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Jonathan E. Rivkin, M.D., An Individual v. the Union Central Life Insurance Company; Sharp Rees-Stealy Medical

March 2, 2011

JONATHAN E. RIVKIN, M.D., AN INDIVIDUAL, PLAINTIFF,
v.
THE UNION CENTRAL LIFE INSURANCE COMPANY; SHARP REES-STEALY MEDICAL GROUP INC. LONG TERM DISABILITY INSURANCE PLAN, DEFENDANTS.



The opinion of the court was delivered by: Hayes, Judge:

ORDER

The matters before the Court are the Motion for Summary Judgment filed by Defendants The Union Central Life Insurance Company ("Union Central") and Sharp ReesStealy Medical Group Inc. Long Term Disability Insurance Plan ("Plan") (ECF No. 26) and the Cross-Motion for Summary Judgment filed by Plaintiff Jonathan Rivkin, M.D. (ECF No. 29).

I. Background

It is undisputed that Plaintiff is disabled from his occupation as a physician since March 2003 and is insured under a group disability plan issued by Union Central to a multiple employer trust. Effective February 1, 2002, the Sharp Rees-Stealy Medical Group ("SRSMG"), Plaintiff's employer at the time, obtained a certificate of coverage under the multiple employer trust. It is undisputed that Plaintiff's predisability "Average Monthly Earnings" ("AME") were $18,114.26 and the gross benefit amount under the Plan was $7,245.71 (i.e., 40% of his AME). See ECF No. 26-1 at 10 (Defendants); ECF No. 29-1 at 6 (Plaintiff). It is undisputed that Plaintiff has a "Residual Disability," as that term is defined in the Plan. It is undisputed that Plaintiff has worked in another occupation since the onset of his disability, but Plaintiff at times has earned less than 20% of his AME, thereby entitling Plaintiff to a "Total Disability Benefit" under the Plan. The parties dispute whether the Total Disability Benefit may be offset by any portion of Plaintiff's "Current Monthly Earnings" ("CME").

A. Plan

The SRSMG "Coverage Schedule" reflects that SRSMG chose the following Plan options:

Total Disability: Option IV. ...

Integration Method: ... Option I Direct Method ... see 'How is Your Total Benefit Calculated'. ...

Residual or Partial Disability Benefit: Option VI -- Residual Disability. Return to Work Benefit: 12 months -- Option II. (Admin. R. at 1355-56, ECF No. 30-8).

The Plan contains the following relevant provisions: Option IV Total Disability or Totally Disabled means during the Elimination Period and until You reach the end of Your Maximum Benefit Duration, You are unable to perform the material and substantial duties of Your Own Occupation due to an Injury or Sickness. Your Maximum Benefit Duration is shown on the Coverage Schedule. ...

Option VI Residual Disability means as a result of Injury or Sickness which caused Disability, You are unable to perform the material and substantial duties of Your Own Occupation on a full-time basis, and You are:

1. performing at least one of the material duties of Your Own Occupation or another occupation on a full-time or part-time basis; or

2. performing each of the material duties of Your Own Occupation or another occupation on a part-time basis.

If Option VI, Residual Disability Benefits Apply, What Are The Qualifications To Receive A Total Disability Benefit? You will be paid a Total Disability benefit if you:

1. become Totally Disabled while insured under this Plan,

2. are Disabled throughout the Elimination Period and remain Disabled beyond the Elimination Period;

3. are under the care of a Physician who is providing treatment for the Injury or Sickness causing the Disability;

4. submit proof of Disability satisfactory to Us; and

5. are employed, Your Current Monthly Earnings are less than or equal to 20% of your Average Monthly Earnings.

...

What Are The Requirements To Qualify For A Residual Disability Benefit? If You are Residually Disabled and have Current Monthly Earnings in excess of 20% of Your Average Monthly Earnings, You will be paid a Residual Disability Benefit if You meet the following qualifications:

1. You satisfy the Elimination Period with the required number of days of Total Disability and/or Residual Disability and become entitled to receive LTD benefits under this Plan;

2. You submit satisfactory Proof of Disability to Us that You are Residually Disabled as defined in this Plan; and,

3. You are earning less than 80% of Your Average Monthly Earnings.

... 50% Offset of Earnings -- (Option II)

What Happens After 12 months of Return To Work Benefits Have Been paid? After 12 months of Partial or Residual Disability Return To Work Benefits have been paid, We will calculate Your Monthly Benefit using the 50% Offset of Earnings method. To determine Your benefit, calculate Your Total Disability Benefit as shown in the section titled 'How Is Your Total Disability Benefit Calculated', Option I.... From the Total Disability amount determined, subtract 50% of Your Current Monthly Earnings. The amount remaining is Your Monthly Benefit.

The sum of Your Monthly Benefit and Current Monthly Earnings may not exceed 100% of Your Average Monthly Earnings. If this sum exceeds Your Average Monthly Earnings, Your Monthly Benefit will be reduced by the amount in excess. ...

How Is Your Total Disability Benefit Calculated?

Your Total Disability benefit will be determined (see 'Integration Method' in the Coverage Schedule) as follows: Direct Method -- (Option I)

Take the lesser of:

1. Your Average Monthly Earnings multiplied by the Direct Benefit Percent shown in the Coverage Schedule [i.e., $7,245.80]; or

2. The Maximum Monthly Benefit shown in the ...


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