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Home My WebLink About95-04212 . ~ ~ J ~ ~ 'lit l:::l. J J . ~ ~ j C'6 - ~ \ ~ en :;~ ::c :-~.; -, c::I: u.Je:. '-' ;z;':',:' .. '@ <D '~ o.c~" '" ,~ , en ,- '. ,,' J f ...... <1; , .... .... -' V'> , , WHITE AND WILLIAMS !HJllE 1800 IMOO MARKf. SIR[CT PUllADELPHIA. PA 19103.7301 WHITE AND WILLIAMS By: Andrew F, Susko, Esquire Michael J. Olley, Esquire Identification No,: 35664/56118 1800 One Liberty Place Philadelphia, PA 19103-7395 (215) 864-6228 Attorneys for Defendant, The Paul Revere Life Insurance Company M. CLAIRE POWERS COURT OF COMMON PLEAS CUMBERLAND COUNTY v, NO, 95-4212 Civil Term THE PAUL REVERE LIFE INSURANCE COMPANY CIVIL ACTION LAW TO THE PROTHONOTARY OF THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY: Pursuant 10 28 U,S,C, ~1446(e) and 29 U.S.C. ~IOOI el. g:g,. named defendant. The Paul Revere Life Insurance Company files herewith a certified copy of the Petition for Removal. filed in the United Stales District Court for the Middle District of Pennsylvania, WHITE AND WILLIAMS By: Attorneys for Defendant, The Paul Revere Life Insurance Company Js.... (Re~. 07t8UJ fh, JS"(..,' (U,,, ~.., I''d I'" -',Iu"".1 U"l.t.l"l,,"'d I",," "'.Ih" Ifl'.' '10'1""'''' Ih, ""e 'V.III...."'.9. ''''5''III'''''''f'5''9'tfo "bw1uUI fI,'" 01 tV,,'1 "lI'Il"T'., I~"U'''''' ll, I". J"lI,( I' Cu"I,.,n{, ullll. U"'lrd SUIII ,n PI"".' 19" ., ".. " 'h_ II ,P' ("......111 'u, I",. ",I dud,,, ltw" tlU INlTRUCfIO~' O~ Uti "l\l(AU OF 'HI fORM I . I (8) PLAINTIFFS DEFENDANTS M, Claire PC7iIers 1'he Paul Revere I.ire Insurance Canpany 1028 West Foxcroft Drive 18 Chestnut Street Campbill, PA 17011 Worcester, MA 01609-1528 CIVIL COVER SHEET (b) C0\.1~l'f Of RLSIClNCE or f,P5Y listED PLAI'WFF _C~~Jancl (nC(pt t,.. u S PLAt~',fF CASESI (c) AnOR~n~ .flflM NAMr. AOOIU!liS AND tELEPHO'jE NUMBERI Lori K. Scrratelli, Esquire SERRJ\TELLI, 5aIIFFWIN Ii BRa'IN, P,C, 2040 Ling1estown Road, Suite 106 Harrisburg, PA 17110-9445 II, BASIS OF JURISDICTION "'" .. ,. ,,.., "''''','', CDUNn or FUSIOENCE OF FIRst L1sno DEFENDANT _______ IIN U 5 PLAINtlrF CASES ONLY, NOIE IN LANO CONOE'-'NATION CASES USE HiE LOCAtiON OF THE TRACt OF LAND INVOlVED AnaRND'S IIF KNOWNI Andrew F. Susko, Esquire WlIITE AND WILLIJ\MS 1800 One Liberty Place P 'Ia I hia PA 19103-7395 III, CITIZENSHIP OF PRINCIPAL PARTIES ,"".... _....oc. tFor o.VllflllyoC....011'y1 'OR~,....,u"oCN 1O.'QlIIOf:fI~. ~ 1 US Gov.,n""n' X 3 F~tf.1 O,,"tlo" PI.lnll" IU S Gc...{""....e"l Nol . PJrtwl PTF OEF PTF OEF CIII"n 01 Thl. Stili' X' " Incorpoll'~ 01 Principal Plact ~: . .: . . 2 US Go~"nm.nl X . Dlv""ly 0' Bv.lne.. In Thl. Stili. Def.nd.nt I!nrncall' C'I'll'l1''''P 01 Clllzen 01 Anolh., Still' 2 2 Incorpolll~ and PrincipII PI.u S XS Pa..'I!s'I1It"....'.,' 0' Bw.lne.. In Anolh" Stll. Cmzen o. SUbtKl 01. 3 "3 Fort.on H.llon :: I . . Fortlon Country IV. CAUSE OF ACTION ,(.', ""I ~ "~"Il. \'4,,,,'llJ"o='lll...kIl:" '0Ii"'" h.lo,o,.'oO ...""1....1',."."'1..' 0/1 (AiIIf. OOOlO'C"I.......~llQto4.''''..I!lo.....tU-.I.\,.. This is a claim for employee benefits pursuant to the Employee Retirement Income Security Act, 29 U.S.C. Section 1001, et.~. In addition, there is diversity of citizenship between thp p"rt;p" ,Inn thp '"l'Clllnt in controvl'>rsy is in p"cos" of $100.000.00 and therefore. this case V, NATURE OF SUIT ,PLACEAtV. ItVOtVEBorOtVLYI is being rerroved pursuant to Section l446(e). CONTRACT TORTS FORfllTUIU IPlHAllY WfIRU" Y ,'0,"""W",. PlRSONAllNJURY PlRIONAllNJURY ..... ~~;~. h,.,. .22 ~II _ 120 .......... 310 4"V'., , 312 ev........ ....-.. .... . 1I1J!ir. 1!l1 _: 130............., 31$ A""'.... p"......, ~~-:::; 825 Ot~O:~;';'l ~tH~,t .23 ~;... _.;140.....,."..."""...__. LotCoo'. ..385p.._..~_ ...130L~..c'll.' 21USC,,7 .: ISO R<<.ao.... 01 o.f<Pot"""" 320 A...~. L.t.>r' , PouMI WbM, 140 R R' '"..c' I ("'CIl'C''''I''W ~ S.."Idr' . 311 A.o.tIOt ~ J\,,~ 330 J..,....l""CI'C....' ....." P.~l 150 ...,..... R'9' . '51 ~., ~1 L'_'t ~'" MO e>c;~D"Qr' ...: '52 Rcc-""..., at OorI_tod 340 v...... _"1, ".."" ~ LoW't 345 ........ P.~"..' PlRSONAl PROPlRrt .. lhc' ......._. Wl'ot" . 170 QINo ".w LAlOR ...: 153 p","",~ ~O\...p.t,......' .350"""'" .......'. .37' ""'.. '" l"""'", :t WI.....' .......t, 355 ......~, ~.. 310 OIN< P..~. -..: no StQU1'Iol1'" s...t. P>tzMt ~,'toool. ...~ 0...,. ~ '10 QlrI., C:DI"'It1 310 O\!'I.- ...._. . 315 ~ 0..... .: "5 Cor>itAC' p,adwct WNot) "-'t Pou1uct lAboM, ftUL !'ROPl"rt CIVIL RIGHtS "''''JI'''1' .....2f~,....~. ...,~...... ""to"P"":......., .............. "'0 Or.. c.....R..,... PROSONla PETmONS : 2'0 L.""c:Ot'.,...,....<;~. _ 220 'Qlf(Illtoo'. : 230 Rr' L.... , r....'..''"I ..: 2..0 fooItlOlI'd _ 2"5 toofP"OIMfLltrO" .-: 2tO A, QlII.. Rel''''''-' s'aw_!{.Il~. ........"". .._,,~.t'.o, no c-.,., sn 0............. S4Qv__.,c>.... ....,.... VI, ORIGIN PROPERTY alOIfTS .120 Ct:c/y'9"" ; 130 P,,_ NO f.............. .110 '''' tMU St.~..I1' '" 720tlllO''''''''' ""<0'" 130 uo.. '-"ir" -........ 00\(-.-. .....' _ 7'0 R....., L.... on . 710 ~lllU ,_ X 791 l""" R.!i'lC 5<<'~"" Ac1 l I RIlY 611 "''''I'J91II, .6I28lac11t1ll1Q1WJI 113 OI....C 0l'NW II~gl1 I" SSiD '" IV! liS RS' "~gfl ftnlRAl TAlIUITS 170 fAt" IU 5 ......... r<lDtfrdl"'. I" .RS - f""" Pill, ~uo;c ~f<09 , Orog<"'" Plotl!~d<l"O X 2 I1l!t"I(J~Ud "om SlaleCwr\' 3 RelNnd.d Irom APQed'le Court tPLACE AN . IN ONE BOX ONLYI .; .. AIM!Iol<lledo- Aeopo"ect TI,n"."e12"o'" 5 another dl!loI",1 IIPl"C,ty) . I Mul11d11111(1 111'OIIlor1 VII, REQUESTED IN COMPLAltn VIII, RELATED CASE(S) IF ANY NONE C~ECK " T~IS IS . CLASS ACTION DEMAND S "'OERFRCP23 In excess o( $25,000.00 ISfOf' 'l""rutl'OflI, DAlE StGNAtURE OF ATTORNEV OF RECORO A 9-6-95 UNITED STATES DISTRICT COUAT . - S .-~..oo St". ~---.... ~I ...: "10 ",*",-,,, :.: .30 e.r... ....., ew.."'o;l :. 00 c:on-.rt. ICe ,,_" "t _"60~ : "0 RIt."_lIIfVtool:tod,,., CorI\ClI~'~ ..110~s-", 150 s.c....."'~~ft (lcNI"V' 175 C..-- c~ IZUSC )110 ~. lit ~vlwfll AdI . ~ 112 (cCl"O'ft( St..,.,...... Ad -_ 113 E_~. ........, ::IM(...."'~A(l ::. Its J.MCtgtoOd 1rIcI'....IlOtlAd __100 ..."rJ'..o.t...........". ~1~,,""lkl -. _:I50~.."uI Sial. $UMt;, ..110 u... St....-orr ..-. Appe,. 10 o.,lr,cl :.: 1 .Ndge I'orn "'gtllllle .NOQ"NInl C"flC. yES OIl/)' " c1,m,f1".c1,f1 campi.,,,, JURY DEMAND: x.: VES .: NO JUOGE _ DOCI(ET t.tUMBER , ESQUIRE 1: CV -95-1504 IN THE UNITED STATES DISTRICT COURT FOR TilE MIDDLE DISTRICT OF PENNSYLVANIA M. CLAIRE POWERS FILED NO. SCRANTON SEP 071995 PER 1) (11 f( DEPUTY CLERK - v, THE PAUL REVERE LIFE INSURANCE COMPANY NOTICE OF REMOVAL TO THE HONORABLE JUDGE OF THE SAID DISTRICT COURT OF THE UNITED STATES: f!; I'"l I Petitioner, The Paul Revere Life Insurance Company, defendant in the above-named action, respectfully requests that this mailer be transferred from the Court of Common Pleas of Cumberland County to the United Stales District Court for the Middle District of Pennsylvania and respectfully represents that: I, This mailer is a civil action which was tiled and is now pending in the Court of Common Pleas of Cumberland County, docketed at Civil Action No. 95-4212. 2, The action was instituted in the Cumberland County Court of Common Pleas on or about August 7, 1995, when plaintiff tiled a civil action in the office of the Prothonotary of the Court of Common Pleas of Cumberland County. In the action, plaintiff seeks money damages against the Petitioner. , - 3, Although the Complaint seeks damages in excess of S25,OOO,OO, the amount in controversy is in excessive of S50,OOO.OO exclusive of costs, A true and correct copy of the plaintiff's Complaint is attached hereto, made a pan hereof and marked as Exhibit" A". 4, In the Complaint, plaintiff alleges that plaintiff's employer paid a ponion of the premium for the disability poliey at issue in this case and plaintiff funher alleges that defendant has refused to pay plaintiff benefits due under the disability policy, 5, Defendant received a copy of the plaintiff's Complaint by cenified mail on August II, 1995, 6. The controversy in this action is between plaintiff citizen of this state and defendant citizen of a foreign state because: (a) Petitioner, The Paul Revere Life Insurance Company is incorporated in Massachusetts and has its principal place of business in Worcester, Massachusetts and is therefore a citizen of the state of Massachusetts for the purposes of this action: and (b) Plaintiff, M. Claire Powers resides at 1028 West Foxcroft Drive, Camphill, Cumberland County, Pennsylvania 170 II. 7. Because there is diversity of citizenship between the plaimiff and the defendant in this action, Petitioner, The Paul Revere Life Insurance Company respectfully requests that this action be removed from the Cumberland County Coun of Common Pleas to this Coun in the United States District Coun for the Middle District of Pennsylvania pursuant to 28 U,S.C, *1332. 8. In addition, plaintiff's claims against The Paul Revere Life Insurance Company arise under and relate to an employee henefit plan regulated hy the Employee Retirement Income Security Act of 1974 (ERISA), 29 U,S.C, *1001 la.~, Based upon infllnnatilln and helief, the plaintiff received her -2- - ..... disability policy through her employer and that policy was issued pursuant to an employee welfare benetit plan, as that term is detined in ERISA, for the purpose of providing plan bene tits to the plaintiff and her beneticiaries, See 29 U,S,C, ~IOO2(1), 9, Title 29 ~1144(a), provides that ERISA's provisions "shall supersede any and all state laws insofar as they may now or hereafter relate to any employee benetit plan," Because the plaintiffs Complaint alleges breach of contract on the part of The Paul Revere Life Insurance Company, the plaintiffs claim "relates to" an employee benetit plan and, is therefore preempted by ERISA, See Pane v. RCA Com., 868 F.2d 631, 635 (3rd Cir. 1989) (state law claims for breach of contract, breach of covenants of good faith and fair dealing, intentional infliction of emotional distress and punitive damages held to be preempted by ERISA). 