HomeMy WebLinkAbout95-00376
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...
DAVID C. ATKINS,
Plalndtr
v.
I IN THE COURT OF COMMON PLEAS
I CUMBERLAND COUNTY, PENNSYLVANIA
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I NO.1
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I eVIL ACI10N . LAW
PROVIDENT LIFE AND ACCIDENT
INSURANa COMPANY,
Defendant
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AND NOW comes Plaintiff DAVID C. ATKINS, by and throulh his attorney, Stev.n
J. Schiffman, Esquire, and the law nnn of Serratelll, Schiffman 61: Brown, PC, who fll.s thl.
Complaint and av.n as followS!
I. The Plaintiff Is DAVID C. ATKINS, an adult Individual with resldenc. at 4183
Cov. Court, Apt 106, Mechanlcsburr, Cumberland County, Pennsylvania, 17055.
2. Th. D.f.ndant Is PROVIDENT LIFE AND ACCIDENT INSUItANa
COMPANY, an Insurance corporation licensed to do business In PennSYlvania with a home
omce address at I Founuln Square, Chatunoola, Tennessee, 37402.1338.
J. On or about April 27, 1992, the PlaIntiff purchased a policy of Insuranc. from
Defendant Insurlnl hlms.1f from disability as denned In the pOlicy, a copy of which Is
attach.d hereto as Exhibit "A" (hereinafter referred to as the "Pollcy"). The effective date
of the policy was July I, 1992. The pOlicy was Issued June 29, 1992.
4. Plaintiff had previously paid the premiums which the D.f.ndant had requested as
paym.nt for lu pOlicy.
.
IS. Accordlnl to the terms of the polley, Plaintiff was to be Insured with an exclusion
for disability relatlnl to any Injury to or disease of a lumbar or sacro-lIIac spine, lu muscles,
IIlamenu, disc., or nerve roou.
6. Plaintiff, as the resL!lt of an automobile accident, became disabled on Auaust 24,
1992, at which time the policy was In full force and effect, and Defendant belan paymenu
to Plaintiff under the policy.
7. On November 8, 1993, Defendant Informed Plaintiff that, as of September IS,
1993, they would no lonpr continue to make paymenu to Plaintiff as his Injury was limited
to the problems set forth In the exclusion as set forth above.
8. Plaintiff has met all conditions precedent under the policy.
9. Plaintiff continues to be disabled from InJurfes InvoMnl his shoulden, rtaht scapula,
and muscles In the neck. Further, Plaintiff Is totally disabled as denned In the policy due to
psychlatrtc and psycholollcal overfays, Includlnl depression, pnerallzed dahtness and loss of
nexlblllty, all of which are covered by the policy and not wIthin any of the exclusions.
10. After repeated demand, Defendant has refused and continues to refuse to pay
the benenu as required under the policy from September IS, 1993, throuah the present.
II. The refusal and failure of the Defendant to pay benenu under lu policy to the
Plaintiff Is without basis and fact and Is In violation of the lanauap and coverap of the
pOlicy.
2
12. In furth.r violation of lu polley and the laws of the Commonw.alth of
P.nnsylvanla, the Def.ndant has unr.asonably and unfairly withheld polley beneflu due the
Plaintiff under the policy as set forth above.
13. Th. conduct of the Defendant Includes, but Is not limited, to the followlnll
Falllnl to live equal consideration to the claim as to not payln,
the claim,
Falllnl to obJectively and fairly evaluate the Plaintiff's claim, and
Compelll"1 the Institution of this lawsuit to obtain polley
b.neflu that should have been paid prompdy and without the
nec.sslty of IId,adon.
14, Plalntln~ ilt all dm. relevant hereto, fully complied wIth all terms and conditions
(a)
(b)
(c)
of the pOlicy and all conditions pr.cedent and subsequent to his r1,ln to recover under the
polley.
15. Nonetheless, the Defendant refused, without le,al Justlncatlon and cause, and
condnues to refuse to nelOdate In IOOd faith and/or to pay the Plaintiff beneflu due under
the pOlicy In connection with his dIsability.
16. Parall'aphs one (I) throullh fifteen (15) are hereby Incorporated by reference
as If fully rewritten herein.
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IlIhlblt A
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"OLICY
ICHII)ULI
In.ur.d - DAVID CATKINS
Iff.ctlv. D.t. - July 1, 1992
Inu. D.te - Jun. 29, 1992
Policy Numb.r - 0'-5$7-'07514'
Flr.t R.n.wel D.t. - July 1, 1995
R.n.w.l Term - Tw.lv. Month. '
Monthly Policy Premium payabl. from July 1, 1992 until the tlr.t UPDATE InQr.... D.t.
<... PIG' 5 <cont.)),
Non-SMoker G~Q'. Monthlv PoLicy Pr.MluM ...................................
SMok.r lurch....g. . . . , . , , . . . . . . , , . . . t . . , . , . , . , . , . . t I . , . . . . . . , t . . . . . . . . t . . . . . .
Poll cy Il.. ,.. . . . . . . . I . . . . . . . I . . . . . . I . , . . , t . . I I . . . . , . . . , . . I . . I . , . . . . . . . . , t . .
Hult'"l. PoLicy l.au. DI.count ..............,.....,....."..........".......
N.t Monthly Polley Pr.mlum
,........"...........,..".,...,................
t24.94
42.49
U.2!l
-t.n
UI.O!l
Oth.r Pr.mlum PlyinG M.thod. <N.t Pr.mlu..),
4565.29 Annullly
41'6.30 S.ml-Annullly
'''.97 Qu.rterly
Thl. poll~y I. I..u,d on . modlfl.d pr.mlum IrrlnG'm.nt und.r which you will PlY r.-
duc.d p,'.mlulIII until July 1, 1997. Your premium will then b, th.t .hown on P.G' S
<cont.) .
------------------------MOHTHLY IIHI1IT POR TOTAL DIIAIILITY------------------------
U,500.00
---------------------------------IlIHIHATIOH "IRIOD---------------------------------
90 d.y. ot Tot.l DI..blllty
111,ln.tlon P.rlod I. d.fln,d on PIG' 4, An Ellmlnltlon P.rlod .tlrtlnG Itt.r your
65th blrthdlY mu.t con.l.t .ntlr.ly ot dlY' ot Totll OI.lblllty. It the E11,'nltlon
P.~lod I. fulflll.d during I p.rlod of dls.blllty, the first .ub..qu.nt dl.lblllty
due to I dlff.r.nt or unr.llt.d CIU.. will not r.qulr. .n Ellmlnltlon P.~lod, provld.d
th. tlr.t .ub..qu.nt dl.lblllty occur. within the tw.lv. month p.rlod trot the .nd
ot the prior dl.ablllty, durinG which the Ellmlnltlon P.rlod w.. .Itl.tl.d.
-------------~------HAXXHUH IIHlPIT "IRIOD' FOR TOTAL DI.AIILITY--------------------
InJurl.. or "ckn,..l
Tolll OI.lblllty .tlrtlnG b.for. your 'l.t blrthdlY ... to your '5th blrthdlY
Totll DI.lblllty .tartlnG on or aft.r you~ 61.t blrthdlY
but b.forl your '2nd b'rthday ,................................... 41 Month.
Tot.l DI.ablllty .tlrtlnG on or Itt.r your 62nd blrthdlY
but before your 63rd birthday....................".............. 42 Month.
Totll Ol.ablllty .tlrtlnG on or Ift.r your '3rd blrthdlY
but before y~ur 64th b\rthday .............................,...... 36 Month.
Totll DI.ablllty .tlrtlnc on or Ift.r your 64th blrthdlY
but before your 65th blrt"'day .................................... SO lItonth.
Tot.l DI.lblllty stlrtlnG on o~ Ift.r your '5th blrthdlY
hut before your 75th birthday ...,........,.....'................. 24 Month.
337(65-65) PA
DAVID CATKINS 06-557-6075141
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Total Dlaablllty atartlng on or altar yo~r 75th birthday...........
(~olloy lonedull II oon'Inuld on nl.' ~III.)
12 1I0nth.
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337~U"'DATI
DAVID c AT~INS O'~337~'07S1~'
"'aga 3 (Cont.)
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'OLICY 8CHIDULI (contlnuld)
.......................................................................................... ----... ..UPDA TI-"'''' -,............................ -.......................- -- ---.... -... ___.....
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Thl bln1111. Ind pr.mlum nlm.d b.low will b. lulomlllcllly Incr....d wlthoul .vld.nc.
01 In.urlblllty, .. 10llow.,
UPDATE tI.w MonlhlY H.w Monthly H.I
Iner.... IIn.11 I 10r Pr'lIlu. 10r
Data TolIl DI.lblllly thl. Policy
7/01/93 U,610.00 133.09
7/01/94 U,730.00 U5.39
7/01/95 U,IU.OO U7.97
7/01/94 12,000.00 UO.17
7/01/97 12.140.00 170.17
Th. prlllllulI .hown 10r Ih. UPDATE Incr.... dltad July 1, 1997 Iho Includ.. In Id-
ju.tm.nl due 10 the modl111d pr.mlulI Irrlng.lII.nt und.r which your policy w.. I..u.d.
UPDA TE hn.11 I I ner.Dlu Ir. .1hct I ve on Ih. UPDATE Inere... Dllu .hown. If.n
UPDATE Increl.e Dlt. .hown doel nol coincide with. rln.w.l d.l. 10r Ihl. policy, the
Iner'I" will b. .11.cllve on the nlxl rln.wll d.tl,
,
An UPDATE Banl111 Incr,," will .pply only 10 . parlod of dl..blllly which .brh
11hr Ih. I1hctlv. d.l. 01 Ih. Iner..... It mu.t qUall1y .. . "Plr.ta p.rlod 01
dl..blllly. 11 the pr.llllulI 10r Ihl POlicy I. b.lng w.lv.d on the .11.ctlv. dlt. 01
the Incr...., the pr..lum 101' Ih. Incr'I" will 11.0 b. w.lved. Wh.n you r"u.I p.ylng
prllllum. 10r the polley, yOU muet .1.0 .t.rt ".ylng Ih. pr..lu. 101' the Incr.....
You .re .nlitl.d to UPDATE a.n.111 Incr'I'" on the d.t.. .hown .bov.. If YOU do nol
.ce.pl In Incr...., your r.1u..l.
1. 10r1.11. your rlghl on Ih.t UPDATE Incr.... DII. 10 Ih. UPDATE a.n.1It Iner....'
2. po.lpon.. Ih. .ch.dul. of b.n.fll Incre.... to Ih. n.xl UPDATE Iner.... D.I" 11
.nYI
5. .dju.l. the pr.mlu.. 10r the r'II.lnlng Incr....., 11 .ny, .Inc. .ueh pr..lu.. .r.
b...d on your .tt.ln.d Ig. .1 Ih. tllll. 01 .n U'DATE l.n.111 Incr....' .nd
4. In no w.y .xl.nd. Ihe 11.1 UPDATE Increl.. DII. .hown Ibove.
Elch r.fu.11 01 In UPDATE a.n.1It Increl., r.duc.. Ih. numblr 01 UPDATE l.n.1It In-
cr..... to which YOU w.r. .nllll.d by on.,
11 yoU h.v. not r..ehed your 60lh blrlhdlY on Ih. 1,.1 UPDATE Incr.~.. 0.1.. yOU "v
IPply for.n IlIIIndll.nl providing .ddltlon.l UPDATE IInl111 Incr...... You e.n do thh
by lI.klng forll.l .pplle.llon within the p.rlod 01 60 d.y. prior to Ind 51 d.ye .1t'r
the 1..1 UPDATE Incr.... D.I.. Approval will b. lubhct 10 OUl' undlrwrltlnll .uld.-
lln.. Ih.n In .11ecl.
