity that produces stress — be it work or
arguing with his wife. For that reason, you and he
decided that he should not return to work. Medically,
he could tolerate this, and if he wanted to return to
work, you would not suggest otherwise.
Defendant also relies on an opinion it obtained from Dr. Richard Nesto, a cardiologist who was an Associate Professor of Medicine at Harvard Medical School. Dr. Nesto's report noted, among other things, that Mr. Napoli had performed well on his stress test and concluded that "he is in an excellent prognostic category and in usual circumstances would be able to return to full employment . . . ." Dr. Nesto was of the opinion that it was unlikely that stress on the job contributed to the development of Plaintiff's atherosclerosis. Dr. Nesto stated that in his opinion:
Although the relative risk of a "triggered" cardiac
event is higher when exposed to stress, the absolute
risk of an acute cardiac event in [sic] a daily basis
is so small it is not quantifiable.
The question before the court comes down to whether a party should be considered totally disabled if there is even the slightest risk that the stress of his work might cause another heart attack. The principles to be applied in answering this question were set forth in Lasser v. Reliance Standard Life Ins. Co., 146 F. Supp.2d 619, 628 (D.N.J. 2001):
It is a basic tenet of insurance law that an insured
is disabled when the activity in question would
aggravate a serious condition affecting the insured's
health. See Stark v. Weinberqer, 497 F.2d 1092,
1098-99 (7th Cir. 1974); Oppenheim v. Finch, 495 F.2d 396,
398 (4th Cir. 1974); Stillwell v. Sullivan, 1992 WL
401971, *6 (D.Kan. Dec. 30, 1992). As noted in the
Applemans' treatise, "The insured is considered to be
. . . disabled where it is impossible for him to work
without hazarding his health or risking his life." 1C
Appleman, Insurance Law & Practice § 651 at
241 (1981) In fact, this proposition is sufficiently
well-settled that in many jurisdictions it travels
under the name of the "common care and prudence rule."
E.L. Kellett, Annotation, Continuation of Work as
Affecting Finding of Total or Permanent Disability
within Insurance Coverage, 24 A.L.R.3d 8, § 3(a)
(1969); see, e.g., McGowan v. Orleans Furniture Inc.,
586 So.2d 163, 166 (Miss. 1991); John Hancock Mut.
Life Ins. Co. v. Poss, 154 Ga. App. 272, 267 S.E.2d 891,
Insureds with heart conditions or who have experienced
heart attacks provide an obvious context for the
application of these principles. E.L. Kellett,
Annotation, Heart or Vascular Condition as
Constituting Total or Permanent Disability within
Insurance Coverage, 21 A.L.R.3d 1383, § 3 (1968).
Where medical prudence requires a cessation of work
activity, the insured is disabled . . .
However, the courts attempting to determine whether someone who has had a serious heart attack and by-pass surgery is totally disabled have reached different results. Compare Pompe v. Cont'l Casualty Co., 119 F. Supp.2d 1004 (W.D. Mo. 2000); Buffaloe v. Reliance Standard Life Ins. Co., No. 99 Civ. 710, 2000 WL 33951195 (E.D.N.C. 2000) with Rosenthal v. First Unum Life Ins. Co., No. 00 Civ. 3204, 2002 WL 975627 (S.D.N.Y. 2002); Mihok v. Magnetek, Inc., No. 10 CV 2446, 2002 WL 1162843 (C.D. Cal. 2002). These apparently inconsistent results may be attributable to the different factual situations rather than a disagreement as to the governing legal principles.
Obviously, every case must be judged on its particular facts. While this is a close case, it is reasonable to conclude that the Plaintiff's heart condition did not render him permanently disabled to act as a bond broker.
There is no substantial difference of opinion between Dr. Frelich and Dr. Nesto. Both of them agree that returning to work would pose some risk for Plaintiff. While Dr. Nesto says the risk is "so small it is not quantifiable," Dr. Frelich does not quantify the risk but says only that Plaintiff's return to work "could" trigger a heart attack.
It does not appear that most people today who have suffered heart problems similar to Plaintiff would consider themselves disabled. The Court can take judicial notice of the fact that although the Vice-President of the United States has had serious heart problems, he has not considered the risk of his high stress job as rendering him disabled. Similarly, all of us know people active in high stress professions, including judges, who have had coronary by-pass surgery similar to Plaintiff's.
Since many with conditions as serious as Plaintiff's continue in high stress occupations, how is the Court to draw the line between those who are permanently disabled and those who are not? Perhaps a practical way to answer the question is to ask: Is it likely that the person would have returned to work, even if he did not have disability insurance or other substantial assets? Here, the evidence in the record supports the conclusion that Plaintiff would have returned to his normal occupation if he needed that income to support himself and his family. As noted above, Dr. Frelich told one of the Defendant's doctors that he would not have opposed Plaintiff returning to work if that is what he wanted to do. In addition, Dr. Nesto's opinion that there was such a slight risk of future problems that it was unquantifiable, supports the conclusion that one who depended on the income from his work would not be deterred from going back to work by the risk that Plaintiff faced. Thus, on this record the Court concludes that the Defendant properly determined that Plaintiff was not permanently disabled.
For the foregoing reasons, the Defendant's Motion for Summary Judgment is granted and the Complaint is dismissed.
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