10, This Court has original jurisdiction to entertain this action pursuant to 28 U,S,C, ~1331 (federal question jurisdiction) and pursuant 10 29 U.S,C, ~1132(e) (ERISA jurisdiction) because the plaintiffs claims are preempted by ERISA and fall within that statute's civil enforcement provisions. See MetroDolitan Life Insurance ComDanv v. Tavlor, 481 U,S, 58 (1987) (a complaintliled in state court purporting to plead a state common law cause of action for improper denial of benetits under an employee benetit plan regulated by ERISA is removable to Federal court). II, Based on the foregoing, The Paul Revere Life Insurance Company asserts that this action is properly removable on the grounds that this court has original jurisdiction over this case under 28 U,S,C, ~1331 and 29 U,S,C, ~1132(e) as well as based upon diversity of citizenship pursuant to 28 U.S,C. ~1332, -3, . - WHEREFORE, Petitioner, The Paul Revere Life Insurance Company respectfully requests that this action be removed from the state court into this court for trial and detennination and that this court make an Order of removal for the said action, WHITE AND WILLIAMS By: Attorneys for Defendant, The Paul Revere Life Insurance Company Dated: Seotember 6. 1995 -4- ., IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA M, CLAIRE POWERS NO, v, THE PAUL REVERE LIFE INSURANCE COMPANY NOTICE TO THE PLAINTIFF TO: Lori K, Serratelli, Esquire SERRATELLI, SCHIFFMAN & BROWN, P,C. 2040 Ling1estown Road, Suite 106 Harrisburg, PA 17110-9445 PLEASE TAKE NOTICE that defendant, The Paul Revere Life Insurance Company has filed a Petition in the United States District Court for the Middle District of Pennsylvania for removal of an action now pending in the Court of Common Pleas of Cumberland County entitled M. Claire Powers v. The Paul Revere Life Insurance Comoanv. Civil Action No, 95-4212. PLEASE TAKE FURTHER NOTICE that Petitioner. The Paul Revere Life Insurance Company has at the same time filed with the United States District Court for the Middle District of Pennsylvania a copy of the Complaint served upon it and which was filed and entered in the Court of Common Pleas .. of Cumberland County, A copy of said Petition for Removal is attached to this Notice and is hereby served upon you. WHITE AND WILLIAMS By: Attorneys for Defendant, The Paul Revere Life Insurance Company Dated: Seotember 6, 1995 -2- , - IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA M. CLAIRE POWERS NO, v, THE PAUL REVERE LIFE INSURANCE COMPANY PROOF OF FILING Andrew F, Susko. Esquire, hereby cenilies that a copy of the foregoing Notice of Removal is to be tiled with the Prothonotary of the Coun of Common Pleas of Cumberland County immediately upon receipt of the cenilied copy from the United States District Coun for the Middle District. WHITE AND WILLIAMS By: USKO, ESQUIRE Attorney for Defendant, The Paul Revere Life Insurance Company . .. VERIFICATION I. ANDREW F, SUSKO, ESQUIRE state that I am allorney for defendant. The Paul Revcre Life Insurance Company in this mailer and statc that thc facts set fonh in the foregoing Notice of Rcmoval are true and correct to the bcst of my knowledgc. information and belicf; and funhcr thatthc statemcnts made therein are subject to the penalties of 18 C,S,A, ~4904 rclating to unsworn falsification to authorities. Dated: SeDtember 6, 1995 - EX H I BIT "A" . ... ,. . 1 . H. CLAIRE POWERS, P1aintitt IN THE COURT OP COMHON PLEAS OP CUMBERLAND lOUNTY, PENNS:nVANIA NO. 1:/- 'i),/)..- OU-'-IjL--:JtL1-I'- CIVIL ACTION - LAW V9. THE PAUL REVERE LIPE INSURANCE COMPANY, Detendant l'. \ \~; ~~~\:J liQ1:.I~li YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within TWENTY (20) DAYS after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judqment may be entered against you by the Court without further notice for any money in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TARE THIS PAPER TO YOUR LAWYER AT ONCE. IP YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFPICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. COURT ADMINISTRATOR CUMBERLAND COUNTY COURTHOUSE FOURTH FLOOR 1 COURTHOUSE SQUARE CARLISLE, PA 17013 (717) 240-6200 TRUE COPY FROM RECORD In Testimony whereof, I here unlo set my hand and lhe s I of sa' I Carlisle, Pa._ Thl. d Y l (,. 19 r j I t,' <" LJ (.'; .- j":' "I - . - . u:> LJI - - M. CLAZRB POWBRS, Plaintitt' : IN THB COURT OF COMMON PLBAB OP Ct1MBBRLAND COUNTY, PBNlfSYLVAHZA VS. NO. CIVIL ACTION - LAW THB PAUL RBVERB LZFB ZNSURANCB COMPANY, Defendant NOTICIA USTED LB BAS SIDO DEMANDADO EN EL TRIBUNAL. si desea alegar defensa alguna alas reclamaciones expuestas en las paginas siguientes, usted de be ir a la audienca, Advertencia: de no comparecer ante dicho tribunal, su caso sera decidido en su ausencia y, sin mas notificacion, el tribunal puede dictaminar un Decreto contra usted por cualquiera reclamacion 0 compensacion alegada en la Peticion. Usted puede perder dinero 0 propiedad u otros derechos import antes a usted. LLBVB ESTOS DOCUMBNTOS A SU ABOGADO EN SEGUZDA. SI NO TIENB UN ABOGADO 0 NO TIENE CON QUE PAGAR TAL SERVICIO, VISTE 0 LLAME A LA SIGUBINTE DIRECCION. COURT ADMINISTRATOR CUMBERLAND COUNTY COURTHOUSE FOURTH FLOOR 1 COURTHOUSE SQUARE CARLISLE, PA 17013 (717) 240-6200 , - M. CLAIRB POWERS, Plaintiff IN THB COURT or COKMON PLEAS or CUKBBRLAND COUNTY, PBNlfSYLVANXA VB. NO. CIVIL ACTION - LAW THB PAUL REVERB LIFB INSURANCB COMPANY, Defendant \ \t(iS tJ.~\1 \ t~" COMPLAINT AND NOW, comes Plaintiff, M. Claire Powers, by and through her Attorney, Lori K, Serrate1li, Esquire, and the law firm of Serrate1li, Schiffman, Brown and Calhoon, P.C. and files this Complaint and avers as follows: 1, The Plaintiff is M. Claire Powers, an adult individual residing at 1028 West Foxcroft Drive, Camp Hill, Cumberland County, Pennsylvania 17011. 2, The Defendant is The Paul Revere Life Insurance Company, an insurance corporation licensed to do business in Pennsylvania with a home office at 18 Chestnut Street, Worcester, Massachusetts 01608, 3, On or about November 17, 1992 the Plaintiff applied for a policy of insurance from Defendant insuring herself from disability as defined in the pOlicy, a copy of which is attached hereto and incorporated herein as Exhibit "A" (hereinafter referred to as the "policy"). The effective date of the policy was January 1, 1993. The policy was issued on or about January 1, 1993. - - 4. Plaintiff's employer had previously paid 90. 6t of the premiWll and Plaintiff paid 9.4' for a total of 100' which the Defendant had requested as payment for its policy. 5. According to the terms of the policy, Plaintiff was to be insured if she became totally disabled or residually disabled. 6. Plaintiff, became disabled progressively from January 1, 1993 to the point where she could not perform the duties of her position and applied for disability on September 29, 1994, at which time the policy was in full force and effect. 7. Plaintiff notified Defendant of her total disability on September 29, 1994, 8. By letter dated April 12, 1995 Defendant notified Plaintiff that the payments would not be made to Plaintiff based on Defendant's conclusion that Plaintiff was not totally disabled as defined in the policy, 9. Plaintiff has met all conditions precedent under the policy. 10, Plaintiff continues to be disabled from the increased debilitating effects of mUltiple sclerosis. Further, Plaintiff is totally disabled as defined in the policy due to the increasing debilitating effects of multiple sclerosis, 11. After repeated demands, Defendant has refused and continues to refuse to pay the benefits as required under the policy from September 29, 1994 through the present. - - ~~ 12. The refusal and failure of the Defendant to pay benefits under its policy to Plaintiff is without basis and in fact is in violation of the language and coverage of the policy. 13. In further violation of its policy and the laws of the Commonwealth of Pennsylvania, the Defendant has unreasonably and unfairly withheld policy benefits due the Plaintiff under the policy as set forth above. 14. The conduct of the Defendant includes, but is not limited to, the following: (a) failing to give equal consideration to the claim as to not paying the claim; (b) failing to objectively and fairly evaluate the Plaintiff's claim; (c) compelling the institution of this lawsuit to obtain policy benefits that should have been paid promptly and without the necessity of litigation. 15. Plaintiff, at all times relative hereto, fully complied with all terms and conditions of the policy and all conditions precedent and subsequent to her right to recover under the policy. 16. Nonetheless, the Defendant refused, without legal justification and cause, and continues to refuse to negotiate in good faith and/or to pay the Plaintiff benefits due under the policy in connection with her disability. , - 1" -~~ COUNT I BREACH OF CONTRACT 17. Paraqraphs one (1) through sixteen (16) are incorporated hereto by referenced as if fully set forth herein. 18. By failinq to pay the Plaintiff the benefits due under this policy, as set forth above, the Defendant breached its contractual obliqations to Plaintiff under the policy. WHEREFORE, Plaintiff demands jud9ll1ent aqainst the Defendant in an amount in excess of $25,000.00, toqether with interest, court costs, attorneys fees, and such other relief as this Honorable Court shall deem just and proper. Respectfully submitted, 7 , 'I_~-~ (:..t. Lor VK Serratell~, Esqu re SERRATELLI, SCHIFFMAN AND BROWN, P.C. 2040 Linqlestown Road suite 106 Harrisburq, PA 17110 (717) 540-9170 Attorney for Plaintiff . .. '~ ~. VERIPICATION I verify that the statements made in the foregoing Complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa, C,5. Section 4904, relating to unsworn falsification to authorities. Date: ~ 3J'I9F %/~~ M, Cla~re Powers : :: Ln ~ lk en ,- - ..t .. _. I ~ -. '-J '(') C- '" . .... c..... ~ - :3' C"') ~ A R \;.., ,.... r-- ~ - <.., c.." I'() => ~-:r. ....... '"\ ~ ~ ~~ .... ~-'i - '---l (::) ~ ~ ~~ J, , , , . Hili"".' .~"U.. ,.r.u.....nu. Olo...oIO'.""""'tntI1U.""'" . " S l..o,..." f.RRATUI.I. SCttlPFMAN 6( BIUlWN r. . limn 106 . .