('allcy Sch.dUl. II contlnu.d on n..t p.... )
55 7 -UPDA TE
DAVID CATKINS 06-557-6075148
,... 5(eont.)
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DII'IHlnOHI
InJurl.. m.ln. Iccldentll bodily Injurll' occurring whll. thl. policy I. In forc..
"olen... mun. .Ickn... or dl..... 'lOt dll.moud or trutld befqrl the Effectlvl Oat.
of thl. policy. Pre-I>ll.tlng condition. Irl, howlvlr, covlrld und.r thl. policy to
thl '>ltent .et forth In thl "Prl-eNI.tlng Condltlqn Limitation" prqvl.lon qn "lgI 5.
Phy.lalan uln. any plr.on othlr thin YOU who I. Ilcln..d by hw. Ind I. let Ing loll thin
thl .COPI of the Ilc.n.., to trelt lnjurlu or Slcknl" which ruulh In covlr.d 10...
Tobl Dt..blllty or tohlly dl"blld, beforl your 55th bl rthday or beforl blnefl II
havI blln Plld for tin year. for I period of dl.ablllty, whlchlv.r I. latlr, mlln.
that due to InJurl.. or Slckne..,
1. you Irl not Ible to perform the .ubet,ntlll Ind mlterlll d~tl.. of your qCCU-
PI t I on J Ind
2. YOU Ire receiving cere by I Phy.lclln which I. Ipproprllte for the condition
clu.lng the dl.lbllity. We will wllve thl. requirement whln r:ontlnued clre
would b. of no ben.flt to you.
Aft.r your 55th blrthdlY Qr Ift.r blnlflt. hlv, b.en "'lid for t.n y..r. for I p.rlod
qf dlublllty, whlchev.r I. llt.r, Tot81 DI.lblllty qr tot Illy dlubl.d mun. thlt
due to InJurl.. or Slckne..,
I. you Ire not eble to perform the .ub.tlntlll and mlterlll dutle. of Iny occupa-
tion for which YOU Irl re..onlbly .ulled blcau.. of Iducatlon, training Ot. 0-
perllnc., with due rlglrd to your vocltlon and urnlng. It the .tart of
d I ub III t y, and '
2. YOU ar. rlcelvlng Clrl by I Phyelclln which I. Ipproprllte fqr thl condItion
cllu.lng the dllllblllty. We will wllvl thl. requlre",ent when cqntlnued cllre
would bl of no blneflt to you.
your occUP'tlon ",eln. thl occu",atlqn (or occuPltlon., If "'ore then ani> In which YOU
Irl rlgullrly englgld It the time you become dl.ablld.
plrlod
force.
rlod,
of dl..blltty mun. a perlqd Qf dlublllty .tlrtlng while thl. pQllcy I. In
Succe..lve period. will be delmed tQ be the eeme period unle.. the liter pe-
1.
2.
I. due to I different qr unreleted ceu.e, or
.tlrt. 1II0re thin .IN 1II0nth. Iftlr the Ind of thl prlvlQu. plrlod!
In which IVlnt, thl laler Plrlod will bl II new or "Plrltl PlrlQd qf dlseblllty. A
nlw Ellmlnatlqn Plrlod IIIU.t thin bl mlt. And, a nlw HI>llmu", Benlflt P.rlqd will Ipply.
1Illllllnltlon PerIod mune thl numblr of dey. of dlublll ty thlt mu.t ela".. In I period
of dlublllty beforl blneftte blcoml peYlbll. Thl number Qf dlY' Ie ehown on "ege
S, Th..e daye n..d not be conllcutlveJ they cln be Iccumuhled during I Plrlod of
dl.lblllty to .Itl.fy en Elimination Plrlod. "nef't. Ire not plYlbl., nor dQ thlY
IccrUI, during In Ellmlnltlon Plrlod.
SS7-D-"-6-PA
DAVID CATKINS 06-557-607514.
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I.NI"ITI
TOTAL DIIAIILITY
W. will PlY the Monthly ..n.1It 10r Totll DI..blllty .hown on ~.g. S I' 10110w.'
1. "n.1Ih .tart on the dlY 01 TCItal DI..blllty 10110wlng the Ilhllnltlon hrlod.
2. "ne1lh will contlnll' while you are totally dl.lbled dllrlng the p.rlod 01
dl.ablllty but not b.yond the HINI.um lenl11t ~.rlod.
In nCl IVlnt will YOU bl conlldlrld to hlVI morl thin on. dl.ablllty at thl .... tl...
Thl1act thlt a ell.ablllty I. c.II..d by .or. th.n on. lnjllry or Slckn... or 1rom both
will not mattar. w. will pav b.n.1It. 10r the dl.ablllty which provld.. the gr.lt.r
b.n.11 t.
'..IUH'TIV. TOTAL DIIAIILITV - LOll 01' IP..CH, HIA.ING, lIGHT D. THI UI' 01' TWO LIHII
Vou will be pr..um.d totllly dl.abled 11 InJurl.. or Slckne.. re.ult. In the .ntlr.
and p.r.an.nt 10.. 01, '
1. 'Pllch J
2. h.arlng In both .ar.,
S. th..1 ght 01 both IY" J or
4. the u.. 01 both hand., or 01 both 1.et or 01 on. hand and one 100t.
VOIl III1.t pr...nt ..tl.1actory pro01 01 your Iou. Vour .blllty to work will I10t
mltt.r. Furth.r medlc.l clr. will not b. r.qulr.d. B.n.1It. will b. Plld ,ccordlng
to the Total Dl.lblllty provl.lon. 01 till. policy. lut, b.ne1ll1 will .tart on the
date 01 10.. 11 IIr I I er than the d.y b.n.11 h .tart II .hown on ~.\,. S. If Iou occur.
b.10r. your 65th blrthdlY, the Honthly len.1lt 10r Totll DI'lbl!lty will b. paid a.
long I' YOU llv. r.glrdl... 01 the HaNlmum I.n.ttt P.rlod .hown on Page S.
'.ANI'LANT IU.G..V
Vou 11I1 ght b. dl.lbl.d 1rolll the tr.n.p\ant 01 part 01 your body to another p.r.on.
11 10, w. will con.ld.r It to b. the r..1I1t 01 a Slckn....
COIHlTIC IU.GI.V
VOIl IIIlght be dl.abl.d 1rom .urg.ry to Improv. your app.ar.nc. or to corr.ct
dh,rtgurement. 11 '0, w. will con.ld.r It to b. the rllult 1)1. Slckn....
WAIVI. 01' P.I"IU"
A1tar YOIl have b..n totally dl.abllel 10r '0 d.y. during a periOd 01 dl.ablllty, w.
will,
1. r.1ltnd any prllllulII which b.ca.. dUll a'nd war. paid whlll you w.r. totally dh-
abled, .nd
2. walv. the paym.nt 01 .ach pr.lllluIII which th.r.a1t.r b.eoll.. due 10r a. lonl ,.
the Il.rlod 01 dl.ablllty h.ts. After It and., to kllP thl. polley In force,
YOIl mu.t aoaln illY any pr'lIllum. which b.eolll. du..
For pr'IIItum. to b. wllv.d, YOIl MU.t olv. u. .atl.1Ictory pro01 01 dl.lblllty.
U7-*-l
DAVID CATKINS 06-357-6073141
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1l1}f~.ILITAnON
Totll DI.lblllty - Your p.rtlclp.tlon In. progr... ot occup.tlonll rehlblllt.tlon 101111
not ot It.elt be con.ld,red . r.covery trom Totll DI.lblllty.
'~pen.e - It, during I period ot Totll DI.lblllty, YOU notlty u. In writing thlt You
wlnt to Plrtlclplte In . progr.m ot occup.tlon.l "eh.blllt.tlon, w. 101111 conelder
Plying tor the "...on.bl. e~pen.e. yoU Incur tor tr.lnlng .nd educ.tlon. Th. Ixtent
ot our roh 101111 be d,ter..l"ed by wrltte" .gr.....nt with YQU. Oe,"r.lly, we 101111 P,y
to" the r...on.bh co.t ot tr.lnlng Ind .duclt Ion which I. not othe"loIl.. cOII.red und.r
hulth clr. In.urlnc., worker.' compen..tlon or .ny public fund 0" progr.m.
A progrlm of occup.tlon.l rehlblllt.tlon MU.t b. d..lgn.d to h.lp YOU return to work
Ind ber
1. .. form. 1 ~rogrlm of reh.bllltltlon .t In .ccr,dlt.d gr.duat, .chool, coll.gl
or bu.ln.., Ichool, or It I Ilcen..d vocltlonll .choQI,
2. . recognized progrlm operlt.d by the federll or . .t.t. gOllernm.nt, or
5. .ny other prof..llon.lly pl.nn.d reh.blllt,tlon program Q1 trllnlng or 'duc.-
tlon.
IIHlFn, llHlH POLICY RIIHIIlID AI'TlR YOUR 65TH IUTHDAY OR FIVI YIARI, IoIHICHIVIR II
LATIIt
It thl, policy I. continued In Iccord.nce with the "Condltlon.l Right to Ren.w ~1t'r
Your 65th Ilrthd.y or Fill. Yur., Whlchelle" I. LIt.,," on Plgt 1, .11 ot the b'",'lt
prolll.lonl on ".g.. 6 Ind 7 101111 b. Includ.d In the conti"u.d policy. (If II Trut"',nt
01 Injurl.. I.n.tlt I"d/o" e "r.li..ln.ry T.rm '.netlt I. cont"ned In thll polley,
It e.n be Includ.d In th. contlnu.d polley. No oth.r "Addltlon'l I.n.tlt.", 11 'ny,
n....d on "'0' 5 101 III b. I nelud.d In th. cont I nu.d poll cy.) The H'x'lIIu" It".. 1 I t ".,.Iod
.t.,.tlng whll. thll policy I. '0 contlnu.d II .hown on "Ig. 5. The HonthlY 1.".'lt
tor Tot.l Dlublll ty 101111 not chang. unl.., YOU choo.. to r.n.w loll th . 1....1' 'lIIount.
'AYHlHT POR PART OIl HOHTH
It Iny p'YIII.nt und.r thl. pollcv I. tor p.rt ot . month, the d.lly r.te 101111 b.1/50th
01 th. p.v...nt which would h.lI. b..n ...de 11 dl.lblllty hId contlnu.d tor th. whole
",onth.
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557-U-PA
'DAVID CATKINS 06-55'-6071141
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PRI"IUKI AHD RIHlWALI
,OLXCV TIR"
Th. flr.t t.rM of thl. policy .tlrtl on tha Eff.ctlv. Dati .hown on ~IOI 5. It Ind.
on thl Flr.t Rlnlw.l D.tl al.n .hown. L.tlr tlrM' will b. the plrlod. for which you
p,y rlnlw.l prl.lu.. when dUI. All tlrMI will beoln .nd Ind .t 12.01 A.H., St.nd.rd
TI.., at your hO.I. Thl rlnlwll prlMlu. for I.ch tlr. will bl dUI on thl d.y thl
pr.cldlno tlrM Ind.. .ubjlct to thl orlCI plrlod.
GRACI PIRIOD
Thtl policy hll I 51 dlY oracl plrlod. Thl. .Ianl that If I rlnlw.l prlMluM I. not
paid on or before the dlte It I. due, It MlY be Plld during thl ne~t 51 dlY', Durlno
the orlce period, thl policy will .tlY In force.
CONDITIONAL RIGHT TO RIHIW A~TIR YOUR 65TH IIRTHDAV OR ~IYI VIARI, WHICHlYIR 11 LATIR'
PRI"IUHI ARI HOT GUARAHTIID
(Continued frOM Ploe I)
'You cln renew thl. policy.. long I' you Ir. Ictlvely Ind gainfully working full tIMI.
