The opinion of the court was delivered by: Newcomer, S.J.
This is an action to collect benefits under an insurance plan pursuant
to the Employee Retirement Income Security Act ("ERISA") section
502(a)(1)(b), 29 U.S.C. § 1132(a)(1)(B).*fn1 The parties' cross
motions for summary judgment, and their responses thereto, are now before
Plaintiff, Charles I. Cohen, is a 55 year old labor law partner at the
Washington, D.C. office of Morgan, Lewis & Bockius LLP ("Morgan Lewis"),
a law firm with its administrative offices in Philadelphia,
Pennsylvania. The defendant, Standard Insurance Company ("Standard"), is
an insurance company with its principal place of business in Portland,
In 1992, defendant sold Morgan Lewis a Group Long-Term Disability
Insurance Policy (the "Plan") which had an effective date of April 1,
1992. The Plan provides partial disability coverage to a participant who
is "working in [his] own occupation but, as a result of Sickness, Injury
or Pregnancy, [is] unable to earn more than the Own Occupation Income
Level." The Plan further provides that "Sickness means your sickness,
illness or disease" and that "Injury means an injury to your body."
Additionally, an attorney's "Own Occupation" means his "speciality in the
practice of law."
Despite participating in various trials of medication intended to
improve his condition, plaintiff again began to suffer chest pain at
work. These pains would last from ten minutes to nine hours, and in May,
1998, plaintiff underwent a second cardiac catheterization. This
procedure revealed that plaintiff's left anterior descending artery was
50% blocked, and his right coronary artery remained 100% blocked.
Plaintiff's treating cardiologist, Dr. David Pearle, concluded that
plaintiff was experiencing angina due to myochardial ischemia.
Additionally, Dr. Pearl recommended that plaintiff reduce his work hours
because he determined that plaintiff's condition was aggravated by work
stress. In light of Dr. Pearle's recommendation, plaintiff reduced his
workload and began a part time schedule in August 1998 which resulted in
a reduction in plaintiff's compensation.
Then, on August 18, 1998, plaintiff submitted a Long Term Disability
Claim to defendant stating that he suffered from coronary artery
disease, and that he experiences chest pain when under stress at work. In
a November 17, 1998 letter, defendant denied plaintiff's claim concluding
that plaintiff was not partially disabled. Defendant's conclusion was
based upon the opinions of two consulting physicians, Dr. Bradley Fancher
who is board certified in internal medicine, and Dr. Henry DeMots who is
a board certified cardiologist and professor of cardiology at Oregon
Health Sciences University. More specifically, Dr. DeMots concluded that
plaintiff can perform both sedentary work and work which requires
significant physical activity. In addition, Dr. DeMots concluded that
work stress would not place the plaintiff at risk of a heart attack or
death. Dr. Fancher's opinion concurred with Dr. DeMots' opinion. These
doctors formed their opinions after reviewing the medical records
assembled in connection with plaintiff's claim, but neither examined
plaintiff or consulted with plaintiff's treating physicians before
providing their opinions. Plaintiff's claim was further denied because
defendant found that plaintiff had not actually altered his work hours,
his travel schedule or his compensation as plaintiff had claimed.
On January 11, 1999, plaintiff appealed this denial to defendant, and
again provided records showing his reduced hours and compensation.
Plaintiff also submitted letters from his treating physicians including
Dr. Pearle. Among other things, Dr. Pearle's letter recommended that
plaintiff retire, or make "major job changes" "based upon the occurrence
of angina and myocardial ischemia on a recurrent basis." In addition,
Francis M. Malone, the managing partner of Morgan Lewis, and Charles P.
O'Connor, then Chairman of the Labor and Employment section of Morgan
Lewis, both wrote to defendant on plaintiff's behalf in support of his
appeal. Mr. O'Connor's letter stated that Mr. O'Connor had personally
suffer a cardiac event in the middle of a business meeting.
Defendant submitted plaintiff's appeal to Dr. DeMots for his
evaluation, and on February 22, 1999, defendant reaffirmed its denial of
plaintiff's claim. Defendant denied plaintiff's claim primarily because
Dr. DeMots concluded that the risk of a heart attack does not increase
when one works. Dr. DeMots acknowledged that some medical literature
supports the view of plaintiff's physician, Dr. Pearle, that work related
stress is a risk for patients with artherosclersosis, but noted that
neither the American College of Cardiology ("ACC") nor the American Heart
Association ("AHA") support this view. Further, Dr. DeMots stated that
"the impact of work is negligible and is just as likely to be positive
rather than negative."
After defendant denied plaintiff's appeal, defendant forwarded
plaintiff's file to defendant's Quality Assurance Unit for additional
review. At that time, plaintiff submitted a letter from Dr. Pearle that
addressed the opinions of Dr. DeMotts. Defendant again denied plaintiff's
claim in a letter dated August 10, 1999. Once again, defendant concluded
that plaintiff's medical condition did not prevent him from working full
time, and contended that plaintiff had not actually altered his work
hours, his travel schedule and his income.
The determination of the Quality Assurance Unit exhausted the
administrative review of plaintiff's claim. However, on December 10, 1999
plaintiff requested reconsideration of his claim, and submitted evidence
that plaintiff had altered his work hours, his travel schedule, his
practice and his income. Then, on January 10, 2000, plaintiff supplemented
his request with a letter that advised defendant that he had recently
applied for life insurance with defendant. That letter further explained
that defendant denied plaintiff life insurance on January 4, 2000 because
plaintiff was "an unacceptable mortality risk."
On January 28, 2000, defendant denied plaintiff's request for
reconsideration in a letter. In that letter, defendant abandoned its
claim that plaintiff had reduced his hours, and his compensation, but
continued to maintain that plaintiff's heart condition would not be
adversely affected by work related stress. Additionally, that letter
attempted to address plaintiff's argument that ...