(., )040-.,"":t"'I1""" """II IhUJdlll>,I'A ,,^lfI',41U ... . ,. .. io' ~~~ !J~5: ~ ::.. "'. ~ ~ ~J~ r " ~ .' VB. IN THE COURT OF COHMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 1j- 4 2- tJ- (llc t~L ;J l-l-1,"-- CIVIL ACTION - LAW M. CLAIRE POWERS, plaintiff THE PAUL REVERE LIFE INSURANCE COMPANY, Defendant HQ:rI~~ YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within TWENTY (20) DAYS after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you, YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. COURT ADMINISTRATOR CUMBERLAND COUNTY COURTHOUSE FOURTH FLOOR 1 COURTHOUSE SQUARE CARLISLE, PA 17013 (717) 240-6200 . va. I IN THE COURT OP COMMON PLEAS OP I CUMBERLAND COUNTY, PENNSYLVANIA I I NO. I CIVIL ACTION - LAW M. CLAIRE POWERS, plaintiff THE PAUL REVERE LIPE I INSURANCE COMPANY, I Defendant I NOTICIA USTED LE BAS SIDO DEMANDADO EN EL TRIBUNAL. si desea alegar defensa alguna alas reclamaciones expuestas en las paginas siguientes, usted debe ir a la audienca. Advertencia: de no comparecer ante dicho tribunal, su caso sera decidido en su ausencia y, sin mas notificacion, el tribunal puede dictaminar un Decreto contra usted por cualquiera reclamacion 0 compensacion alegada en la peticion. Usted puede perder dinero 0 propiedad u otros derechos import antes a usted, LLEVE ESTOS DOCUMENTOS A SU ABOGADO EN SEGUIDA. SI NO TIENE UN ABOGADO 0 NO TIENE CON QUE PAGAR TAL SERVICIO, VISTE 0 LLAME A LA SIGUEINTE DIRECCION. COURT ADMINISTRATOR CUMBERLAND COUNTY COURTHOUSE FOURTH FLOOR 1 COURTHOUSE SQUARE CARLISLE, PA 17013 (717) 240-6200 . ..~,...,. ~ " .. .. M. CLAIRE POWERS, Plaintiff VB. I IN THE COURT OP COMMON PLEAS OP I CUMBERLAND COUNTY, PENNSYLVANIA I I NO. I CIVIL ACTION - LAW I I THE PAUL REVERE LIPE INSURANCE COMPANY, DBfendant . . COMPLAINT AND NOW, comes Plaintiff, M. Claire Powers, by and through her Attorney, Lori K. Serratelli, Esquire, and the law firm of Serratelli, Schiffman, Brown and Calhoon, P.C. and files this Complaint and avers as follows: 1. The Plaintiff is M. Claire Powers, an adult individual residing at 1028 West Foxcroft Drive, Camp Hill, Cumberland County, Pennsylvania 17011. 2. The Defendant is The Paul Revere Life Insurance Company, an insurance corporation licensed to do business in Pennsylvania with a home office at 18 Chestnut street, Worcester, Massachusetts 01608. 3. On or about November 17, 1992 the Plaintiff applied for a policy of insurance from Defendant insuring herself from disability as defined in the policy, a copy of which is attached hereto and incorporated herein as Exhibit "A" (hereinafter referred to as the "policy"). The effective date of the policy was January 1, 1993. The policy was issued on or about January 1, 1993. '. .. . . 4. Plaintiff's employer had previously paid 90.6\ of the premium and Plaintiff paid 9. 4iI; for a total of 100\ which the Defendant had requested as payment for its policy. 5. According to the terms of the policy, Plaintiff was to be insured if she became totally disabled or residually disabled. 6. Plaintiff, became disabled progressively from January 1, 1993 to the point where she could not perform the duties of her position and applied for disability on September 29, 1994, at which time the policy was in full force and effect. 7. Plaintiff notified Defendant of her total disability on September 29, 1994. 8. By letter dated April 12, 1995 Defendant notified Plaintiff that the payments would not be made to Plaintiff based on Defendant's conclusion that Plaintiff was not totally disabled as defined in the policy. 9. Plaintiff has met all conditions precedent under the policy. 10. Plaintiff continues to be disabled from the increased debilitating effects of multiple sclerosis. Further, Plaintiff is totally disabled as defined in the policy due to the increasing debilitating effects of multiple sclerosis. 11. After repeated demands, Defendant has refused and continues to refuse to pay the benefits as required under the policy from September 29, 1994 through the present. '. .. . . 12. The refusal and failure of the Defendant to pay benefits under its policy to plaintiff is without basis and in fact is in violation of the language and coverage of the policy. 13. In further violation of its policy and the laws of the Commonwealth of Pennsylvania, the Defendant has unreasonably and unfairly withheld policy benefits due the Plaintiff under the policy as set forth above. 14. The conduct of the Defendant includes, but is not limited to, the following: (a) failing to give equal consideration to the claim as to not paying the claim; (b) failing to objectively and fairly evaluate the Plaintiff's claim; (c) compelling the institution of this lawsuit to obtain policy benefits that should have been paid promptly and without the necessity of litigation. 15. Plaintiff, at all times relative hereto, fully complied with all terms and conditions of the policy and all conditions precedent and subsequent to her right to recover under the policy. 16. Nonetheless, the Defendant refused, without legal justification and cause, and continues to refuse to negotiate in good faith and/or to pay the Plaintiff benefits due under the policy in connection with her disability, '. . .. COUNT I BREACH OF CONTRACT 17. Paragraphs one (1) through sixteen (16) are incorporated hereto by referenced as if fully set forth herein. 18. By failing to pay the Plaintiff the benefits due under this policy, as set forth above, the Defendant breached its contractual obligations to Plaintiff under the policy, WHEREFORE, Plaintiff demands judgment against the Defendant in an amount in excess of $25,000.00, together with interest, court costs, attorneys fees, and such other relief as this Honorable Court shall deem just and proper. Respectfully SUbmitted, , CI I ,f'I. '-~~~ Serratell , Esqu re TELLI, SCHIFFMAN AND BROWN, P.C. 2040 Linglestown Road suite 106 Harrisburg, PA 17110 (717) 540-9170 Attorney for Plaintiff . . VERIJ'ICATION I verify that the statements made in the foregoing Complaint are true and correct, I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. section 4904, relating to unsworn falsification to authorities. Date: 4 J,I9lf.r ~C~w~ EXHIBIT A .. .' . .. """"'""':- ,.. 1 '!~l .., "oJ. ....., \ "":" ..{;... ;,' ,J '~~A '~"".~ ',"".1 , . 4,'''l f', ,,:;. ;.,.~ ,?,:. "~'] ~i.':: .!".....1 :~1 -'\~ ~. ...~ ;~;i ,:,..:1 ~~ :.:;" .'~' -... ;' [,i -;.1_ .' .... ..... ...'.. " .: ~ ,...1 ': t ;;1 ?'::! 'rl ,~ "~l , i .; J j ': j . ,~',! .~ '~ THE PAUL REVERE LIFE INSCRANCE COMPANY 18 CHESTNUT SmEET WORCESTER, MASSACHUSETTS 01608 The Paul Revere Life Insurance Company Will pay the benents provided In this Policy for loss due to Inlury or Sickness. We nave Issued this Policy to You In consideration of the payment of the premium and the statemeots made In Your application, Your application IS pan of thiS POliCY, Insured M CLAIRE POWERS Policy Number 01025905480 JAN 01, 1993 Date 01 Issue NON.CANCELLABLE AND GUARANTEED CONTINUABLE TO AGE 65, NO CHANGE IN PREMIUM RATES, As long as the premium IS paid on time. We cannot change Your Policy or its premium rate unlll Your 65th birthday. CONDITIONALLY RENEWABLE AFTER YOU REACH AGE 65, SUBJECT TO CHANGE IN PREMIUM RATES, You may continue Your Policy for a Total Disability beneril wllh a limited benefit period while You are actively and regularly employed full time, There 's no age limit. ihis option is explained In PART ;, When You are no longer actively and regularly employed aller age 65. You may continue Your Policy for the rest of Your Iile. The benefit will be limited to a Hospital Confinement Indemnity. ThiS benefit Will take the place of all other beoefits under the Policy. ThiS option IS explained in PART a. PRE,EXISTING CONDITION, During the first two years from the Date of Issue. We will not pay benefits for a Pre-existing Condition If it was not disclosed on Your application. Also. We will not pay benefits (or any lOSS We have exclUded by name or speCific description, A Pre-existing Condition disclosed on the application which has not been excluded by name or speCific deSCription is covered under thiS Policy as of the Date of Issue. YOUR RIGHT TO CANCEL, If You are not satisfied with Your Policy, You may cancel It. Return the Policy to Us or Our agent by midnight of the tenth day aileI' the date You receive It. If You return the Policy by mall. It must be properly addressed, postage prepaid, ano postmarked no later than midnight ofthat tenth day, Our mailing address is 18 Chestnut Street. Worcester, Massachusetts 01608, Within ten days alter We receive the Policy, We Will refund any premium You have paid. The Policy will be considered to nave never been issued. READ YOUR POLICY CAREFULLY, It IS a legal contract between You and Us, Signed for The Paul Revere Life Insurance Compaoy, lL I/. 13<. ~ Secl'tl:ary rY~ ~ ~ Prnidtnt '::'MIt7!:\!:> :, "U.$\"CMt.:SI!~\ 'I)~.?,\R.':':C:?';::-;C 990 PA '10 iJlSABILITY INCOME POLICY ;;-.E "REc:i'lRED "RCF:SSICNAL 91,' TABLE OF CONTENTS Rllnewal Provisions Policy SChedule Automatic Increase Benefit Part 1 - Definitions Part 2 - Benefits Total Disability Benefit Residual Disability Benefit Recovery Benefit Presumptive Total Disability Benefit Cosmetic or Transplant Surgery Rehabilitation Survivor Benefit Limited Guaranteed Insurability Benefit Part J - Exclusions Part ~ - Premium and Reinstatement Part 5 - Waiver of Premium Part 5 - Recurrent and Concurrent Disability Part 7 - Renewal Option After Age 65 If Employed - Total Dlsaoility Benefit Part ~ - Renewal Ootion After Age 65 If Not EmployeD. Hospital Confinement Indemnity Part 9 - Claims Part 10 -General Provisions i , i , , , , I , i , I A CODY of Your application, added benefits You have purchased, and any! added prOVISions are attached atlhe back of the Policy. 990 PA "0 !JISABIL:TY INCOME POLICY -"'E '''lE;::;lRED P"lCF:SSIONAL p F Page .. 3 3 6 6 a ,8 \0 10 10 11 11 11 11 . ~ 12 13 13 14 .- 15 16 17 c .. .