FrOM tl.e to tlml. WI cln rlqulre proof th.t you .rl .ctlvlly .nd gainfully working
full tl.l. If you .top working, (e~clpt by rl..on of Totll DI..blllty), thl. policY
will t.r.ln.te, I~cept th.t COVlrlge will contlnul to thl Ind of any plrlod for which
pr..luM h.. blln Icceptld.
Pr'MluMI .u.t be p.ld on time. They will be b..ed on our tlble of r.tl. by att.lnld
.oe In Ifflct It tl.e of renlw.ll for Plr.on. In your ...1 rltl cl... who .re In.urad
undlr pollcle. of thl. form. Othar th.n your .ttllned 101, the flctor. u.ed to da-
t.r.lnl your rltl cl... will bl the ...e I' tho'l that IPplled to you on the Effectlv.
Date of thll policy.
Th. blneflt provlllonl which will be Included In the continued policy Ire de.crlbld
on ~'Ol 7.
RIIHITATIHlHT
If . rln.w.l prlMlu. I. not Plld blfore the OrlCI plrlod Ind., the policy will l,p.I.
L.tlr acceptancI of the premium by u. or by our loent authorlzld to .coept p'YMlnt
without rlqulrlno In eppllc.tlon for reln.t.te.ent will reln.t.te thl. poliCY.
If WI or our loent require .n IPpllc.tlon, you will be olven a conditional rlcllpt
for thl pre.lu. tendered. If the appllc.tlon II approved. the policy will bt rlln-
.tatad .. of thl approval dlte. Lacklno .uch approvel, the policy will be reln.tlted
on thl ~~th day Ifter the dlt. of the condltlon.l recllpt unla.. we hlv, pr.vlou.lY
written you of our dl.approvel.
Th. reln.t.ted policy will coyer only 10" thlt rl.ult. fro. lnjurle. which occur
Iftlr the d.te of reln.t.temant or SIckne.. .. mlY b.oln More thin 10 dlY. .ftlr .ur.h
dlte. In III oth.r re,plctl, your rlohtl Ind our. will re.lln the ...., .ubjlct t~
.ny provl.lonl noted on or Ittlched to the reln.tlted policy.
557-PR-rA
DAVID CATKINS 06-557-6075141
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IUIPINIION OURINO MILITARV IIRVlel
11 you Intar 1ull-tl.1 Ictlv. duty In thl mllltlry (lind, 1.1 or Ilr) 'Irvlc. 01 Iny
n.tlon or Internltlonl1 luthorlty. YOU ..y IUIPlnd your policy. lut, yOU mly not
IU'Plnd thl policy during .etlvl duty 10r trllnlng l..tlng S monthl or lau. Thl
polley will not bl In torc. whlll It II IUlp.ndld, Ind VOU will not bl rlqulrld to
PIV prlmluml, Upon rlcllpt ot your wrlttln r.qullt to IUlplnd thl polley, w. will
retunll thl pro-rltl portion of Iny prl.lu. p.ld tor. plrlod blyond the dltl w. rlc.lvl
your rlqu..t.
It your tull-tl.. let Iv. duty In .'lltlry ..rvlcl Ind. b.tor. your 45th blrthdlY. you
mlV pllCI thl. pollcv blck In torc. without Ivldlnel at In.urlblllty, Your covlrlga
will Itlrt Igaln whanl
I. WI hlVI racllv.d your wrlttln rlqUllt to pllCI thl policy blek In forea, Ind
2. yoU hlva pa I d thl ,'lqU I rid pro-rlt a prIM I um for covlrlga unt II thl nallt prl",1 UIII
dUI dltl.
Howlvlr, your rlqullt Ind promlum PlY.lnt .Ult bl raellvld bV u. within 90 dlYI Ittar
thl dati your letlva duty In thl .,lltlry .Irvlel Indl. Prl.lu.. will bl .t tha .Iml
r.tl that th.y would havI blln h.d your pollcv rl..lnld In torcl. Thl polley will
not covlr Iny 10.. dua to Injurll' which occur or Slcknl" dllgno.ld or trlatld whlla
thl pollcv II IUIPlndld, In III othlr rllPlct. yOU Ind WI will hava thl la"'l right.
undlr thl policy I' b.torl It wa. IUlplndld.
PRIMIUH AOJUITMENT AT DEATH
Any prlmlum paid tor a Plrlod blvond thl date at your dllth will bl rltundld to YOur
..htl.
CLAIMS
NOTICE 0.. CLAIM
Wrlttln notlcl at clll. .u.t be glvan within 20 dlv' Ittlr I cove rid 10.. .tlrt. or
a. .oon .. r'..onablv po..lbll, Tha notice c.n be given to u. at our ho",e ottlce.
Chathnoogl, Tann...... or to our agant. Notice Ihould Include your nallle Ind the
po 11 cy nu",ber,
,CLAIM ,"ORMI
When wa rlcalvl your notice of clal., WI will .end you elal. forlll. tor filing proof
of 10.1. It the.e form. Irl not given to you within 15 dlY', yOU will mlet the proof
of lOll rlqul ruente by gl y I ng II' a wr I t ten .tatalllent of the nlture Ind 11Itant at your
10... You mu.t give u. thl. proot within thl tl.e .It forth In the Proof at La..
leet Ion.
PROlll" llI' LOIS
11 thl polley provide. tor periodic PlVlllent for I continuing 10", you .u.t glvI u.
wrlthn proot of lOll within 90 dlY' Itter the Ind at lIeh plrlod tor which WI .re
lhbll, For Iny other lou. wrlttln proot ",u.t bl glvln within 90 dlY' .tter lueh
10...
If It wa. not rll.onlbly po..,bll tor you to give written proot In thl tl.e requlrld,
we will not reducI or dlny the cl.l. 10r thl. re..on It the proof II tiled .. loon
a. rlllonlblv pO.llble. In any IVlnt, tha proof requlrld IIIUlt be turnllhad no Iltlr
than onl Ylar attlr thl 90 day. unll" you arl llgally unlbll to do 10.
S57-C-PA
DAVID CATKINS 04-337-4073148
Pa"'l 9
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TI~ OF PAY"'NT QP CLAI"I
After we recllv. written proot ot 10", WI will PlY ~onthly III benlflt. th.n due YOy
10r dl'ublllty. hne11h 10r Iny Qthlr 10.. covere<j by thl. policy will be Plld u
.oon I' we recllve proper written pro01.
PAYMlNT ~ CLAI"'
Ilnl1lt. will bl peld to you. Any benl1lt. unplld It dlath will be paid to your 1'-
tate.
11 blnl1lt. arl paYlbll to your I.tate, WI cln pay bene1lt. up to .1000 to 'o~lonl
rellted to you by blood or ~Irrllge WhOM we con.lder to be entitled to thl blne1It..
WI will be dl.chlrged to the Ixtent 01 Iny .uch plyment ~Ide In good 111th.
PHYIICAL IXA"INATIONI
We, It our e)(Pln.l. hlVI the right to hive you IXlmlned u 01len u I. ru.on.ble while
I clllm I. Plndlng.
"IS'TATI"INT OF AOI
If your Ige h.. blln mlntltld, thl benl1lt, will be tho'l thl prlmlum plld would havI
bought It thl corrlct IgI.
LlOAL ACTlQHS
You ~IY not .tlrt I llgll Ictlon to rlcover on thl. policy within 60 dlYI Iftlr yoU
glvI u. rlqulrld proot 01 10... You ~IY not .tlrt .uch Ictlon Ifter threl Ylar. froM
thl tlml proof of 10.. II rlqulrld.
GINeRAL PROVISIONS
INTIRI CONTRACT
Thl. policy with thl IPpllcltlon Ind IttlChld PIPlrl I. thl Intlrl contrlct bltweln
you end u.. No chlngl In thl. policy will bl efflctlvl until Ipproved by onl of our
officer.. Thl. IPprovll MUlt bl noted on or Ittlchld to thl. policy. No Iglnt ~IY
chlngl thl. policy or wllvl .ny of It. provl.lon..
TIHI LI"IT ON CIRTAIN DlPINS.S
1, A,tlr t~o Yllr. troM thl E'flctlvl Dltl of thl. policy, no MI.ltltlmlnt., I)(cept
1r.udullnt Illll1tahMlntl, MIdi by you In thl IPpllcltlon for thl. policy will
be u'ld to yold the policy or to dlny I clllm for 101. Incurred or dl.lblllty
thlt .tlrt. Iftlr thl Ind of .uch two Yllr Plrlod.
2. No ClllM 'or lOll Incurrld or dlublllty thlt ltartl Iftlr two ynr. 'rOM the
e,tectlvl Dlte 0' thl. policy will be r.ducld or dlnlld on the ground thlt I
.I~knl" or phy.lcll condition not I)(cludld by nlme or IPlcl11c dl.crlptlon had
Ixl.tld blforl thl Efflctlvl Dltl of thl. policy,
CQNPOR"ITY WITH STATI STATUTIS
Any provision 0' thl. policy which, on Its IftlCtlvl datI, I. In conflict with thl
11101. of thl Itetl In which yoU rl.ldl on thlt dlte I. chlngld to conform to thl miniMum
reqUlrlMlnt. 0' tho.e 11101..
AUIGHI'1IINT
No 1..lgn~lnt ot Int.rut In thll policy will be binding on u. until I copy I. on file
with UI. II mu.t hi approvad hy onl of our officers. WI Irl nol re.ponslble for the
vIlldlty ot Oily IIllgnlllln\.
!3 7 -Qr
DAVID CATkINS 06-337-6073118
PI9I 10
, " 'If ITATlMINT 0' ~LICIT!NO M'NT, ' " '. ~""
flow w.1I an~ how long have YOI, known Ih. P,opo,od In'"'od?,'L1.,.JlM,."uk...:..."~ t.LI.~.,___,
SOllelllng ~onl ,RiAltAJl.iL!A,.~L&..:;sa.,_..____.___
Topay., 1,0, Numb"L'\li:. 'W:..l.3..'l.l.I.,_
'''0'0''0 IN.U".D'. ADD"..... AHD IOCIAL IICU"ITY NO,
I.' RI"~.nel A~~,...? .!..ST11'J/l..L,~J:l.T..cAlIll'__I!.11,-~A___ .. . __.,._..I_'.Q.lL
'I 1',,"" j ^o l\1S1r..I.WlCI.NQ......'.d....*/ {\A 1").,61""0\\1'" ,1)1'1', IIP(:<Jde
"'''11'''''' ""'1\"\', \." 101A. ''', l..:nmr 11l.1.Jf l'
Ibl BUlin... Add''''? -UL1<atlAL;U,~~,~..JIalrilA__.._.__UQ1L
Ic' So.:loI Secunly No, ~a.U_. .
Sind NOlle..:
o R.lldoncl
IllI BUlln.11
(":"1: oJ.. '- ~ '" J ,j ') C 'i i'/
\1"J "~~\ ~ CI5-(((') jl'!J' -1IUl..."
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~1'~~illPpl1.~OV1~ftE!.!-lle and_A-=~.!nLI~.~!.~c. CO'J"lpan~ 10( In5lJranc~.E~~~.!'n fhlt lolloYM r
./ Jnn~~"-oAIJI'\:) Co. I\TI<i .~S I I
-. iCrRliglilH l#"'01d).W.Tgn"16.~TirDifi-,. . :;-. ""00 IrtIi.~
~cuP4110n Yilllll........... IIl.,~I/"L ,.~~~ ~
lei Employ" Sl'LO.r/lllAl.ltl.tulr....~ JJ"'"~ '~, E.ect d"".. ,~,
(d~ Ar'VOUlctIV"yqIWO,klullllm,lnln,.bo'i.occupaUon1 V..B No 0 II) L.n
I. u.,amed . r1)m OU, up . urren nu allt u nor nn, 0
1Il'a1 TIIJt F'urpoSIS 1M., SuSln.." UP"'". If .,y), of e.rntd Income Cal,nda, V'4r LISI Callnds, '1'1'
SIII'V . $ S_, .----. --'ffi>
Olh., 10.ocllb.1 "',.,. ""'rrr s~,IJXJ:r..,_.. __.. ~~ "''''' Ml S '~I~' I~
lbl Un..,nlCJ Income FJrlO, 2 '1"'1 IInl.,,,I, Otlfldencj", IIC,I, S~:... 1_
4, II) 00 you haVdor .111 yOu IpplYl"!) lor olher (I) IndIVidual (21 ASIIXIlUlon 131 afOUp, or 1.1 Employer 5,,:h PaydlubllllV
Ineom. cov.rBQCI or (~) Ov'r""OO e.llp,nu dl'.bdlly cOII,rlQ'" V", U NO~ (II YIII IV' det'lllS b.low)
~ om.n 1 ~Pt or ! onth 1l1ii1>i11iY _, I on nl P " d
, j:;. ~ \4J4l-O-J...u.. P- MM...
