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Mastroianni v. UNUM Provident Corp.

October 16, 2003

THERESA G. MASTROIANNI, PLAINTIFF,
v.
UNUM PROVIDENT CORPORATION SUCCESSOR TO THE PAUL REVERE LIFE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Rodriguez, District Judge

OPINION

This matter is before the Court on Plaintiff's motion for summary judgment and Defendant's cross-motion for summary judgment. For the reasons set forth below, Plaintiff's motion will be granted.

BACKGROUND

The following facts are undisputed by the parties. Plaintiff Theresa G. Mastroianni ("Mastroianni") began her career as a self-employed certified shorthand court reporter in 1976. In August 1997, Mastroianni began feeling pain, numbness, tingling, loss of dexterity and weakness in her elbows down to her fingers. By June 1998, she was diagnosed with cubital tunnel syndrome ("CTS"), which was caused by the overuse and hyperflexion of her elbows on a repetitive basis. Prior to August 1997, Mastroianni had no medical problems and enjoyed good health, and it is clear that her occupation as a court reporter caused her CTS.

In April 1998, Mastroianni ceased working as a court reporter and applied for total disability benefits under a disability insurance policy ("Policy") Mastroianni purchased in July 1986 from Defendant The Paul Revere Life Insurance Company ("Paul Revere"). Paul Revere began paying benefits to Mastroianni under the "sickness" portion of the Policy, which would provide benefits until Mastroianni reached the age of sixty-five. Mastroianni believed that she should receive benefits under the Policy's "injury" provision, which would provide lifetime benefits. Mastroianni filed a Complaint in the Superior Court of New Jersey, Law Division, requesting a declaration that her disability is due to injury under the terms of the Policy. Paul Revere removed the action to this Court.

Each party seeks summary judgment in its favor. Mastroianni and Paul Revere agree that the only issue presented is whether Mastroianni should receive benefits under the Policy's "injury" or "sickness" provision.

DISCUSSION

A. Summary Judgment Standard

"Summary judgment is proper if there is no genuine issue of material fact and if, viewing the facts in the light most favorable to the non-moving party, the moving party is entitled to judgment as a matter of law." Pearson v. Component Tech. Corp., 247 F.3d 471, 482 n.1 (3d Cir. 2001) (citing Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986)); accord Fed. R. Civ. P. 56 (c). Thus, a court will enter summary judgment only when "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(c).

B. The Policy

Mastroianni's Policy with Paul Revere states in relevant part: "Total Disability" means that because of injury or sickness . . . You are unable to perform the important duties of Your regular occupation; and . . . You are not engaged in any other gainful occupation; and . . . You are under the regular and personal care of a Physician.

"Injury" means accidental bodily injury sustained after the Date of Issue and while Your Policy is in force.

"Sickness" means sickness or disease other than a Pre-existing Condition which causes loss commencing while Your Policy is in force.

C. Insurance Contract Interpretation Under New Jersey Law

Both Mastroianni and Paul Revere agree that there is no issue of material fact, and that one of the parties will be entitled to judgment as a matter of law. The matter of law to be determined is the interpretation of the Policy's "total disability" benefit, which would then indicate whether the "injury" or "sickness" provision applies to Mastroianni's cubital tunnel syndrome.

Both parties also agree that New Jersey law governs the interpretation of the Policy. It is the duty of a federal court sitting in diversity to "predict the course that the New Jersey Supreme Court would take if presented with the [same] legal issue." Lang v. New York Life Ins. Co., 721 F.2d 118, 119 (3d Cir. 1983).

In New Jersey, insurance contracts are given special scrutiny because of the "stark imbalance between insurance companies and insureds in their respective understanding of the terms and conditions of insurance policies." Zacarias v. Allstate Ins. Co., 775 A.2d 1262, 1264 (N.J. 2001) (citation omitted). In the absence of ambiguity, insurance policies should be given their plain, ordinary meaning, and courts should not write a better policy for the insured than the one purchased. Id. (citations omitted). Insurance contracts are subject to special rules of interpretation, however, because they are contracts of adhesion. Id. (citations omitted). When there is ambiguity the insurance policy should be interpreted to "comport with the reasonable expectations of the insured, even if a close reading of the written text reveals a contrary meaning." Id. (citations omitted).

In interpreting Mastroianni's insurance contract with Paul Revere, two key phrases in the Policy must be defined in order to determine the duration of benefits owed to Mastroianni: "accidental bodily injury" and "sickness or disease." The distinction between the two terms is significant, because if Mastroianni's disability is not classified as an "accidental bodily injury," it could be deemed a "sickness or disease," which would directly affect the amount of benefits paid.

New Jersey courts have struggled to define these two terms, particularly concerning what constitutes an accidental injury. See, e.g., Linden Motor Freight Co, Inc. v. Travelers Ins. Co., 193 A.2d 217 (N.J. 1963). "The broad words `accident' and `accidental'-in their common and popular sense of something unforeseen, unexpected, unusual . . . -necessarily encompass many varied types of happenings and what they should or should not include in an insurance policy largely depends on the viewpoint of the person whose judgment is to govern." Id. at 223. The New Jersey courts have interpreted insurance policies that cover accidental bodily injuries as providing coverage for either "accidental means" injuries or "accidental results" injuries, depending on the context of the term in the policy and the nature of the injury itself. See id. at 219, 232; Gottfried v. Prudential Ins. Co., 414 A.2d 551, 551 (N.J. Super. Ct. App. Div. 1979) (Kole, J., dissenting), rev'd, 414 A.2d 544 (N.J. 1980) (reversing the appellate court substantially for the reasons expressed in the dissenting opinion).

Specifically, the term "accidental bodily injury" was defined in Gottfried. There, a forty-four year old man died of acute myocardial infarction after eating a light dinner, playing a vigorous forty-five minute basketball game, and walking up an incline. Gottfried, 414 A.2d at 552. The decedent had no prior history of heart problems and enjoyed generally good health. Id. A doctor testified that all men at about the age of twenty develop a condition called coronary arteriosclerosis, but the condition does not become a disease until certain symptoms develop. Id. In this case, the dinner, basketball game, and walk uphill caused the condition to develop into a disease, resulting in the decedent's heart attack, which would not have occurred but for the decedent's voluntary strenuous activity. Id. at 553.

The decedent's wife applied for accidental death benefits from her husband's life insurance policies, which extended coverage for "accidental bodily injury." Id. at 552, 553. The insurance company denied coverage, stating that coverage was intended for death resulting from some unforeseen and unexpected "accident," not an accidental death resulting from voluntary exertion. Id. at 552. The trial and appellate courts agreed with the insurance company, and found that policies providing for "accidental bodily injury" insured against injuries caused by "accidental means or causes," ...


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