- 91-' POLICY SCHEDULE POLICY NUMBER: 010259054B DATE OF ISSUE: JAN 01, 1993 INSURED: POLICY OWNER: M CLAIRE POWERS THE INSURED ,--***************-*-***********-***************-****-**************************- SUMMARY OF PREMIUM PREFERRED NONSMOKER ANNUAL PREMIUM FOR DISABILITY BENEFITS ANNUAL PREMIUM FOR ADDITIONAL BENEFITS TDTAL ANNUAL PREMIUM -SELECT 30 ANNUAL PREMIUM $1,215.4B $462,OB $1.677 ,56 $1.174,29 YOUR ANNUAL PREMIUM EMPLOYEE SECURITY PLAN $1.174.29 *YOU HAVE A SELECT PREMIUM AS INDICATED, THIS PREMIUM WILL REMAIN IN EFFECT UNTIL YOUR 65TH BIRTHDAY, IT IS SUBJECT TO CHANGE IF YOU RENEW YOUR POLICY AFTER YOUR 65TH BIRTHDAY, ************************************************-*******************************- TABLE OF DISABILITY BENEFITS FROM INJURY OR COMMENCEMENT DATE FROM SICKNESS CELIMINATION PERIOD) I 1B1ST DAYC180l I MAXIMUM MONTHL Y AMOUNT MAXIMUM BENEF IT PER IOD* $3,200,00 TO AGE 65 ----------------------------------------------------------. QUALIFICATION PERIOD FOR RESIDUAL DISABILITY: 0 DAYS *THE MAXIMUM BENEFIT PERIQD MAY CHANGE DUE TO YOUR AGE AT TOTAL DISABILITY, PLEASE SEE POLICY SCHEDULE II, ********************************************************************************- MODIFICATION OF COVERAGE NONE. f**********f****'************.***********f*.*****.***.************************_*. 990 PREFERRED PROFESSIONAL DISABILITY INCOME POLICY 91-1 POlley SE:HI'DUlE POLICY NUMBER, 0102590548 DATE OF ISSUE: JAN 01, 1993 INSURED: M CLAIRE POWERS POLICY OWNER: THE INSURED .*******************************************************************************, TABLE OF ADDITIONAL BENEFITS ADD I TI ONAl BENEFITS ATTACHED AMOUNT OF BENEF IT MAXIMUM BENEF IT PER 100 ANNUAL PREMIUM PRIOR TO AGE 6: ;:OST OF LIVING ([107) 4;~ - CP I - 7~~ .397.76 iOTAl OISABIlITY IN YOUR OCCUPATION .64,32 -------------------------------------------------- , POLICY SCHEDULE II POLICY NUMBER: 0102590548 DATE OF ISSUE: JAN 01, 1993 INSURED: M CLAIRE POWERS I POLICY OWNER: THE INSURED I t.*******************************************************************************- I MAXIMUM BENEFIT PERIODS FOR TOTAL DISABILITY BENEFITS PAYABLE TO AGE 65, IF TOTAL DISABILITY BEGINS: BEFORE AGE 61 TO AGE 65 AT AGE 61 BU T BEFORE AGE 62 48 MONTHS AT AGE 62 BUT BEFORE AGE 63 42 MONTHS A T AGE 63 BUT BEFORE AGE 64 36 MONTHS AT AGE 64 BUT BEFORE AGE 65 30 MONTHS AT OR AFTER AGE 65 BUT BEFORE AGE 75 24 MONTHS AT OR AFTER AGE 75 12 MONTHS .... POLICY SCHEDULE III 'POLICY NUMBER: 0102590548 DATE OF ISSUE: JAN 01. 1993 INSURED: M CLAIRE POWERS POLICY OWNER: THE INSURED ,,*..*..*.......*.*.............**..........................***.*..***.**..**.*..- AUTOMATIC INCREASES PRIOR TO YOUR 60TH BIRTHDAY. YOU MAY AMEND THIS POLICY TO PROVIDE FOR AUTOMATIC INCREASES TO MONTHLY BENEFITS. YOU CAN DO THIS BY APPLYING TO US, APPROVAL WILL BE SUBJECT TO OUR: UNDERWRITING GUIDELINES, PART 1 DEFINITIONS THE FOLLOWING WORDS HAVE SPECIFIC MEANINGS. THEY ARE IMPOR. T ANT IN DESCRIBING YOUR RIGHTS AND OUR RIGHTS UNDER THE POLICY REFER BACK TO THESE MEANINGS AS YOU READ YOUR POLICY, 1,1 -Policy" means the legal contract between You and Us. The policy, the applic3110n. the Policy Schedule, and any attached papers that We call riders, amendments. or endorsements make up the entire contract between You and Us, 1,2 .You. and "Your" refer to the ,nsured named in the Policy Schedule. 1,3 .W.., .Us. and .Our" refer to The Paul Revere Life Insurance Com- pany, Our Home Office is 18 Chestnut Street, Worcester, Massachusetts, 01608. 1,4 .Dat. of Issu.. means the date that the Policy becomes effective, It IS shown on Ihe Policy SClledule, 1.5 .'njury" means aCCidental bodily Injury sustained after the Date of Is. sue and wnile Your Policy is In force. 1.6 .Slckn.... means Sickness or disease which is diagnosed or treated after Ihe Cate of Issue and wnile the Policy is in force. Complicallons of pregnancy or complicallons of childbirth are treated as any other Sickness under the Policy. Sickness Includes Disability due 10 normal pregnancy or normal childbirth. l,i .Physlclan. means any licensed practitioner of the healing arts prac' licing Within the scope of hiS or her license, A Physician must oe a person other than You. 1.8 .Physlclan's Care. means the regular and personal care of a Physi- Cian whiCh. under prevailing medical standards, is appropriate for the condition causing the disability. 1,9 "Your Occupallon. means the occupation or occupations in which You are regularly engaged at the time Disability begins. 1,10 "Tolal Disability" means that because of InjUry or Sickness: a. You are unable to perform the important duties of Your Occu- pallon:and b. You are receiving Physician's Care. We will waive thiS re, quirement If We receive written proof acceptable to Us lhat further PhYSICian's Care would be of no benerit to You. 1.11 .Resldual Disability", prior to the Commencement Date, means :hat due to Inlury or Sickness which begins prior to age 65: a. (1) You are unable to perform ooe or more of the important duties of Your Occupallon; or (2) You are unable 10 perform the Important duties of Your Occupallon for more than 80% of the time normally reqUired to perform them: and b, You are receiving Physlclan's Care. We Will waive thiS reOUlre- ment,f We receive written oroof acceotable 10 Us Ihat further care would oe of no beneritlo You: and c. You are not Totally Disabled, 990 FA '(0 .6- 91-1 " r As of the IIrst Commencement Date to occur, ReSidual Disability means that due 10 the continuation of that Inlury or Sickness: a, You Incur a Loss of EarnIngs wnlle You are engaged In '(our Occupation or another occupation: and b, You are receiving PhYSICIan's Care. We will waive Ihls reo QUlrement if We receive wrllteo proof acceptable to Us that further care would be of no benefit to You: and c. You are not iotally Disabled, ReSIdual Disaolllty musl follow right after a period of Tolal Disability that lasts at least as long as the Qualification Period. if any, ThiS pe. rlOd is shown on the Policy Schedule. 1.12 .Dlsablllly"or .Dlsabled. refers to a continUing period of Total and/or ReSidual Disability, For a MaXimum Benefit Period 'To Age 65- or .Lifetime., successIVe periods Will be deemed to be continuing If: a. Due to the same or related causes: and b, Separated by no more than 12 months. For all other MaXimum Benefit Periods. successive perIods Wilt be deemed to be continuing if: ' a. Due to the same or related causes: and b. Separated by no more than 6 months. Otherwise sucn periods Will be deemed to be new and separate Disabilities, The MaXimum Benefit Period IS shown on the Policy Schedule. 1,13 .Commencement Date. is the day shown on the Policy Schedule when benefits beglo during a Disability. 1.14 .Ellminatfon Period" is the initial period prIor to the Commencement Date during the continuance of iotal Disaollity for whiCh benefits will not be paid. The Elimination PerIod is shown on the Policy Schedule. 1.15 "Maximum Benefit Period" is the longest period of lime for which We Will pay benefits during any Disability, It IS shown on the Policy Schedule. We will not pay ReSidual Disability or Recovery benefits beyond the later of: a. Your 65th birthday: or b. ihe dale on which 24 months at Disability bene!1ts have been paid, 990 ,', 1.16 'Compllcatlons af Pregnancy" means: a. conditions requiring mealcal treatment prior or subsequent to the termination or pregnancy wnose diagnoses are distinct rrom pregnancy, but wnlCh are aaversely affected by prey' nancy or caused by pregnancy, SUCh as acute hephrltls, nephrOSIS, cardiac decompensatloo, missed abortion, disease of the vascular, hemoaeleatlc. nervous, or endOCrine systems. and Similar medical and surgical condlllons of comparable se- verily: but will not Include raise labor. accaslonal SPoiling, phYSICian prescrlbea rest during the period 01 pregnancy, morning sickness and Similar conditions associated With the management 01 a difficult pregnancy not coostltutlng a classlnably distinct complication of pregnancy: and b, hyperemesIs gravldarum and pre-eclampsia requiring hospital connnemeot, ectopIc oregnancy wnlch is terminated, and spontaneous termination of pregnancy which occurs ouring a period 01 gestation in wnlch a 'liable blnh is not pOSSible. c, conditions requiring meoicaltreatment aileI' the termination 01 pregnanc,/ whose diagnoses are distinct Irom pregnanC'/, but which are adversely affected by pregnancy, or caused by pregnancy, PART 2 BENEFITS The monthly benents payable un~er thiS Policy are subject to the terms 01 Pan 9 'Claims', 2.1 TOTAL DISABILITY BENEFIT We will periodically pay a Total Disaollity benent during Your Total Disability. The monthly amount We Will pay IS Ihe MaXimum Monthly Amount. It is shown on the Policy Schedule, Th.s benent will begin on the Commencement Date. We will continue to pay it while You remain Totally Disabled. 3ut in no event will We pay beyond the MaXimum Benent Period, For perloas 01 less than a month, We Will pay 1/301h 01 the benent for each day 01 Total Disability. 2,2 RESIDUAL DISABILITY BENEFIT We witl periodically pay a Residual Disability benent during Your ~esldual Dlsabilll'/. The monthly amount We will pay eouals: Loss 01 EarninQs X MaXimum Monthly Amount Prior Earnings During any Disabllil'/ each 01 the nrst 6 monthly payments 01 this beoent will not be less thao 50% ollhe Maximum Monthly Amount. The benent will begin on either the Commencement Oate or the day aiter Your Total Dlsabilil'/ ends. II later. We Will pay Ihls benent while Your Resldule Dis' ability continues, but not beyond the MaXimum Benent Period. For periods 01 less than a month, We Will pay 1/301h of the benent lor each day of ReSidual Disability, -Loss af Earnings' lor any month means Your Prior Earnings minus Your Monthly Earnings lor the month lor wOIcn a benent IS claimed. This oifference Will be conSidered Loss 01 Earnings :0 Ihe extent It IS due 10 the InJUry or SiCk, 1ess which caused the Disability, -he "oss of Earnings must be at least 20% of Prior Earnings, II the Loss 01 Earnings for any month '5 is''. or more of Prior Earnings. We Will aeem Ihe loss to be 100% of orlor E3r",ngs, 990 ::>A YO .~, " What is the Total Disability benefil? When IS the ReSidual Disability benefit payable? How IS the Residual Disability benefit calculated? 