________ /ALi...__ __
rbl 00 YOU hav, Soelill SlfCurlly ~lJb,lllul. cov,rOQIt') V,. r1 NoJl.f Amounl '___Company
(0) II Iny CO,",lgl 10 ~. 'OIlI.cod by Ihl coverlg. IPPII.d 1011 VI' \oJ. No III If "VI''', completl ~o,m 1336,0.
(~I 00.. you, nIt worth "C_ SO,OOQ,OQQ? VII 0 No IJ II "Y.,' comp"tl Form 1336.NW,
II) Hlv. YOtl 'mokld clg...nll wllhln Ih.'10I12 month,1 VIIS No C
5, H.~. you ltIIlf' bttn medically dlagnolld III hdvlng 0' been lreal.d for' VII No
III High blOOd Pl...ur, dllll:J"", cancer Irthnfls, n'hm. ,mphysema rJf ,mollonal nervoua 0' menial r::-
dllordlr or dll.,.... or dlsordlr~ 'YII IIrs or sp.tch') , , " " ' ., . 1_0 ~'
Ib) OI.....lJr dIsorder,,' Ih. nf("~apln._ Mltllrt, lung I, brelal' or In" r;lrClJlalory dlg.llIv" uflnar;. .
or"prodIJCIIV"YIIfn\sl., .", , .... ..". ,. "..
$, Hlv. you tv" been dllgnolltd by II mlmb" at the mldlcal prOf.lllllon as haVing AcqUl,1d Imn'lun'
O.ncl...cy Synd,oml IAIOS) 0' Aldl Rllllld Com pi.. IARCJ?
7, Hlv' you ,VIr Uled barbllU'III.I, ntrcottclI, ')Iettlnts f)r hBlhlclnoo,n., or .vlr lought h.lp or lrllltm."l
,,,, Ihlll UII 0' alcohol UII?, 0 Il'I
8, Other Ihln abOv., hev. you, within th. palt 5 Yldfl, had medical or surgIcal adVlc. or Ir..tmanl, hId e
phYlicllI '11.""'''"11101'1. or blln und.r Obl,rv.llon lor Qny dill'" or dIsorder?, II 0
9, Hlv' you ""If mid. application tor OllabUlty, H.llth or ut. Inluranc. which 1'1.1 brtftf'l deellnltd, modlfled
or rlrld? (II "VII", glv, 1'111",11 or orgonlllllon, kInds ot In,uranc., d,.11I and "a.ons,l, . " ."., I 0 J!
10, 00 you h.v.. phYllcillmpalrm.", 0' deformity, 0' Ilk. any lyp. of p"lcnbtd m'dlc'llon1, I iJ .Ill'
(Glvl d.tllll of "V,," arW~lr, IQ 0&.10, Inctud. dl'gno..., dll'l, Ph)"lcl.n. and .ddr....')
s......,\'.t\Lc~ J;i'S4.~.~lAlLl\ ~.....allrU"""~ ~U"I-__~~. ~..t~ fI.....14.<I InnIC,:i_'clll'"
. , ~iUitiNii, ,,\~~~"f;i(M-'''CII'
1IollCll,Iii.\I.Il""''', ~""",lDr&A~E.Jl~Jd'..JItJ'~"'.I""'''''' ~~-._1"1-1"""".s.uIl.___n
1,.1.1'\1 LrMl '~..m,.G/o;'"'i- .(jt/t~~WAI. 'lMi~r._I,.iL~Q.'fUlU&JU,,&..AoIiu.WI~.Jll.L7rlJ:L.ll~,m,
":'J1Jt~,.AltwlLllJ)Al1,~._~_I:lIl~*"'. ~y c;..'"'r.HJ;Jf1..-tJMJlUliJl,.iJu,,,,,
11,lal WI" 'fOur employ" poly lor ail dlllilbrllly C()\Ilfaql 10 be camed by you ""111'1 rlr'} PO"tQn ollhl "r,,.,'ltljm 10 b, ,n(IUd., In your
laubI, .ncom.) 'liltS' : No l(llbl How much prtmlum 'II liald With thl' llIJphellllon') ._--M.t,.,.
TO Ihl bllt()fmy hnQWltdQIt and bltll" all 01 Ihe 'OrI9011\9 sliJI,mtf1ll1and .1101'"011''' Plrt II. " any, arlhl! Appllcetlon 6811
tru, compl'" .and co"ecl1y IIBhtd fh.y "" Ott,rlld 10 PrQVldltnr LII, an" ACCtdenll/1SUranc. Company tlI Ihl bill. tor lIMV
,nlUrl"tlt IUUItJ on thIS AppllcatJlm I h,ave rltClttvltd a dllt;tollJr' COr'lctrnlnq 111 Ih, MffJlctllnlorm.hon Bur..u. and 121 an
,n..,"lIg.lIv, conltum" "port whIch may bl mid' ror uII WIth '''"5 ,lQp!luhon
I aulnarlZI anyllcI"slJl1 phYSICian mlldlcal prllCllhon~r hO'5~:UIIl chnll: orOlhrrr mldlcal or medIC.ll1.."lItlalld IIIClhly,lnaur."c,
company, th.MftdlClIllnrormllllon Bur"au or OlherorO",lllIllonl, Instllutlon or p,rsont".' hll any flfComsor knOWledQ' otm.
m my hutlh 10 I)IV" to P'rJ\llrJ,nll.,le ;u1d Acr:ld,nl In~urn"c' Company and or lis '''Insur,r, any 'Iuch Informetlon
I dulhf,mn .III s!lld SOIJrCIS IIIIC'DI Ii'll M~lcallnlormallor, BlJruu fa 91'VI suet'! rltCZZrtJl 0 nQwlltdQ.IO e:QlJl'D Inc fhlll
,lQ.w1r.y IS ItmplOVIfO hV I'rovldftnt L,'" ilnrl ACCld,nlln!llJrBnC' COmpI"y 10 (OUIC! lJnO'UCh11~.tton _'
A UJl)V rll tht~ .1ulhr)rtlllhnn '\/'Iitll h~ '" 1111111 .., In" r'Jflqln.ll Slgn.lur.." . ~ :J~
5lqrl1td,11 C'.Lwn/v;JU Pn PrOQOl1Id InSlJrtt(!), ------ ,~~~=-=-.-__
._...,...?t;J~II'1 ~tAIP I r..,ttlly Ihall hBv~ !rlJly ""d acc\Jtltl'ly rtcordld ort rhls IIppll.
It'll' ;z.. 7. 'Jlly",' , 912.. r:IN10"". ,n' rm on PpllXV tf'l. Propes., Inlurfd
Flltl'" Qttln, .-.. 'Ill ~ K'1tt.,. l_ ____
I "', \ 1 .. ',' 'r' 1,' .pr I IC,,"511!d ~9~.~~rohJr s 5iijnaIUr,)
F..,rn"3.1".PA _ '.,',~ \.~'( ,qJ?JtHIlrlt'C~~~.
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DAVID C. ATKINS,
Plalndft'
I IN THE COURT OF COMMON PLEAS
I CUMBERLAND COUNTY, PENNSYLVANIA
I
I NO.1 95.376 eVIL
I
I
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I CIVIL ACTION. LAW
v.
PROVIDENT LIFE AND ACCIDENT
INSURANCE COMPANY,
Defendant
~
I, Steven J. Schiffman, Esquire, of Serratelll, Schiffman & Brown, P.C., hereby certify
that I served by certlned mall, rewm receipt requested, a certlned copy of the Complaint
nl.d to the above tenn and number, and attach the treen card received back as proof of
service.
BROWN
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[),hl1^,r:", ..,~.,I",t.," '.1ry'"tJ:t:'lIc
6" "~~JI'.''''.llll\'', 1 ',1' . \1:llj'-" 'I' . ,l,." 'IllY
tt'r (,..;.. hP, .!...,: :...,.... _, i. .l~, I '/;1Ii
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By
S
Datedl February 7, 1995
S\r.I:lm to am subscribed before me this
7th ~Y/Of Feb ~' 1995. ,:
,tI ' ( < r,' ,( ./
lc
My Cbmmisslon Explresl
'I
,''I'' 1,"" ,11,,' I
IN THE COUR'f OF (:OMMON Pl.t:AH
OF CUMBt:RI,ANO COUNTY, FA
-
PAVlIl C. ATKINS.
Plnlnt Iff,
VB.
PROVlPl!NT I.HE AND ACClOENT
INBURANCt: COMPANY,
Defendant.
No, 376 Clvll 1995
CivIL ActIon -- Law
NOTICE OF FILING NOTICE OF REMOVA
""totlll!UNI'rEO' BTAnS 11l6TIHCV ,
OURT FOR TilE MlODl,E DISTIUCT OF PI
KEEfER, Wooo, ALLEN 6. RAHAL
110 WIILNUT STAtET
MAILlNrl ADDf1Ue p, 0,80_ 118113
tlAlllllSOUllG, PA, 17108 .0113
-
HI71,tURf.lIlO
hB III ,2 2~ PH '95
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,..I I,: IllilW,IM,y
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, IN ,Tall COURT or COIOlON PLlA/J or
, CUMBERLAND COUNTY, PINNBY~VANIA
,
, NQ. 376 Civil 1995
,
, Civil action -- law
,
I
DAVID C. ATItINB
Pla1nhu,
PROVIDENT LIFE AND ACCIDENT
INSURANCE COMPANY,
Defendant
MOTJC. O' 'ILIHO MQTIO' O' ..KOVAL
TO TH. UMIT.D .TAT., DI.TRICT COORT
'OR TH. KIDDLI DI.TRICT O' P....YLV~
tOI Lawrence E. Welker, Prothonotary
PLEASE TA~E NOTICE that a notice of removal of the above-
captioned action from the Court of Common Pleas of CUlllberland
County, Pennsylvania, to the United States District Court tor the
Middle District of Pennsylvania, a true and correct copy ot whioh
i. attached hereto, was duly tiled this day in the Harrisburg
office ot the Cl!lrk of the united States District Court t'or the
Middle District ot Pennsylvania.
Respectfully submitted,
REE~ER, WOOD, ALLEN , RAHAL
BYI
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C ar ..__ . RUbendall, II
Attorney I.D. *23172
Donald M. Lewis, III
Attorney I.D. *58510
~10 Walnut street
P.O. Box 11963
Harrisburg, PA 17108-1963
(717) 255-8038
Attorney. for Defendant
Provident Life and Accident
Insurance cOMpany
I'
Dated' February 13, 1995
2. Th. complaint oon.titut.. the initial pl.adlnq ..ttinq
forth a claim for reli.f upon whlch the action or proc..din9 i8
ba..d.
3. A. all.qed in the compllint, plaintiff i. a citiz.n of
the Commonw.alth of P.nn.ylvania.