9' , " .. "Prior Earnings" means the greater of: a. Your average Monthly Earnings for the year lust before Your Disability began: or b. Your highest average Monthly Earnings for any 2 successive years during the 5 year period lust berore Your Disability be. gan. Starting as of the first ReView Date. We Will make an inHatlon adjustment 10 Your Prior Earnings. We Will multiply Your Prior Earnings by the CPI Factor. The result Will be used untJlthe next ReView Date 10 compute ReSidual Disa- bility beneflt amounts payable. However. Ihe inflation adjustment increase Will be alleast 7% of Your Prior Earnings amount. The Infiatlon adjustment Will not apply once the Disability ends. But It Will apply to recurrent Disability deemed continuing under the Recurrent Disabll. ity section 01 Your Policy. "CPI" means the Consumer Price Index for All Urban Consumers. It is pub. IIshed by the Untted Slates Department of Labor. If Ihls index IS discontinued or If the method for computing It is materially changed. We may choose an. other index which WIll be sublect to the approval of the Pennsylvanta Insur. ance Commissioner. We Will choose an Index which in Our opinion would most accurately refiect the rate of change In the cost of liVing in the United States. CPI will then mean the IndeX We chose. "Review Date" means the date that occurs: a. After each successive 12 months of Disaollity; and b. While Your Disability continues. No ReView Date Will occur on or after Your 65th birthday. "Index Month" means the calendar month four months prior 10 the calendar month in which a ReView Date occurs. 3ut the first Index Month for any Dis. ability wlIi be the calendar month 4 months prior to the month in which Your Disability began. "CPI C.hang." means the result of a computation We Will make as of each ReView Date. We Will diVIde the CPI for the most recent Index Month by the CPI for the Index Month prior to the most recent Index Month. "CPI Factor" means the result of the CPI Change as of the current Review Date multiPlied by the CPI Change for each prior ReView Date occurring since the Disability began. The CPI Factor as of the first ReView Date will equal the CPI Change as of that ReVIew Date. A CPI Factor Is determined as of eacn ReView Date whIle Disability continues. "Monthly Earnings" means Your salary. wages. commissions. bonuses. fees. and income earned for services performed. If You own any portion of a bUSiness or profeSSion. it means: a. Your share of the income earned by that bUSiness or profes- sion; Less Your share of bUSiness expenses wnrch are deductible for Federal Income tax purposes: Plus Your salary and any contributions to a pension or profit sharing plan made on Your behalf. b. - .. Monthly :arnlngs does not Include: a. Income from deferred compensation plans. disability ,ncome pOliCies. or retirement plans: or ~ Income not derived from Your vocatlonai aC:IVltles 990 .g. We will allow either the C3sn or accrual accounting method. But dUring a Disability the same method must be used wnen determining Loss of Earnings. As reqUired by state law. the ReSidual DlsaOlllty benellt Will be reduced by the amount of any first pany benefils paid under automoolle ,nsurance and by any worker's compensation benefits. There IS no reduction for Total Disability oenefits. 2,3 RECOVERY BENEFIT We Will periodically pay a Recovery benefit dUring Your Recovery after You have satlslfied the Elimination Period, and while You are not entitled to Total or ReSidual Disability oenefils. "Recovery" means a period whIch beginS prIor to age 65 during whIch: a. YOu 'ncur a Loss of Earnings wnich follows TOlal Dr ReSIDual Disability Whlcn continued at least to the Commencement Date: and b. The Loss of Earnings is the Direct result of the prior Inlury or Sickness whIch caused the Total or ReSidual Disability; and c. You are working full time In Your Occupation. "Full lime" means at least as many hours as You were working before Your Disability began. The month", amount We pay Will be calculateD as If You were ReSidually Disabled. ThiS benellt Will begin on the day after Your Total or ReSidual Disability endS. We Will continue to pay this benefit while Your Recovery continues. We Will not pay beyond the end of the MaXImum Benefit Period. 2.4 PRESUMPTIVE TOTAL DISABILITY BENEFIT If Inlury or Sickness causes You to totally and Irrecoverably lose: a. Your power of speech: or b. Your hearing In both ears: or c. Your SIght In both eyes: or d. Use of both hands: or e. Use of both feet: or f. Use of one hand and one foot: We Will presume You to be Totally Disabled as long as such loss continues and Whether or not You are able to work or require PhYSICian's Care, The Total Disability benefit Will begin on the date of the above loss. We Will pay It for the amount and MaXimum Benefit PerIods shown on the Policy Schedule. But We Will pay benefits for Your lifetime If: a) the MaXImum Benefit PeriOd IS "to age 65" or "lIfelimeH, and b) such loss occurs prior to age 65. 2.5 TOTAL DISABILITY BECAUSE OF COSMETIC OR TRANSPLANT SURGERY After 6 months from the Dale of Issue. If You become Totally Disabled be- cause You have surgery to: a. Improve Your appearance or prevent Disfigurement: or b. Transolant pan of Your bOdy to someone else: We Will conSider You to be Totally DisableD due to Sickness, if the above surgery 's non-elective. you '.'I,ll be covered as of the Date of Is- sue. 990 ?A '10 .10- Coin benefits be paid if not Disabled? Can Total Disability be automatically assumed? IS cosmetic or transplant surger{ covered? 91.1 -- What happens" a program of retraining or rehabilitation /s entered? IS there a benefit if You die? When are you not covered? What If a disability results from a Pre-ex/sting Condition? 990 .' " 2.8 REHABILITATION We Will pay for the c~st of servIces Incurred In connecllon With a program of vocatIonal rehabilitation If: a. We enter Into an agreement With You on both the program and the ser'/lces: and b. The cost of the services IS not covered by another plan or pro. gram, Participating In such a program Will not affect Your eligibility for benefils un. der Your Policy. 2.7 SURVIVOR BENEFIT If You die after the Commencement Date and prior to age 65, and while You are eligible for Total Disability benefits, We WIll pay to Your oeneficlary 3 limes the MaXimum Monthly Amount payable at the lime You die. Your ben- efiCiary Will be Your estate. But You may name someone else by wrulng to Us. 2,8 LIMITED GUARANTEED INSURABILITY BENEFIT You may elect 10 Increase Your Monthly Total Disability Benefit by 530.00 on any POlicy Anniversary thaI IS not more than five years f~m the Policy Issue Date. The premium for thiS benefit increase Will be determined by Your at- tained age on the PoliCY Anniversary. PART 3 EXCLUSIONS 3.1 EXCLUSIONS We will not pay ?olicy benefits: a. Due to an act or aCCident of war. whether declared or unde. ClareD: or b. For a Disability to which a contributing cause was Your com- mission of or attept 10 commit a felony or to which a contribut- ing cause was Your being engaged in an illegal occupation. 3.2 PRE.EXISTING CONDITION During the first two years from the Date of Issue, We will not pay benefits for a Pre-existing ConDition if It was not disclosed on the Application. Pre. Existing Condition means a Sickness or phYSical conDition for which medical adVice or treatmenl was recommended by or received from a Physician within a five-year periOd preceding the Date of Issue. A Pre-exIsting COndition disclosed on the application which has not been ex- cluded by name or soeclfic deSCription IS covered under thiS Policy as of the Date of Issue. Also We Will not Day oenefits for any loss We have excluded by name or sdeclfic deSCription. - PART 4 PREMIUM AND REINSTATEMENT 4.1 PAYMENT OF PREMIUM The first premium on Your Policy IS payable on the Date of Issue, After that. premiums are payable in the amount and mode snown on the Policy Sched- ule. Payments may be made at Our Home Office, 18 Chestnut Street. Worcester. Massachusetts 01608, or to Our agent. Premiums may be paid annually or semi-annually. If Our rules permit it. You can pay the premiums quanerly or monthly. We will allow You to change thiS by written request. But, We will not allow a change while You are Disabled. 4,2 GRACE PERIOD After the first premium has bet!n paid. a grace oerrod of 31 days is allowed for late payment of premium. Your Policy Will rema,n In force during the grace period. If the premium is not paid when it is due or within the grace period. the Policy will lapse, 4.3 REINSTATEMENT If Your Policy lapses because the premium is not paid W" ~n due or within the grace period. it Will be reinstated if We or Our agent ac;~pts payment of the premium without reqUiring a reinstatement appllcalion. If We receive the premium due at Our Home Office within 57 days from the date the premium was due. We will not require eVidence of Your insurability. If We receive the premium after 57 days. We will require a reinstatement ap- plication, We will Issue You a conditional rece'Pt for the premium. If We ap- prove Your application. the Policy will be reinstated as of the date of Our approval. If We disapprove Your application. We must do so In writing within 45 days of the date of the conditional receipt or the Policy will be reinstated on the 45th day. The reinstated Policy Will cover only loss due to: a, Injury sustained after the date of reinstatement: or b. Sickness that beginS more than ten days after such date. Except for this and any new proviSIons that are aDded to the reinstated Policy. Your rights and Our rights Will be the same as beiore the Policy lapsed. 4,4 PREMIUM REFUND AT DEATH Upon notice of Your death. We Will make a pro rata refund of any premium actually paId for a period beyond the date of Your Death. 990 PA YO .12- When are premiums due? What happens if a premium payment is late? How can a lapsed Policy be reinstared? Is there any premium refund at death? g,-, When will premiums be waIved? What If a disability reoccurs? What If a disability ,s due to more than one cause? 390 " PART 5 WAIVER OF PREMIUM 5.1 WAIVER OF PREMIUM After You have oeen Disabled for 90 days, We will waive any prefT,lUm that becomes due wnlle You remain Disabled. Your Pollc', and ,ts benefits will continue as If the oremlum had been paid. We wIll also refund any premium paid that became due durrng those first 90 days of Disability. When You are no longer eligible (or Waiver of Premium, You can continue Your Policy in force by paYing the next premium thaI becomes due. Waiver of Premium will not apply to any premiums which become due after You elect the RENEWAL OPTION IF NOT EMPLOYED. HOSPITAL CONFINE- MENT INDEMNlr, BENEFIT In PART 8, PART 6 RECURRENT AND CONCURRENT DISABILITY 6.1 RECURRENT DISABILITY a. For MaXimum Benefit Perrods "To Age 65" and "LifeUme" If after the end of a Disability 'Iou become Disabled from the same or related causes. We w,lI deem It a separate Disability. But if SUCh recurrence occurs wIthin 12 months of the end of the prror period. We Will deem It a conUnuallon of the prior Disa- bIlity. SUCh periods of Recurrent Disability separated by 12 months or less will be deemed to be continuing In order to determine the Commencement Date, Such perrods of Recurrent Total Disability separated by 12 months or less will be deemed to be continuing In order to determine compleUon of the Qualification Perrod, If any. b, For All Other Maximum Benefit Periods: If after the end of a Disability You become Disabled from the same or related causes. We will deem It a separate Disability, But If SUCh recurrence occurs Within 6 months of the end of the prior perrod, We Will deem It a continuation of the prior Disa- bility. Sucn periods of Recurrent DisabIlity separated by 6 months or less w,lI De deemed to be continUing In order to determine the Commencement Date, Such perroDs of Recurrent Total Disa- bility separated by 6 months or less Will be deemed to be con- tinuing In order to determine completion of the ~uallficatlon PeriOD. If any. 6.2 CONCURRENT DISABILITY If a Disability IS caused by more than one Inlury or Sickness. or from both. We Will pay benellts as If the Disability was caused by only one Inlury or Sickness. We Will not ~ay more than one Disaollity benefit for the same oerrOd. We Will always pay the largest benefit. ,'J" ]' PART 7 RENEWAL OPTION IF EMPLOYED, TOTAL DISABILITY BENEFIT -LIMITED BENEFIT PERIOD 7.1 RENEWAL OPTION After Your 55th blnhday You may continue Your Policy for the Total Disability benefit while: a. You remain actively and regularly employed full lime for at least 30 hours per week; and b. The premium IS paid on lime, We can require proof after Your 65lh blnhday that You have conunued to be actively and regularly employed full lime. You cannot elect this option after the RENEWAL OPTION IF NOT EMPLOYED, HOSPITAL CONFINEMENT INDEMNITY BENEFIT in PART 8 becomes effective, The Policy must be in force when You elect this OPtion. 7.2 TOTAL DISABILITY BENEFIT - LIMITED BENEFIT PERIOD If You elect thiS OPtion, We Will pay the Total Disability amount Suolect to the same prOVIsions. exceptions. and IImllallons In the Policy. For Total Disability starting: a, After Your 65th birthday. but before Your 75th birthday. the Maximum Behefil Period will be 24 months or the period shown on the Policy Schedule if less: and b. After Your 75th birthday. the Maximum Beneflt Period Will be 12 months. 7.3 PREMIUMS The premium Will be the rate then in effect for Your rating group. We can change the premium rate but only if We change the rate for everyone who has this policy form in Your rating group In Your state. Any premIum paid after Your 6SIh blnhday for a period not covered by Your Policy under thiS option Will be returned to You. Or at Your request. We will apply II to the premium payable under the RENEWAL OPTION IF NOT EM- PLOYED. HOSPITAL CONFINEMENT INDEMNITY BENEFIT in PART 8. 990 PA 'Ie .14- Can the Policy be renewed after age 65 "You are still working? How will the benefit period be limited? What will the premium be? 91.' " PART 8 RENEWAL OPTION IF NOT EMPLOYED, HOSPITAL CONFINEMENT INDEMNITY BENEFIT Can the Policy De renewed after age 65 if not working? 8.1 RENEWAL OPTION When You are no longer actively and regularly employed after Your 651h blnhday You may continue Your Policy for the rest of Yoyr life. as long as the premIum is paid on time. The benerlt WIll be limIted to a Hospital Confinement Indemnity. ThiS benerlt will take the place of all other benefits under Your Policy and, unless We state ot~~rwlse. any benefits under riders added to the Policy. The Policy must be ,n force wnen You elect thIs OPtion. What WIll the Denefit De? 8.2 HOSPITAL CONFINEMENT INDEMNITY BENEFIT If You elect thiS ootlon, We Will pay You a Hospital Conllnement Indemnity of 100 dollars per day whIle You are confined In a legally operated hospital be- cause of Inlury or Sickness. ' This benefit will begin on the date You are conllned. We will continue to pay It while You are confined. But We Will not pay for more than 6 months durong each continuous conllnement. ;:or the purpose of this benefit, after a period of confinement ends and You are confined again from the same or related cause Within 180 days, We Will conSider ,tto be a continuation of the first confinement, ;:or the purpose of thiS benefit. -hospital. means: a. an Institution operated pursuant to law which is licensed or approved as a hospital by the responsible state agency: b. it is Primarily engaged In prOVIding medical care and treatment of Sick or Inlured persons on an in-patient baSIS for which a Charge IS made: and c, It prOVides 24 hour service by or under supervision of regIs- tered graduate professional nurses (R.N:sJ ;:or the purpose of thiS benefit. -hospital. will !!E! mean: a, convalescent homes. convalescent. rest. or nursing facilities: or b. faCilities promaroly for the aged. drug or alcoholic rehabilitation. and those primarily affording custOdial or educational care. What other Policy provIsIons will change? 8.3 EXCEPTIONS What WIll the premIum De? Under thiS OOllon, the WaIver of Premium. the Recurrent Disability. and Ben- efit prOVISions of the 1"0111:'1 Will not apply. However. all of the other prOVIsions. exceptions. and limitations In the Policy Will apply. 8.4 PREMtUMS ihe premium Will be the rate then In effect for Your rating group, We can change the premium rate but only if We change the rate for everyone who has the policy form In Your rating group In Your state. L g90 . ~ s- -- PART 9 CLAIMS 9.1 TIME OF LOSS All losses must occur while Your Policy IS in force. But, termination of Your Policy will nOI affect any claim for Total Disablllly thaI beginS within 30 days of the date of an Inlury causing such Disability. 9.2 WRITTEN NOTICE OF CLAIM Written notice of claim must be given to Us Wllhln 30 days arter a covered loss starts. If thIS cannot be done, then notice must be given as soon as reason- ably possible, The notice will be sufficIent It it identifies You and Is sent to Our Home Office. 18 Chestnut Street. Worcester. Massachuserts 01608. or is given to Our agent. 9.3 CLAIM FORMS After We receive !~~ written notice of claim. We will send You Our proof of loss forms within 1; Jays, If We do not. You will meet the written ~roof of loss requirements If You send Us. Within the time set fonh below. a written state- ment of the nature and extent of Your loss. 9.4 WRITTEN PROOF OF LOSS Written proof of loss must be sent to Us Within 90 days after the end or each period for which You are claiming benefits. If that is not reasonably oosslble. Your claim Will not be affected. But. unless You are legally incapacitated. written proof must be given within one year of the date it was required. We can also require reasonable proof from You of Your. a. Prior Earnings: and b. Monthly Earnings for the month for which Disability is claimed, This may include personal and business tax returns filed with the Internal Revenue Service. financial statements. accDuntant's statements or other proof acceptable to Us or which We may require. We can have an audit per- formed as often as is reasonably required while Your claim IS continuing. Such an audit will be at Our expense. 9.5 EXAMINATIONS At Our expense. We can have a PhYSician of Our choice examine vou as often as reasonably required while Your claim is continuing. 9.6 TIME OF PAYMENT OF CLAIMS After We receive satisfactory written proof of loss: a, We woII pay any benefits then due that are not payable ;:erlodlcally: and b. We Will pay at the end of each 30 days any benefits due that are pay- able periodically - sublect to continuing proof of loss. 990 PA YO .16- When must losses occur? When must wfltten notice be gIVen? Is there a (arm for proof of loss? What types of proof of loss might be required? Can there be an independent exam performed? When WIll benefits be paId? 91-' To whom wIll benefits be paId? When must notIce of an assIgnment be sent? What If there IS a mIsstatement of age? Can the Policy be changed? For how long is the Policy contestable? What if /he Policy differs wIth scate reQulfements? When can legal act/on be Drougnr under Ih,s Policy? 990 9.7 PAYMENT OF CLAIMS All benefits w,lI be ~ald to the Policy Owner named on the Policy Schedule. If any benerlt IS payaole to Your estale or If You are not competent to give a valid release. We can pay up to 1.000 dollars to one of Your relatives whO We believe IS entolled to ,t. If We do that on good faith, We Will not be Iiaole to anyone for the amount We pay. 9.8 ASSIGNMENT We will not be bouno by an assignment of Your Policy or any claim unless We receive a written assignment at Our Home Office before We pay the ben- efits Claimed. We Will not be responsible for the validity of any assignment. An absolute assignment IS a change of Policy Owner to the assignee. A collateral assignment IS not a change of Policy Owner: in thiS case benefits will be paid 10lnlly to the Policy Owner and the assignee. 9.9 MISSTATEMENT OF AGE If Your age has been misstated, the benefits under the Policy Will be those that the oremlum vc. ,aid would have purchased at Your correct age, PART10 THE CONTRACT 10.1 ENTIRE CONTRACT; CHANGES This Policy (With the aopllcallon and attached papers) is the entire contract between You and Us. No change in this Policy Will be effective until approved by a Comoany officer. ThiS approval must be noted on or attaChed to this Policy. No agent may change this Policy or waive any of its provisions. 