4. provid.nt is a corporation incorporated undlr the law.
of the state of T.nn....., with it. principal plac. of bu.in...
located at On. Fountain Square, Chattanooga, T.nn..... 3740a,
and i." th.r.for., a cith.n of the state of T.nn..... und.r a8
U.S.C. . 1332 (c).
5. The amount in controv.rsy .xceeds the .um of $50,000,
.xclusiv. of int.r..t and co.t..
1I. The acUon .ouqht to b. remov.d 11 on. over whioh thi.
Court: h.. oriqinal jUl'1Idiction under 28 U.S.c. . 1332, .nd is
on. that may ba r.mov.d to thi. Court by d.fendant, pur.uant to
28 u.e.c. . 1441, in that th.r. i8 complet. divar.ity of
citi..n.hip among the part i.. and an amount in oontrov.r.y
axc..dinq the .um of $50,000 exclu.ive of intere.t and coats.
1. Notio. of thi. notice of r.moval has b..n qiv.n to the
CUmberland County Court of Common Pl.as .s indicat.d in the
attached c.rtificate of notice to state court.
-2-
Dated I 'ebrua~ 13, 1885
Attorneys for Defendant
Provident Life and Accident
Insurance company
e. The jurisdiotional ba.i. for removal of this action to
the United states Di.trict Court e~isted at the time the lotion
WI. commencld and exist. a. of the time this notice of removal i.
tUld.
Re.pecttully IUbmitted,
KEEFER, WOOD, ALLEN , RAHAL
, I
BYI
/)~":n
IV'I--l.ot: ;. . ,.-, Id'J-
~ Charl W. Rublndall, II
Attorney I.D. *23172
Donald H. Lewil, III
Attorney I.D. *58510
210 Walnut street
P.O. Box 11963
Harrisburg, PA 17108-1963
(717) 25!l-8038
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O..TX'loat. 0' .OTIO.
'1'0 .1J.I1.1J.IJ1 coualJ.l
Dona14 M. Lewi. III, Isquire, state. that he i. one of the
attorneys for defsndant Providsnt Life and Accident Insurance
Company in the above-referenced action, and that on February ~,
199~, he mailed to the prothonotary of the Cumberland county,
penn.ylvania, Court of Common Plea., a copy of detendant's notice
of removal.
The above statement. are made subject to the penal tie. for
perjury pursuant to 18 U.S.C.
I 1621. _,
~ ~ :~-
~_L"..{?~l,_ ......:. ~
nald M. j..fw . IU
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DAVID C. ATKINS,
Pl,'ndtr
v.
I IN THE COURT OF COMMON PLEAS
I CUMBEJU.ANb COUNTY, PENNSYLVANIA
I
I NO.1
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I CIVIL ACTION. LAW
PROVIDENT LIFE AND ACCIDENT
INSURANCE COMPANY,
Defend'l'lc
~
AND NOW comes PI,'ntlff DAVID C. A TKJNS, by ,nd throulh his attorney, Steven
J, Schiffman, EsquIre, and the law flnn of Serratelll, Schiffman & Brown, PC, who mes thIs
ComplaInt and avers u followsl
I. The Plalntlffls DAVID C. ATKINS, an adult IndivIdual wIth resIdence ,t 4183
Cove COUIt, Apt 106, Mechanlcsburr, Cumberland County, PennsylvanIa, 17055.
2. The Defendant Is PROVIDENT LIFE AND ACODENT INSURANCE
COMPANY, an Insurance corporation licensed to do busIness In PennsylvanIa wIth a home
offlce address at I Founuln Square, Chacunoora, Tennessee, 37402.1338.
3. On or about April 27, 1992, the PlaIntiff purchased a pOlicy of Insurance from
Defendant Insurln, hImself from dIsability as denned In the policy, a copy 0' whIch Is
acuched hereto as ExhIbIt "A" (hereInafter referred to as the "Policy"). The e"ectlve date
0' the policy was July I, 1992. The pOlicy was Issued June 29, 1992.
4. PlaIntiff had prevIously paId the premIums which the Defendant had requested as
payment for lu pOlicy.
5. Accordln, to thll tenns of the pOlicy, PlaIntiff w~s to be 'nsured with an exclusIon
for l//ublllty relatln, to ~ny Injury to or dIsease of a lumbar or sacro.lII~c spIne, Its muscles,
I,
",aments, discs, or nerve roots.
6. PlaIntiff, as the result of an automobile accident, became dIsabled on AUliUst 24,
1992, at whIch time the polley was In full force and effect, and Defendant belan payments
to Plaintiff under the polley.
7. On November 8, 1993, Defend~nt Infonned Plaintiff that, as of September 15,
1993, they would no lonler continue to make payments to PlaIntiff as his InJury was limIted
to the prOblems set forth In the exclusIon as set forth above.
8. Plaintiff has met all condItions precedent under the polley.
9. PlaIntiff continues to be dIsabled from InJuries Involvln, hIs shoulders, rlrht scapula,
and muscles In the neck. Further, Plaintiff Is totally dIsabled as denned In the polley due to
psychIatric and psycholollcal overlays, Includln, depressIon, lenerallzed t1rhtlless and loss of
nexlblllty, all of whIch are covered by the polley and not withIn any of the exclusIons.
10. After repeated demand, Defendant has refused ~nd continues tel refuse to pay
the benetlts as requIred under the polley from September IS, 1993, throurh the present.
II.' The refusal and failure of the Defendant to pay benetlts under Its polley to the
PlaIntiff Is without basIs ~nd fact and Is In violation of the lanll/are and coveral' of the
polley.
2
Exhibit A
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OIlXDI TO POLXCY.PIlOVUXONI
".n'~ll Condition.
"01 lev Schedule
U,"DATI
De1lnltlon. (Injurle., Slcknl", Phv.fcl.n, Total DI..bllltv,
YOUr occuPltlon, period 01 dl..blllty, 1!1"ln.tlon Plrlod)
'>u:lu.lon, I.. "' ....,. . I ....
Pre-Ixl.tlng Condition LI~lt.tlon
."nl11 II
Tot.l DI.lblllty .....
,"re.u"ptlve Tot.l DI.lblllty
Tran.pllnt Surgery
Co..etlc Surglrv
Walv.r 01 Pre.'u"
"eh.bllltatlon . . . . .
IInl1lt. When ,"olley Itenlwed A1ter Vour "th Ilrthday
or Five Velr., Whlchevlr I. Liter . .
"Iv.ent 10r Plrt 01 Honth . . . . .
Pre.lu.. and Itenew.l.
!'olley TerM , . .. f.... " ........ I . . .
a'.CI ".r I od . . .. .. .. " .. ....."..
Conditional Itlght to Itenlw A1tlr Vour '5th Ilrthd.v or FlvI Vear.
Whichever I. Later - Prlmlum. Are Hot Ouar.nteld
Rlln.tltl.ent ... I , . . . .
Suepen.lon Durlno HIllt.rv Service
,"re.lu. Adju.t.ent at Death
CIII..
Hotlce 01 Clal~ ..
Clal. Porllll . .
,"roo1 01 Lou . .
TI.. 01 Pev..nt 01 Cia'..
,"Iv..nt 01 Clal.. ....
,"hv.tcal Ixa.ln.tlon.
HI..t.te.ent ot Aoe
Leo.! Act Ion.
Gen.ra! Provl,'one
Intlre Contr.ct ......
Tl.. LI,lt on Certain De1en.e.
Confor'ftv With State Statut..
A..ltn..nt ..........".
,"Ige
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ItIAD VOUIl ,"OLley CAIlIFULLY
~.
U7-Q
DAVID C A~~:N' O'-J37"~iJI"
PI" 2
1
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POLXCV
ICHIDULI
ilnlurld - DAVID C ATKIHS
1111ctlvI Dltl - July I, 1"2
I..uI Dlte - June 2'. 1"2
Polley Hueber - 06-557-4075141
FI r.t Itln.wll Dlte - July I, un
Itlnewll rer. - Twelvl Honl/II
Monthly "olley PrllIIlu. plyable 1rom July 1, 1"2 until tha 11rlt UPDATE Inr.:r.... Dlte
(.Ie "Ioe 5 (cont.)),
Non-S.ok.,. 0'1"0" Monthly 'ollc:y ",.""lulI ,t,....,..,..............,.........
S"ok.r Surch.rge . . , , . . , . . t . . . . . . . . . . . . . . . , . . , . f , , ,.. . . . . . t . . t I . t t I . . I . . . I . .
'011 cy F.. , . . . , I . . . . . . . . . , . . . . . . . . . , . . . . . t . . . . .."" . . . t . . , . . . . . . . . . . . . . , . .
Hultlple Policy l.au. Dlu:ount .............,....,.",....,..,..,............
U4.'4
U...,
t4.2'
-..61
N.t Honthlv Policy Pr.",fu," II.... II........... ..lfJl.....".......... .... II .31.05
other Pre.lu. Plying Hethod. (Het PrIMluM."
.34',2' Annullly
.184.30 SI.I-AnnuI~ly
.'4.'70ulrt.rly
Thl. polley II II.ued on I modl11ad premiuM Irrlng..lnt under which you will PIV re-
duced prllllullll until July I, 1997. Your pr..IUI will then be thlt .hown on "Ioe 3
(cont.'.
------------------------HOHTHLY IIHIPIT ~O" TOTAL DISAIXLITV-------------------_____
U.500.00
---------------------------------IlXHIHATXOH "IRIOD-----------------------__________
'0 dlv' 01 Tohl Dlllblllty
111.lnltlon ".rlod I. dl11ned on "Ige 4. An Illllnltlon "Irlod Itlrtlng 11ter your
4,th blrthdlY IU.t con.lat .ntlrelv 01 dl~' 01 Totll DI.lblllty. 11 the 111.lnltlon
"erlod I. 1ul11lled during I period 01 dlllblllty, the 1lr.t lubllCluent dl..bllltv
due to I dl111rent or unrelahd CIUII ~Ill not reClulr. In Illllnltlon "erlod. provided
the 1lr.t .ubllCluent dlllbllltv occur. within the twelve lonth P.rlod 1ro. the end
01 the prior dlllblllty, durlno which the I1IMlnltlon "erlod WI' IItl.1'ed,
.
--------------------HAXIHUH IINI~IT PIRXODI POR TOTAL DISAIILITV---------------_____
InJurl" or Ilekne.,1
Totll OI.lblllty .tlrtlno be10re your 'lit birthday... to your '5th birthday
Totll DI'lblllty stlrtlno on or 11ter your 'I.t blrthdlY
but b..,cu', your '2nd bl rthday ............. ",.. ....... ........... '8 .onth.
Total Dlllblllty Ihrtlno on or 11hr your '2nd blrthdlY
but before your '3rd bl rthdlY It.........."., II If..... II..... . "' 42 .onth.
Total Disability .hrtlno on or athr your '3r~ blrthdlY
but before your '4th birthdlY ..............,..................... 3' .onth.
Tot 11 DI lib III ty ltart I ng on or a1hr your 64th bl rthdlY
but b.fore your '!th bl rthd.y . II II... It.. 1111 tI...... II If It... "' .s. .onth.
Totll DI.ablllty .tartlng on or 11ter your '''~ blrthdlY
but befort your 7'th blrtndlY I...'.'...,......................... 24.anth.
J3i~'!-'!> ~l
J~\ID " H~:'lS H-33i-,:'3I4'
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Totll OI'I~lllty .tlrtlna qn or .1tlr yo~r 7'lh blrthdlY .......,..
('olloV loh.dul. I. oontlnu.d on n.xt p....)
12 ~llMth.
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PIU J (cor\t.)
:AVID C Ai~IH$ l'-SS7-'37JI"
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"OLXCY 8CHIDULI (oontlnued)
~~~----"--"--"-------------~-----------UPDATa---------~-*.._--------_.______________
Th. b.n.1Itl .nd pr.mlu~ named b.low will be .uto~.tlc.lly Incre...d without .vldenc.