10.2 INCONTESTABLE a. ARer Your Policy has been in force for 2 years. excluding any time You are Disabled. We cannot contest the statements in the application. b, No claim for loss Incurred or Disability that starts after 2 years from the Date of Issue will be reduced or denied because a Sickness or ohyslcal conDltoon not excluOed by name or speCific description before the date of loss had existed before the Date of Issue. 10.3 CONFORMITY WITH STATE STATUTES Any provIsion In thiS ?olicy wnlch, on ItS Date of Issue. conflicts With the laws of the state In WhiCh You reSide on that date IS amended to meet the mInimum requirements of sucn laws. 10.4 LEGAL ACTION You cannot !JrIng legal action WithIn 60 days from the date written proof of loss is gIven. You cannot bring It after 3 years from the date written proof of loss IS reDUlreo. ..';'. AUTOMATIC INCREASES BENEFIT RIDER This rlder provides an Automatic Increase Benellt. This benefit,s in lieu of the Limited Guaranteed Insurability Benefit contaoned in Your Policy. The Limited Guaranteed Insurability Benellt IS aeleted from Your Policy. The Benefit The amounl shown on the Policy Schedule will be automatically added to Your monthly Total Disability benefit without eVidence of insurability. ThiS will be done on each Increase Date. The Increase Oates are shown on the Policy Schedule. A benefit Increase will apply only to a disability which starts after the Increase Date, It will not apply to a continuation of a prior disability. See the Recurrent Disabllily section of thiS Policy. Premiums These benefit increases are subject to the timely paymenl of the Annual Premium Increases. These premiums are based upon Your attaoned age on the Increase Date. They are shown on the Policy S:hedule, If all increases go into effect. Your annual premium will increase by the amount shown on the Policy Schedule, If the premium for the Policy is beong waived (See Waiver of Premium section) on the Increase Date. the premium for the increase Will also be waived, When You resume paying premiums for the Policy. You must also stan paying the premIum for the oncrease. Refusal You may refuse an increase by notifYing Us In wrotlng proor to the Increase Date. Your refusal of an increase will not affect the remaining automatic In- creases. However, if You refuse the first two consecutive increases all further Increases Will be cancelled. Then, at Your request. You may increase your monthly Total Disability Benefit by 530.00 on the remaonlng Increase Oates without eVidence of insurability. Renewal When the above automatic increases stop and prior to Your 60th binhday, You may apply for additional automatic oncreases. You can do this by making formal application Within the period of 60 days prior to and 31 days after the last Increase Date shown on the Policy Schedule, Approval wilt be subject to our underwriting gUIdelines. All definitions in Your Policy apply to thiS rider. All prOVISions of Your Policy stay the same except where We change them by thiS rider. The Date of Issue of thiS rlder IS the same as that of Your Policy, or as shown on the Policy Schedule If later I,L I I I ! I #~d~~~! Signed for Us at Worcester, Massachusetts. THE PAUL REVERE LIFE INSURANCE COMPANY I/. /3(. Secretary Praadnu 990 AIB 91-1 COST OF LIVING ADJUSTED BENEFIT RIDER - TOTAL OR RESIDUAL DISABILITY Adlultments Begin After the TweUth Month of Disability This rider provides a COLA Senefitto the Policy to wnlCh It IS added. DEFINITIONS In this rider: "CPI" means the Consumer Price Index for All Uroan Consumers. It is pub- lished by the United States Depanment of Labor. If thiS Index is discontinued or if the method for computing ,t IS materially Change':. We may choose an- other Index. We WIll choose an Index which in our opinion would most accu- rately refiect the rate of change In the cost of liVing In the United Slates. CPI will then mean the Index We Chose. -RevIllw Date" means the date that occurs: 1. After each successive twelve-month periOd of continuous Disability: and 2. Whole Your Disability continues. No ReView Date will occur beYOnd the later of: 1. Your 65th binhday: or 2, The second Rev,ew Date, If Your Disability beginS after Your 63rd blnhday. -ReView Period" means the twelve months of Disability ending just prIor to each Review Date, "Index Month" means the calendar month four months prior to the calendar month ,n which a ReView Date occurs, But the first Index Month for any Dis- ability will be the calendar month four months prIor to the month In which Your Disability began. "COLA Factor" IS used to determine the COLA benefit. II equals A-B, B "A" is the CPI (or the most recenllndex Month. "S" is the CPI for the first Index Month. />. COLA Factor is determined as of each ReView Date whole Disability con- tinues. -MaXimum Percentage" is 7%, You have the right to Increase It to 10% as deSCribed In the Percentage Increase Option section below. "Monthly Benefit for Total Disability" means the sum of the monthly amounlS oayable at a given time. for the Total Disabolity benerlt. ThiS includes any Supplemental SOCial Insurance Benefit rider that may be added to Your Pol- ICY, These amounts are shown on Your Policy SCheDule. ThiS rider does not change them. They are the amounts to which thiS rider applies a cost of living aDjustment. H 1107 87.6 . . " COLA aENEFIT Starting as of the first Review Date. We Will pay a COLA Benellt If You are DlsaDled. ThiS benefit IS added 10 Your other Policy benefits. If You are Totally Disabled. this benefit IS determined by multiplYing the Monthly Benefit for Total Disability by the COLA Factor. But the COLA Benefit cannot: 1. Exceed the Monthly Benefit for Total Disability times a percentage factor equal to the completed number of ReView Periods multiplied by the MaXimum Percentage: or 2, Be less than the amount of the Monthly Benefit for Total Disability times a percentage factor equal to the completed humber of Review Periods mUltiplied by 4%. If You are Residually Disabled. the COLA Benefit Will be determined as above except that We Will use the Monthly Benellt for ReSidual Dlsabllity instead of the Monthly Benefit for Total Disability, . BENEFIT PURCHASE OPTION You may purchase the COLA Benefit described above. ThiS does not apply to Benerlls provIded under any Supplemental Social Insurance Benefit Rider that may be added to Your POlicy. This new Benefit will be added to Your coverage, It Wilt apply only to new Dlsabllltles which start ailer the effective date of the new Benefit. The right to purChase this Benefit is sublect to the follOWing: 1. You have returned to gainful. full-tIme employment after the end of ape" rlod of Disability during which a COLA Benefit was paid: and 2. You have not attained age 60: and 3. You have requested this Benefit Within 90 days from the end of the Disa- bility for which You received the COLA Benefit. These are the only requirements. The new Benefit will take effect within 31 days after We receive Your request. The Premium for this new Benefit will be based on Your attained age, We wlIl use the Premium rates then in effect. The additional Premium must be paid Within 31 days of the effective date. Later premiums for this new benefit must be paid as pan of the renewal Premiums for thIS Policy, This new Benefit Will not be paid if You are receiving benefits under the Re- current Disability provisions of Your Policy. If You do not purchase this Benefit. Your benefit amounts Will revert to the Original amounts for new perIOds of Disability. MAXIMUM PERCENTAGE INCREASE OPTION You have the right to increase the Maximum Percentage to 10%. You may do thiS. without submitting eVIdence of insurability. by following the rules set fonh below. '. .' You may increase the Maximum Percentage on the OPtion Oates of Your chOice. Option Date means each anniversary of the Date of Issue of the Policy stanlng With lhe first and ending With the anniversary which [ails on or next (ollows Your 60th blnhday. The request for an Increase must be made Within an Option Period. Option PeriOD means the period which beginS 60 days before and endS J1 days after an Option Date, The request must be a dated written request signed by You. An Increase will be effective: (al on the Option Date If Your request IS made before that date: or (bl on the date of Your request If it Is made Within J1 days after the Option Date, You can request an increase during any Option Period even If you are disa- bled. but the Increase Will apply only 10 a period of disability wnlch starts after the effective date of the Increase. It must qualify as a separate Disability. The first premium (or an Increase must be paid WIthin J1 days after the ef- fective date of the Increase. Later premiums must be paid as part of the Policy Premium. If the premium for the policy is being waived (see Waiver of Premium provision I on the effective date of the Increase. you WIll not have to stan oaYlng lhe premium for the increase until the premium for your policy becomes payable again. The premium for this rider will increase if You raise the MaXimum Percent- age. The added premium will be based on: al the change In the MaXimum Percentage: bl Your attalnlld age: and cl Our premium rates then in effect at the time of the increase. EXPIRATION DATE FOR MAXIMUM PERCENTAGE INCREASE OPTION ThiS Ootlon Will expire on the earlier of: (a) the date when lhe Maximum Percentage IS 10%; or (blthe date when the last Option Period ends. GENERAL All prOVIsions of Your Policy remain the same except where We change them by thiS rider. This rider will end: 1. When the Policy ends: or 2. On Your 65th binhday, whichever happens first. The premium charge for this rider Will end when Ihls rider ends. The annual premium for thiS rider is shown on the Policy Schedule. /L I , , , I I I I I J/.I3G~~~ d~ ~ ~I , i I The Date of Issue of thiS rider IS the same as that of Your Policy. If We Issued thiS rider after Your Policy, the Date of Issue IS shown below. Signed for Us at Worcester. Massachusetts. THE PAUL REVERE LIFE INSURANCE COMPANY SfCl'ttary President ;'1107 -J- 8i-1i APPLICATION FOR DISABILITY INSURANCE TO: (, THE PAUL REVERE LIFE INSURANCE. COMPANY , () WORCESTER, MA 01608 N2 51967 b. Soc. Sec.' /71 -42-23/ J C,Ht.,=>'b\"1. d.Wt. /35 h, Birthplace (State) PA A (7011 ( ) 51'''p r:t a I 7 ) i~7.