01 In,u"lblll ty, II follow.,
UPDATI
Incr....
D.h
H.w Monthly
"ne1 I t for
Total Dlllblllty
U,'IO.OO
U,7S0.00
tI,"O.OO
U,OOO.OO
U.lH.OO
H.w Monthly Net
Pr.~lulII 10r
thl. Pol lev
7/01/f!
7/01/74
7/0 II"
7/01/"
7/01/'7
US.Of
U5.U
U7.97
UO..7
f70.17
The pr.mlu. .hown for the UPDAU Incr..u d.ted July I, 1"7 a110 Ineludu an .d-
jv.tm.nt due to the modl11.d prtllllum Irrlnvelllent und.r which your polley w.. I..ued.
UPOATi len.1lt Incr..... Ir. .1het IVft on the UPDATE Iner.... D.tu Ihown. I1.n
UPDATI Incr.... 0111 Ihown do.. not coincide with I r.newal dill 10r thl. polley, the
Inc"..le will be .f1.ctlv. on the n.xt ren.w.l dat.,
An UPDATE lene1lt Incr.... will .pply only to I period 01 dlllblllty which .h"te
l1ter the .11.ctlv. dlte 01 th. Incr..... It IIU.t Quall1y .. I ..par.t. p."loCl 01
dlllblllty. If the pr"lulll 10" the polley II being wllv.d on the .1fectlv. d.te 01
the Increlle, the pr..lv", 10r the Incr.... will .ho b. w.lv.d. When yOU r"UIIII p.vlng
p"ellu.. 10r the pollcv, vou mUlt .1.0 .tlrt Plying the pre.lul 10r the Incre..e.
You are .ntltl.d to UPDATE lene11t Iner..... on the d.t.. .hown .bov.. 11 you do not
,cc.pt .~ Inc"e..., yoU" ".1V'll,
1. 10r1eltl YOU" right on th.t UPDATE Iner...e D.t. to the U"DATI l.nl1lt Incr'l.e,
Z. po.tpon.. the Ichedule 01 b.ne1lt Incr..... to the n.~t U"DAT& Inc~.... D.te, 11
any,
S. Idju.t. the pr..IUI. for the r..alnlng Inc"e...I, 11 .nv, .Ince .uch prellllu.. '"e
b...d on your Itt,'n.d aoe .t the tl". 01 .n UPDATI I.neflt Inc"...e, .nd
4. In no WlY e~t.nd. the l..t UPDATE Incr.... O.t. Ihown .bov..
I.ch r.1u..l ot .n UPDATE l.n.1It Incr.... r.duc.. thl nUllber 01 UPDATE len.1lt 'n-
e"e.... to which yoU we"e .ntltl.d by on..
If you h.ve not r..ch.d your 40th bl"thd.y on the I..t U"DATE Inc".... D.t., you "Y
IPply 10r In .",end..nt pr<lvldlng Iddltlon.l UPDATI len.1lt Inc"..I... You cln do thll
by ..klno 10r~.1 .ppllc.~lon within the p.rlod 01 '0 d.y. pr'o" to and 31 d.y. .1te"
the lilt U"DATI Incr.... Date. App"ovll will be Iubject to our und.rwrltlno oulde-
II n.. th.n In efhc\.
(Polley Schedule ,. oontlnued on next P....)
317-UPDATE
D!~!D C ATK:~S 1'-337-'07314'
~IO. 5 (cont. )
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POLICY ICHIDULI (cQntlnu.d)
ADDITIONAL EXCLUIIOHCI)
rn .ddltlon to the IXclullon. contaln.d herein, t~l. pQllcy doe. not covlr 10" clu..d
by!
AHY IHJURV TO OR DISEAS& OF THE LUHIAIl OR SACItO-ILrAC S~INE, ITS HUSCLIS,
LIGAHEHTS, DrSCS OR HIItV& 1t00TS
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DAvro e ATKrH' 0'-5S7"0711"
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O".IHXTIOHS
XnJurl.. malnl Iccldentll bodily InJurle. occurring while thl. poll~y II In 1orce.
SIck"... melnl .Ickne.. or dl.e"1 not dlagnoled or treated be10re tha Effective O,te
01 thl. polley, Pre-.xlltlng condition. Ire, however, cov.red under thl. policy to
the extent ,et 10rth In the "Pre-.xlltlng Condition Limitation" provlllon on PIge 5.
Phyelol.n l1Iun. Iny p.r.on other than YOU who I. llc.nllr;j by law, Ind II Ictlng within
the .cope 01 the llcenll, to trut Injurlu or Slcknu. which ruultl In cover.d Iou.
Total Dfaablllty or totally dl..blad, be10re your 55th blrthdlY or before ben.1It.
have bun paid tor t~n vears 10r a period 01 disability, whichever II I,ter, mean.
th.t due to Injurlel or Slckne..,
1, YOU Ire not Ible to per10rm the .ubltantlll and mlterlal dutlel 01 YOUr or,:cu-
Pit lon, Ind
2. you Ire recalvlno care by a Phy.lclan which II approprlata 10r the condltlc,"
cau.lng the dlublllty. We will wllv. this reoulremant when continued Clrll
would bl 01 no bene11t to you.
A1ter your 55th blrthdlY or a1ter bene1lt. have been paid 10r ten yelrs for a period
01 dlublllty, whlchevar II liter, Total Dlublllty or totllly dlubled IIIlInl thlt
due to InJurle. or Slcknel.,
1. you Ire not eble to par10rm the .ub.tlntlal Ind meterlal dutlel of Iny occupa-
tion 10r which you Ire r.alon.bly .ulted beclule 01 educ.t10n, trllnlno or ex-
perience, with due reglrd to your voeltlon Ind urnlng. It the shrt 01
dlublll ty, Ind
2. YOU .re reeelvlno clre by I PhYllclan whlr,:h I. IPProprllh 10r the condition
clu,'ng the dlllblllty. We will wllve thl. reQulrlllent when continued r,:are
would be 01 no bene11t to you.
your occupatlcn .eln. the occuPltlon (or or,:cuPltlon., 11 more thin one) In whlr,:h yOU
are regullrly enOlged It the time yOU ~er,:ome dl'lbled.
parlcd
10rce.
rlod.
c1 dlnbt1lty .lInl I period 01 dll.blllty .tlrtlno while thll pollcv I. In
Succel,'ve period. will be dee.ed to be the II"e period unl... the liter PI_
l.
2.
II due to I dl11erent or unrellted cau.e, or
,tlrtl 1II0re thin .Ix ~onthe a1ter the end 01 the prevlou. period,
In which event, the l.hr periOd will be I new or IIPlrlh period 01 disability. A
nil' Ilh,lnltlon Period IIU,t then be lIIet. And, a new Hlxh,ul lendlt Period will IPPlv.
Illlllln.tlcn I'trlod ..un. the nUlber 01 day. 01 dlllblllty thlt IU.t ehlllle In I periOd
01 dlllblllty be10re bene1111 become plyeble. The nUlllber 01 dlY' I. shown on "e.,e
S. Theil dlY' nud not be conucutlvII they cln be accullluhhd during I period of
dlllblllty to Iltl.1y In &11~lnltlon Period. lene1lt. I-e not pav.ble, nor do they
Iccrue, during In Ill.lnltlon Period.
!5i-D-5!-4-P1
OAVIO ~ AiKINS 04.517-'Gilt~.
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TQTAl. DUAIILXTY
We ~lll pay the Honthly aen.1lt 10r Total DI.~blllty shown on ~Ig. 5 _I 10110~.,
I. hne1ltl Itart on the dav 01 Total Dlublllty 101l0wlng the Ellmlnltlon Period.
2. hn.1llt will contlnu. while YOU ;are totally dlubled during the Period of
dllablllty but not beyond the Haxlmum Benefit ~~rlod,
IElIEFl TS
In no avent will YOU be con.ldered to have more than one dlsablllt:/ It the la",e tlllle.
The hct that I dlublllty I. cauud by 1II0re thin one Injury or Slcknell or 1rom both
will not utter. w. 1<1111 PlY bene1lt. 10r the dllablllty which provld.. the grul.r
bendlt.
PREIUMPTIVI TOTAL DISABILITY - l.OSS OF SPIF.CH, HIARIHO, SXOHT OR THE USI OF TWD LIMaS
Vou will be prelumed totally disabled 11 Injvrle~ or Slckne.. relvltl In the entire
Ind permanent 1011 011
I. IPuch,
2, hurlng In both tarSI
$, the light 01 both eve., or
4, the uu 01 both hands, or 01 both hat or 01 one hand Ind one 100t.
You IlIUlt Pre..nt .ltl.1Ictory Proof of your lOll, Your .blllty to wor~ will not
matter. Further udlcal clre will not b. reovlred. Blne1lt. will be paid Icc:ordlno
to the Total Olublllty provl.lon. 01 thl. polley. But, bena1lt. will start on the
date01101111urller thin the daybene1lt. .tart II Ihown onPlge $. If lOll occvr.
be10rl yovr 65th blrt,hdlY, the Honthly Bene11t for Total Disability will be plld II
long II yoU live rlgardl.11 01 the HaxlmuIlI Bena11t Period shown on raba 3.
TRAHSPLANT SURGERY
You ",Ioht b. dlubled 1rom the trln.plant 01 Plrt 01 Vour body to Inother per.on.
11 10, we will con.lder It to be the re.ult 01 I Slc~nesl.
eOSMITIC SURGERY
You "" oht be dl.abhd 1rom .urgery to I mprove your IPPurlnce or to correct
dI11'gure..nt. If '0, we will eon.lder I t to be the rllult 01 I Slckneu.
WAXVER OF "REMXUH
A1ter you hive bun totally dlhbled 10r fO dlYI during I period of dl.ablllty, we
will r
I. re1und Iny premlu.. which becI,e due and were paid while yOV wIre totllly dl.-
Ibled, Ind
2. wllve the PlYlllent 01 ueh prlllUII which theru1ter becomu due 10r II lonG II
the periOd of dlleblllty lutl. After It endl, to kup thl. policy I" 10rce.
YOU 'Ult eOlln pey Iny premlu,. Which become due.
For prUlu.. to be wllved, yoU mu.t give UI letl11actorypro01 01 dlublllty.
! 37-J..I.
O~VIO ~ ~;~INS 04-33i-'1;31"
~11l' 6
'"
,. 4'
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, ,
It'NAIZL IT A nON
Totll Dlllblllty. Vour partlc:IPltlon In I provrlm 01 oCC;I/Pltlonal rehablllt.tlon 101111
not 01 It.el1 be conlldered I recovery fro~ Totll.Dllablllty,
I_pen.e - f1. durlnv . period 01 rot.l DII.blllty, you notl1y u. In wrltlno thlt yOU
Illnt to plrtlc:lp.te In a progru 01 oc:cuPltlonll reh.blllt.tlon, we will c:on'lder
Plying 10r the rellonlble e_penlel YOU Inc:ur 10r trllnlno Ind eduC:ltlon. The e~tent
01 our role will b. determined by written IQrUlIIInt with you. aenerllly, we will P.y
10r the rUlonlblt eo.t 01 trllnlng Ind .duc:atlon whlc:h I. not otherwlll covered under
hellth clre Inlur.nce, worker.' eompen..tlon or Iny public: 1und or provra~.
A progrllll of oeeup.tlonll reh.blllt.tlon mu.t be dellgnQd to halp YOU return to work
Ind ba r
1. I for.,l progr.m 01 rehlll1ll1tltlon at.n Ic:cr.dlted grldult. IChool, r,:01lege
or bUllne.. Ic:hool, or It a IIc:an.ed vOC:ltlonll IchoolJ
2. I rec:ovnlz.d progrlm operlted by t.he 1ed.rll or I It.t. oovernm.nt, or
!. IllY other Pr011.IIon.lly pl.nned r.h.bllltlllon progr.~ 01 trllnlng or .ducI-
tlon.
IIHI,.XTS WHEN POLICY RENEWED AFTER YOUR 65TH IUTHDAY OR FIVE YEARS, WHICHIVI!R XI
LATER
11 thll poll~v II contlnu.d In accordance with the "Condltlonll Right to Ranew A1ter
Your '5th IlrthdlY or Plv. Yelr., Whichever I. L.t.r" on PIOI I, III 01 the bene11t
provl.lonl on Ploel 6 and 7 will b. Includ.d In the continued pollr,:y. (11 . Treltaent
01 In;url.. hndlt Ind,lor I Prellmlnlrv r.r~ lene11t II conhlned In thl. pollr,:v,
It c.n be Included In the contlnu.d policy. Ho oth.r "Addltlonll lene1It.", 11 Inv,
fI.lld on Plge 5 will be Ineluded In the continued polley.) The HI_lmum hne11t Period
.tlrtlng while thl. policy II .0 continued I. .hown on Pice 5. The Monthlv lene11t
10r Total DJ'lblllty will not ehlnge unleel yoU ehoo.e to renaw with I l....r Imount.
PAYMINT ,.OR PART OF MONTH
If Inv. Plyunt und.r thl. poll cv 'I tor p.rt 01 I month, the dilly rite will be [,I50th
01 the paYlllent Ilhlch would hive b.en 1II1de 11 d,..blllty hid continued 10r the Ilhole
aonth. .
"
,.
" '
I,
I
I;
UT-I2-I'~
~AVtD C ~r~IHS 06-!37-'~7st"
"'0'7
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,
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PREMIUMS AND RINIUALS
"OLICY TIRM
The 11rlt ter~ of thll policy Itlrt, on the Ef1ectlve Dlte Ihown on Ploe 5. It ende
on the Flrlt Itlnewl! Dlte allo Ihown. Liter ter~1 will be the period. 10r which YOU
PlY renewIl pr.mlu~. when due. All term. will beoln Ind end It 12101 A,H., Stlndlrd
TIMI. at yovr home. The renewIl premium 10r elch term will be due on the dlY the
prlcedlng term end., lubject to the gr.ce period.
GRACI PIRIOD
Thl. pollcv hu I 31 dlY grlCI period. rhll mun. thlt I f I rarlewII premium I. not
plld 0" or be10re the dlte It II due. It may bl paid durlno the nut 31 daYI. Durlno
the grace period. the pol lev will Itay In 10rce.
CONDITXONAL RIGHT TO RENEU AFTER YCUR 65TH IIRTHDAV OR FIVI VIARS, UHICHIVIR IS LATIIt'
PREMIUMS ARE NOT GUARAHT!!D
(Contlnved tro~ Plge I)
You cln renew thll policy.. long.. YOU Ire Ictlvaly Ind galn1Ully worklno full time.
From time to tlml, we cln require pro01 that you Ire Ictlvely Ind glln1ullv working
1vll tl"", If YOU .top worl<lng, (ucept by ru.on 01 Tohl Dlublllty), thl, pollcv
will terminate, except tlllt covarlge will continue to the and 01 any period 10r ...hlch
premium hi' been IccIPted,
"remlulll' muat be paid on time. Tiley will be blled on our tlble 01 ratea by Ittllned
Ige In e11ect It time 01 renewIII 10r perlonl In your II.e rate Clll' who are In.vred
under pollcle. 01 thl. 10r~, Other thin your Ittllned loe, the 1lctor. ueed to de-
~er~lne yovr rite cll.. will be the lime II tho.. thlt applied to YOU on the Effective
Dltl 01 thl. pollcV.
The bene11t provlllon. which will be Included In the continued policy Ire de.crlbed
0" "Ige 7.
RIINI$TATIMINT
11 I renewal prelllulI II not pelel be10re the grlce period end., the pOllcv will liP".
Liter Iccephnce 01 the prul v. bV u. or bV our loent luthor I ud to Iccept paVlllent
without reQulrlno In IPpllcltlon 10r relnltltement will reln.tlte thl. pollcv.
If we or our agent reQuire an IPpllcltlon, you will be given I condltlona! receipt
tor the "rlllv. tendered. 11 the IPpl 1r,:lt Ion I. IPproved, the pollcv 101111 be reln-
.tlted a. 01 the IPprovl1 dlte. Lackfno .uch IPprovII, the pollcv will be relnltlted
on the 45th dlv 11ter the dlte 01 the condltlonll receipt unle.. we hive prevlou.1V
wrlttln YOU 01 our ell.IPproval.
The reln.tated po!lcy will cover only 101. thlt relult. 1rolll Injurle. which occur
11ter the dlte 01 reln.tltement or Slckne.. a. mlV beoln more thin 10 dlY' Itter .uch
dlte. In all other re.pectl, yovr right. Ind our. will remlln the II,e, .ubjlct to
Inv provlllonl noted on or Ittlchld to the reln.tattd polley.
337.P~.'1
j~V!j r. ATKINS ~'-SS;"60;SI'a
1'1" I
; I'~
.. .,.: t
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IUI'WNIION DURINO HILXT~IlY SIRVICI
11 you .nter full-tl'l .etlve duty In tne ~Illt.ry (I.nd, Ie. or Ilr) Ilrvle. Q1 anv
nltlon or Int.rnltlon.l .uthQrltv, YOIl Uy lu.p.nd your polley. lut, yoU "'y not
.u.pend the policy durlno aetlv. clllty 10r tr.lnlng l"tlng 3 ~onl/II or lell. The
polley ..III not b. In 10re. whlh It II Illlpend'd' .nd yoU wIll not be requlrtd to
P'V pr..lulllI. Upon r.c.lpt 01 YOllr written rtQu.lt tq lu.p.nd the pollev, WI will
r.1und the pro-r.tl portion 01 Iny pr.mlum Plld 10r I period beyond the d.t. w. rectlve
your r.QUU t .
If your 1ull-tln Ictlv. duty In military suvlce .nd. bl1or. your 65th blrtndlY. yoU
I'y ~lle. thll polley b.ck In 1orc. without Ivld.nc. 01 Inlllr.blllty, Vour covtr.oe
will .tart IQlln whlnl
1. w. h.v. r.e.lved your wrltt.n reouelt to pllcl the policy blck In 10rce, Ind
2. yOU h.ve Plld the reQulr.d pro-rlt. pr.mlum 10r cov.rlge until the n.~t prlllllulft
due d.te.
How.v.r, your rlQuut and premium plym.nt IU.t be r,cllved Ily II' within to d.v. a1t.r
tne d.t. YOllr active duty In the military lervlc. end.. Prtmllllft' will be .t the I...
r.te thlt tn.y would h.ve bun nld your poll cy r"".1 ned In 1orcI. Th. poll cy will
not cov.r .ny 1011 due to Injurl.. which occur or Slckne.. dl'Gnol.d or tre.ted while
the policy I. IUIPlnded. In III othlr relP.ctl YOIl end w. will hav. the 1'1II. right.
und.r thl polley a. b.10re It wle .u.pend.d.
PRIHXUH ADJUSrHENT AT DEATH
Anv pr..lum p.ld 10r . period beyond the d.t. 01 your delth will b. re1llnd.d to your
..tah.
CL~IHS
HOTIel OF eLAXH
Wrltttn notlel 01 el.l, Illlt be Glv.n within 20 dlY' 11tlr . cov.r.d 10.. It.rtl or
.. .oon II r.llon.blv pOlllble. Th. notice c.n bt glvln to u. .t our hOllll o11lcI,
Chlttanoog., Tlnn....., or to our .gent. Hotlc. .hollld Incllld. your nil. .nd the
Plllf cv nUlbilr.
CUI/'! FORi'll
When we rlc"VI your notlc. 01 clllm, we will ..nd YOU r,:1,'m 10rm. 10r 111lno pro01
of 10... If th..t 10rn Ire not glv.n to yoU within 15 dlY', you will ...t the pro01
of Iou rlqul r...nh bv gl vi ng II' I wr I t ten .htelll.nt 01 the nltur. and extent of YOllr
10... You IU.t give u. thll pro01 within the time lit forth In the "roo1 01 Lo..
IIctlon.
PliOOf' Of LOIS
11 the pol lev provide. for p.rlocllc p.ym.nt 10r a contlnlllno 10", YOU IU.t olve UI
written proo~ 01 10.. wIthin fO d.v. .1ler the .nd 01 uch period 10r which we Ir.
lllble. For .ny other 10", wrltt.n pro01 mu~t be glv.n within '0 dlVI .1ter luch
10...
If It WI' not rl'lonlbly po..lbl. 10r VOIl to olv. wrltt.n proo1 In the tl~e r.qulrtd,
Wt will not r.ducI or dlnv the cl.11 for thl. r..lon If tht pro01 It 111td .. .oon
II rtl.onlblv pOlllblt. In .nv Ivent, the proo1 r.oulrld mUlt be 1ur~l.h.d no lltlr
thin onl y..r .ft.r the '0 dty. unle.. you ar. l.g.lly un.bl. to do 10.
Hi-C.~l
DAVID ~ AT~I~S 06-I!i.~Ji!I"
..e. 1
,111;,__
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. TlHl QII ~AYHINT 01' CLAIMS
A1h~ we ~eclIIl ve wr It hn pro01 01 lOll, ~e w III PlY ~onthly III ben.,I h then due YO\l
10~ dlllblllty. IIneflh 10r Iny other lOll covered by thl. policy will be plld II
'~On I' ~e renelve proper written proot.
"AYHIINT 01' CLAXMS
'.nefltl will be plld to YO\l. Any benetlt. unPlld It de.th will be paid to YO\lr e.-
tate.
11 bene1lt. Ire PlYlble to YO\lr e.tlte, ~e car pay bene1lt. UP to 11000 to 'OMeone
rellted to YOU by blood or mlrrlave wholll we con.lder to be entitled to the bene1ltl.
W. will be dl.chlrved to the e~tent 01 Iny .uch Plyment made In good 111th.
~HYSXCAL IXAHINATIONS
We, at our expenll, hlllve the right to have YO\l e~lmlned II 01ten.. I. re..onlble while
I ClllM II pending.
HISSTATII1IHT 0' AOI
11 your Ive hll been ~11.tlted. the benetlt. will be thOle the preml\lm plld would hive
bO\lvht It the correct Ige.
LEGAL ACTIONS
You 1II1Y not ,tlrt III leVl1 Ictlon to recover on thl, polley within '0 dly. 11ter YOU
vlve u. rloul red pro01 01 lOll. You IIY not .hrt lueh Ict Ion 11hr three yurt 1rol
the tiMe pro01 01 lOll II required.
OIHlRAL PROVIIIOHS
INTUI CONTRACT
Thl' policy with the IPpllcatlon Ind Ittlched piper, II the Intlre contrlct bltl411n
YOU Ind \II. No chlnoe In thll pol lev will be e111~tlve until IPprovld by one 01 ou~
of1Ic.r.. Thll approvd IIIU.t be noted on o~ Ithched to thl. policy. Ho Igent IIIIY
chlnge thl, .,ollc:y or waive Iny of Ita provlllonl.
TIll! LXHIT ON CIRT AIN DIII'IHSIS
1. A1te~ t140 yurt 1~OM the 1111ct I ve Dlte of th I. poll cy, no IIIlutahunh, 11Icept
frludulent 11..tlte.ent., .Ide by you In the .ppllr,:ltlon 10~ thl. pollcv 14111
b. u.ed to void the policy o~ to dlny I clllM 10r 10.. Incurrld or dl.,bllltv
thlt .tl~t. after the end 01 '\leh two ye.r period.
2. No ClaiM "o~ lOll Inc\lrred or dlllblllty that .tarh l1ter two yurt 1ro. the
Effective Date of thl. policy will be rlducld or denied on the ground thlt I
Ilckne.. o~ phy.lcll condition not I~cluded by naMe or .pecl1lc de.c~lptlon h.d
exhted before the 1111ctlve Olh 01 thl. policy.
C~OR"ITY WITN STAT. STATUTIS
Any provlllon of thl. policy which, on Ita 111e\:tlve date, I. In con11lct with the
llw, of the Itlte In which YOU re.'de on thlt dlte I, changed to con10r~ to the miniMUM
rl.ul~ellnt. 01 tho.e llw..
.IIIIN'IIHT
Ho a'.lgn..nt of Intere.t In thl. policy will be blndlno on u. until I coPy lion 11 I.
with u.. It ~\I.t be a"prO)ved by one 01 our oHlc.~.. WI Irt not r.."onllble 10r the
vllldlty ot ,ny Ullonllllnt,
53 i -11'
JAY:, ~ 1T~INS ~6-l3i-ll~l:'a
".U 10
. ,
., " .., IfATlMINT 0' SO~ICITIIIO AOINT , I. '. ~.,",
HQW w',d ~ hQw IC)f'I9 ".~. YOt.l known I", Propo.-d '"1.""". ~ .......t("..\ .. I... ~'. .......1 (l...~... .Le. .,~
SoIIcbn9' .4~1 J2:d~t.~ M. ..~I.lI.LLl.Jl. ~fl..
r..;..,. 1,0, N~mo" ,~~. ~'1'.J 'it.
'''0'0'111111'1,11'110'' AIIO"'IIIIII AND IOCIAL IICUI'IIlY 110.
II' A..,atNl. Aaa"..l '& S.TlP~/,.l /2.,1l~ C.AIM~ ~;i1 PA .
",.:r'"~I.'''', ~1)."IItr":l~CI\~'/I"'U1Pi'~~ "'~"'O,,'f' .".,
10' I,,,,n... AOO'..ll q';l\ "~"";~L'"I>.oL" ~,d ~:1I .PA
I.' So.III Slll~nly No, I("~. 5{". S'~1 ' ,
l'lHl
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"n,l
Sono Noll...,
o ~"'d.nCl
1/ S~lIn,"
Li!~",,~ .. J :l'lC~I?
V\.{,-~-\ "*C~I5'~!s-'?3/'r'J' ~1Hfi'!f
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I h.,ttI~ '""k'O Ft'OYld'I'U lo,', ~Cld''''lln'IJ''''II;' Co,)MOany lo'~.!!!"e. Q"~ Q'; r". 'allOw.,,; 'IC,...",,,.onl:
'.1" ~~ '1::>A~i c. T<; S Ilill~' ,r
~, ,n I II ., n .. . --"L"",
~, 1" Oc.~o."on: . llftM:I'l.t'Ll"..,","~' . ...._,.. . '
Jc Imfi)lOy.r: !l.itld.""',hl "1....AJ.......'" , ) 1.IllCt dull'l: 1:.'-.......... ~,.;...,.(,.~.:...
la N' \'O~ .."'lIy "\NO" MI"m. ,n "'"l.lOvtocev;llIOnl V.. III No 0 I., Lttl9t1l 01 ImOloym""I:,",-..
,II Mr.;. 1",,1ll rr-.. ,""" Vru 0CCI.00_ "" ,toj. CUlT"" """,,.. ~'" ~1Uii ~'IO' ilCl~.. Vln-"~, ,~
... T.. ~... 1M.. 11<I..,... 11_..., .1 "YI' ~, hmllllln.om. CIIIIICl.. y.., LIII CII.ncl.. VI"
'".,y ... . .. ;;. . . . ,. .... ,. S S S
1~1 o:,nl':,~OI"':":~I^t~;, I V~::' Ilnllll.., 01'.. ..S~ : ,~ "11 ,...L.: ....~. ~
.&, (.~ yO\l toI'VIO' It, you IDDI"'''9 O'QI"",I ')lncJIVlouat. 12t A.IOCI,IIM. 131 rOUD. OIl') ImQlO';'1t leI!. P,.,"'I'DIllIY
Incom, (0.,,, ,; or 15~ OV.r1lUO e.."tt'I" OI"DIUI~o~'" .1 v.. NoiD II' 'VII' Iv' d.I'wl t)~.
11 1'1.", ~"Ol .., 1 n~o
.
I
ltH 00 you 1'l''1' $xllt SK~mIY IUOllllull COv.r.Q,' ..,..;.., No 8 Am(lI,ml SComa.".,
I.) I.."y '_Iql '0 O. '1011C1IlI Oy Ih. .0''''9' "'P"lIlIl~i1 V.. CJ NO Ill" "V..", .0mOIIl. 'orm""T5~
IIll 00tI.,....,1III wonIIl"IICIII.OOO,00Q1 VII ': NO B I' "VII" .om;I..I'orm 133S.NW,
1'1 H.vI you I/llOk.., "0"1"" WltIlln Ih. I... '2 montllll VII S No ':
5, H.v. you ...., OlIn """'01'''' ~..., II nlVlIlO or 011II IrI..lIlIlr:t: V.. NO
II. ~"~ prllaurf. dill..... CIM.,. ,,"'n'll, Ulnml. 'rnOf'lYlftfll, 0' .moIlO"", f'I,rVOUI Of mtr'll" I
"_",.,aln"'O'OI_"~""'''rlo..o...n''''''.'''''''''''''''. = yl
Ibl ~.~=::::.::.~: ~~~~~~',n~~: '~~~',b:I,I~'~, ?',I~I,C1,",ul,.',O~" ~,'~.,'~. ~":"~~~ t1I-!
t. HIYI Y'I" ...., IlMl ClIIonoMCl Ily I ",,",0. ~r 1/1, ",..,1cII il'OIlIlICln II "'YiIlO Acq\jt,.., Immun. I
0tfIclInq .~ (NOill or AIel. "'If"'" ComIll.. f,l1lC)1, , , . , , , , , . , , , , , , , , , , , , " 0 Sf .
" HI". ~ ..... ....., bI/OIllIrI'H. n....tlel, ..CI'."II or "1I/lJc:1nOO"'" '" ..., 10\1OI'1 hlfO '" """""'" I
lor 1/I1Ir,," or 1Ic0/l0l ~I.l, , , , , , . , . , , , , , , , , . , , , , , , , , , , , , , , , , , , , , , , ,. ,:; ,,;
I, 011I.. 11I11I _, hlV, yOU, WlltMn ... P.II 5 y...., n.a ",ldlell or MOI.II 'GVICI '" "llIm."t, h.a I I
OIlyalcll 1._IItor'l, 0< e..n ~nc., 00.....,111011 I.. Illy "..... ~, "Iota..l, , , , , , , . , , , , , "I- C I
I, HIV' ~ ...., """11OP'i.II1On 101 OiIlO~IIy. M.II,n or IJI. 1/lIU,.".. wlllCh hU bllll oKlln"', mocllftllll i
0< 1I1IIll1 ~, "VH". QiY. """" 0' OO'O""Utlllll. klncll 0' InllK.".., ".111 IIlcl "-',1, , . , . . , , " .:; .s I
10, Co ,... ~ I OI!Yllc:lllmOI""'tnt or al'OImIIy, or I"'I."Y ry~ 0' p'lIcnO.., OIIIlIICltIon?, , , , , . 'I ': ~ I
10/11I Olltll. ~, ..V...' IIlIWff1 10 05.10, InClVa. al.ono..I, 011", ilI'YIlCI.,,1 IIlcl ",a'HIIII ,
::.. \::;'~..~-=." ~~:' :'::'~;'oI~~:~~~~l!. \3,\;~~~~ J:rt.'I~::,1ft
I. 14~1 f rJ.I.t. AwI..d.;... 1\)#I~YnI.hi 'I;..:lr ~. II~a~lJ&r. i'U'II~'~M&.J~f'~j".(. '" I~" .,. rI-"".rttr
... I"". A.""-"~"I'II~.,..Ar.JI"f..ttt.~y. ~.M'4\M""" ^,j"'~IL:'JI"ld IttUAhJ.',< .1.'''''''1
11,/11 WoI 'fG4II_y. P,y "" alOI_YCO'''1ll1100. camlO oy \'0\1'""" no CllllIIO'"'' 1lI11l1'''''''''''1O O. "'ClVGIIlI '" 'fG4II
'.101. -'COm., v.. C No Ie It)l ~ muc" Otll'l'lnn'l' II OIlCt WlIft lht.IClClIICItO'\' ...a .,L
To Inl 0... Of my '-109' eno UII"', III 01 Ih"OO"lOonO 1111""""" eno '" 01 thollln P.n II. " lilY, 01 mi. ACOIiCIIIOn "I
""I, '0/1111I"', eno 'O"Klly 1I1111l1, Tl'I'Y". o~"lIlIlo P"'''''''''llJlt eno "''''""llnlU'.".. Comp."y II ml CI..llor any
1r'l1W~"'IU. Ott ""1 ,A_ClI~r'l I"'.'" rlC""", CIIICIOI"," ~""lf": I t I t~. MICJlUI tl'llormltlOr'I 1"".lu. .,,12 fa' 11'I
'r'I"IIh9"llr'~tuM."." 'W1'l~" m." D. ""10' 'Of "'.. 'MI'" mil ,iDUllClll6n
I .utl'\Orllt "'~IICIf'l'. Oft~~M, m!IGIC* D'II:I"'O"" ~Clell" =1I1"lrC" 01"''' "'''''4. Of ",IOtClII" ,,,.,.., rtc1lttV. 1I"l""ranel
COtrlGInY.It'l. MtdtC.lnfO'l"I'l.hO",lu'llUo, ome,c"trltl'."on" ''''"IMIOI''l 0' DttlC'" I"'" "..."" 'fCOrdlOP kflOWtlOt' 01 m,
0' ~l'Iy I'IU"f'Il 10 9''We to jI''''WIOtr'lt lorl' ano ~cJG."t I"'IU''''CI C~"'OIl'lV and 0' '" ',,"lIUrtfl ...." II.C" ,"to",,""'''
IIW'lOfll. .It ,,.., IOUfC'" 'lctOIII't, MtcIC* 1"'10""1110" 9u'uu,!0 9,vt lue" '~O~I" ~0Vf1109' fO 10\111&1 '''C .."".
aq."CV tl fI'I'IOIO~'" Oy "'oYtO.", \.11' '"'' ),((no.", 1"I~rarw:' C4"'OIt"l~ 10 COIIICt Ind wc" ror""''''
A :00'1 ,I '"'I I~I"c"urICln '~J1tl :. .. ..no .u 1/"1, :ru;t"" !1l;"IM.,f '
S'9""''' ~"'LJLo/.'.i/I' fe. 0,,,.,,,,, "'u,..ri"i
"',..1'1 r 51111t , a"lty '/"I'll "'IV. "',I" &r\d Icc',;rlltlV 'ICO'"'''' "" ~~'. .e!:t.,
'r't..1.:-:h;1 ~V...___......_.,~ :lhO""""~ C"~COII':Yf"e "CCIOlfG "'w'''':
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I, Don.ld ". Lawi. III, I.quir., on. of the att.orney. tor
defendant, frovident Lit. and Accident In.urance comp.ny, hereby
c.rtify that I have .erv.d the foreqoinq paper upon coun.el ot
r.cord this date by d.po.itinq a true and corr.ct oopy of the
.... in the Unit.d stat.. mail, fir.t-ola.. po.taq. pr.paid,
.ddr....d a. follow.,
St.v.n J. schiffman, I.quire
S.rrateUi, Schiffman , Brown
sui te 106
2040 Linql..town Road
Harri.burq, PA 17110
I<IIlFER, WOOD, ALLEN , RAHAJ:,
By ~.,..t'~""; i4-
{..' DONA LEWIS III
Dated I F.bruary 13, ltt5
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