- '8' 1013 <; Ol.C<U"s, ~I la. Name (Print): 1....1 (Incl. Proto Tille) i e. Sex M 0 F . f. Blrtndate: g I q 5::l I g. Age (nearest!: <4-2- I I. Resloence Address: 102.8 W Fc>C.C-ro.1=+ D.... p I 51'11' t,__+"''' " c", b i j. Business Address: o..r~ S 1'1C:V"V-1S ! 2a. Occupation: E. '(cuo , , Ie. EmPloyer: c. Exacl duties: /Ad.~ I f'\ I d. Length of current employment: e, Nature of Employer'S business: f. If owner. percentage owned: Length 01 Ownershlo: , full time employees: g, Type ot Business Entity; SDle Proprietor 0 PartnershiP 0 Corporal ion Other 0 describe: 3. Have you Within the past 2 years engaged in motorcycle riding, sky diving, hang gliding, mountain climbing, or competi. tion in martial arts? Yes 0 No)l If "yes" give details: 4. Have you smoked cigarettes in the past 12 months? S. Have you been aclively at work full.time for the past 6 months? If "No" gIve details: Questions 6 and 7 need not be answered If a Paul Revere Medical Exam Is required. 6. Have you ever been diagnosed or treated for: (Circle all conditions that apply and give details below) a. Chest pain. high blood pressure, rnental or emOllonal olsorDei] ~) diabetes. cancer. tumor. or fainting spells? Yes~No 0 b. Disease or disorder of the heart or circulatory system, lungs. kidneys. bladder,198nital or reproductive oroanil Coraln or nervous systeJ!ll skin.~ ears or speecn? Yes;liq No C c. Disease or disorder 01 the stomach or Intestines. liver. thyroid. bones, muscles(foini~ back or neck? Yes~ No 0 d. Complications 01 pregnancy? Yes 0 No DAre you currently pregnant? Yes 0 joJo 0 Due date: 7, In the past 5 years. have you had any medical advice or operation. physical exam. treatment, illness. abnormality or injury not listed above? Yes C No)il" Are you currently receiVIng any medical advice or treatment? Yes 0 No X 8. Have you ever used Stimulants. hallucinogens. narcotics or any COni rolled sucstance other than prescribed by a physi. ciano or been counseled or treated for excess use of alcohol or drugs? Yes 0 No)if 9. Give details to all "Yes" answers to 6, 7 or 8, Include exact aiagnoses. dates. duration. physicians nd addresses. ,. . . . . "'.-: - h.\ 'M>.Ilvo 10 .... 2. "-Iao ~ u.J a...s. lr.., Ipt t"'l SSIOt1 ""~. <.lIS '=:.0. "".. 0 a.l d,(.o.-do.t- - d =c: sio 1'\ 0 ~ 11-0,."s.1 lI..IC) t-kl-",,-b....... bb. iOYo.:....... ~ .c;. 10 '1'1 C.AoT, MEoI. "~~Gl<.S ~l ~ (:)..-. ~1Q.n(j Po.tb>.-~on 1:::06, I=.b....i~, 'f'l; -1011'7 h d-/lr"Ildo.... ,0 ~ D,.. \=...2d c..u-c:.o lob, EVa. 10/~ ....lI.IaJ-ud +0 M.C;:. ;;:.."}-..... F~.d...o,.Q. M ......c.lO.....l.A..r~ b c.. . J Cl..L "-' V".Q.la.rac<. 'to ~.. I +- IS:- 10. In lOe ~st 5 years have you had ~ Insurance application rejected or modi lied or received or peen refused any disability or medical benellts? Yes G NO)llIf "yes" give details: ':"51 Yes 0 No)( Yes)QNo 0 11. F'ill,n amounts as RepOrtable for Feaeral Tax purposes a. Salary. Fees. CommissIons do Bonus o. Pension and Profit Sharing Contributions c. :arnongs from other occupations (deSCribe): d. 'iOtal :arnongs (a... b.. C) e. Deductible 3uslness :.~penses NET =."'RNED INCOME (d - e) Estimated Current Annual Rate is ~I ('o"-Is j ,1../,""", I , , I i c./S- -r;? Actual Last year 19~ Actual 2 Years Ago 19..La..... , .....< <;"1')9 is , , : ,C;~J< 7;' J.; /15- , I ~.,- , -.:= " /'.-r u,;:: ~9 " 12. L',. Net worth (assets minus liaPllltles), ,f more than S750.000: 3 JIA 13. Lis:' "nearned Income (interest. dlvlaends. capital gains, rent. etc.). " more than S15,OOO per year' >\ /II /d Ape '54A PA , . \ 30.3 , 14. ~;.:~cril;)~ all disablllly coverage In lorc,,: and ail <:overage applied lor In the past 12 months:,/ndlcate illl is: . ..~) lndlv"iual. B) Social Securtly Substitute. C) AssDciation, 0) Group. E) Salary Continuation, F) Overhead Expense, or . \l) Buy.cut. II none, wrlle "none".. \ I , I EffectIve Date of Discontinuance It f Amount I I , I I '10 -." Company or Source II Paul Revere, give Pol. , II penoihg, check---; I I I I Type (A,B,C, etc.) ! Monthly I Eilm.IBenetlll : Amounl Period Period W.,,"" It is 'Jnderstood and agreed as follows: (~) I ~ave read the statements and answers recorded above. They are. to the best of my knowledge and belief. true and com. olete and correcliy recorded. They Will become oart of thiS Application and the basis for any policy issued on It. (2) ! will permanently discontinue all poliCIes shown to oe discontJnued in answer to Question 14 on or be;.:r'! !h'! dales innicated. (3) No agent or broker has authority to waIve the answer to any Question. to determine insurability, 10 waIve a,',y of tne Com. oany's righls or reQuirements. or to make or alter any contract or oollcy, (4) ~;'e Insurance aopllOO for will not lake affect uniess the 'ssuance and celivery Df the policy and payment of the first premium occur before the ~roposed Insured has Visited. consulted or receIved treatment or diagnOSIs from a phYSician or other medical o:actitloner alter the date of thiS Aopllcation. The only exceotion to thiS is the IOsurance provided in the Conditional Receipt oatached herafrom and issued If at least the Mimmum DepOSit IS maoe with the Aoollcation, (5; ~cceotance ~y the Proposed Insured/Owner of any oollcy issued on thiS Aopllcation Will ratify any changes listed under ":orrections ano Amendments", except that no c~anges may be maDe as to ClassIfication. Age atlss.ue. Form of Insurance, ~mount or Benefits unless agreed 10 In wrlllng oy :he p:oooseo Insured/Owner. . SI;~ad at..Ho-r r,(;b~ ' PR' Dat fI !: 1~ I ca-:lty that' have :ruly and accurately recoroeo on InlS ao. ( pilca:,on the intormallon supolieo cy :he ?ropcseo Ins"reo. ture ~f Proposeo Insured ?7 .' w':-m~()~ X ~Icenseo Agem or BrOker Signature :f .~roooseo Owner IIf aoplicaolel Applicants will be Informed whether or not their application has been accepted within 60 days or be given the reason for any further delay, PAqe 2 15. Describe Coverage Being ReQuested (II BOE, complele supplemenl): Ellm, . I .Benefit Plan Cooe: Monthlv Amt. Period . Period Base 3'.;1.00. I I '. A- I. . ,l I I Optional Benefits Amount Form , "'I . ' J AMI AMI 551B' , , , I, I. I, ' . . I o::::l> Will reQuested coverage be paid for by emoloyer? Yes ill( No = II "yes" how much? Will employer's contribution be included in your taxacle income? Yes C No ~ o. Ust name and address of prooosed owner If other than proposed insured 16, a. c, Send notices to: Resloence 0 Business )( c. Collected With this application in exchange for Conditional Receipt: $ Co j) CORRECTIONS AND AMENDMENTS (For Home Office Use Only) -' .." " .- 990 PA YO NON-PARTICIPATING DISABILITY INCOME POLICY THE PREFERRED PROF:SSIONAL 91-1 -. . . In Your Personal Interest ... , A Message of Importance 7his valuable insurance protection is being made available to you with :~e help and cooperation of your employer, 7his policy cannot be cancelled by the company except for nonpayment of premium. It is therefore Important to you that you continue to pay your premium if your employment status changes. Should such a sit- uation occur. please contact your Paul Revere representative imme- ciately for information about our convenient pre-authorized check and other premium payment plans, In this way you will be assured of ~eeping this valuable coverage in force without interruption. 'ihe importance of the guaranteed right to take your policy with you should not be overlooked. For, if your policy Is allowed to lapse for nonpayment of premiums, a new policy will most likely cost more. In aCditlon, it might contain fewer benefits. or more restrictive provisions. And. of the greatest importance - a new policy may not be available :0 you if your present state oj health has changed. IRev. 5/84) 8B48 ." It It It IMPORTANT NOTICE It It It The enclosed policy. . . . . . is being issued as a replacement in accordance with the information provided to the Company on the application. Please be sure the policyholder understands our policy has been Issued based upon his or her sTatement in the application that the other coverage would be dropped. By making certain the issue basis of this contract Is currently acknowledged and agreed upon. you reduce the chances of any unex. pected problems for your policyholder at claim lime. . As is customary practice. the regular replacement letTer will be senT directly to the insured 60 days after the Issue oate on the contracts. ~'WI-/cl. ['. ,6~ Donald E. Boggs. RHU Sr. Vice President Operations and 01 ManagemenT The Paul Revere Companies :qev. !1ISSI ;t7c.:.5 .0: Ul .0:> ~~ "'Ul Z ZZ Oc.:l ~'" o . U~ ~Z 00 o E-<U I>: 00 OZ U~ c.:ll>: =c.:l E-<~ ZO HU .,. ~ - :s: ...... Ir> ...... N r.-. '" ...~ :::> '""" H'" ....... 'O"~ll.' '...If.'.... Rll. ("""'HO.l.\6.tM~111nllt1, ~ ",," -:"': ~- :-.-"1 1.1,", ,__ c..~ .I: 0I;.,':.r. 1::t.'>O:-~ ::; ~::;~ ....,.il " II:.!::, ;. i..": :J ~.t,; . Ul.... 1>:.... ~:j OC::: "'.... III 1:lP: H ~ U . :E: > c.:l ~ H . o-:l~.jJ 1:l::llr:: c.:l~~ >OC::: 1:lU~ c.:lClJ o-:lUO OZ ~~ c.:lUl =Z E-<H El '" ~ o-i .... > .... U N o-i N qo I '" 0'1 o z c.:l '" H U ~ '" l..O...... SERRATELLI. SCIIIFFMAN lit BROWN. r.c. Sl'ntl06 llMO IJNI..u~JWJoII\II.....t ItAU.I'lli.".r^ 171109483 ... J ! ~ ~ i ~ ; ~ ~ ~ U'I .:J ~ to. ~~;: ....' .. M. CLAIRE POWERS, Plaintiff IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : v. : No. 95-4212 Civil Term CIVIL ACTION - LAW JURY TRIAL DEMANDED THE PAUL REVERE LIFE INSURANCE COMPANY, Defendant PRAECIPE TO THE PROTHONOTARY: On behalf of the Plaintiff we hereby request a jury trial in the above captioned matter. Dated: 'j . /'I . '/.? . Serrate11i, Esq. BE ELLI, SCHIFFMAN, BROWN , CALHOON, P.C. 2040 Ling1estown Rd., suite 106 Harrisburg, PA 17110 (717) 540-9170 Attorney for Plaintiff -. v. IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA No. 95-4212 Civil Term M. CLAIRE POWERS, Plaintiff THE PAUL REVERE LIFE INSURANCE COMPANY, Defendant CIVIL ACTION - LAW JURY TRIAL DEMANDED CERTIFICATE OF SERVICE I, Lori K. Serratelli, do hereby certify that on August 14, 1995, I served a copy of the foregoing upon the Defendant by depositing it in the United States mail, postage prepaid, addressed as follows: The Paul Revere Life Insurance Company 18 Chestnut street Worcester, MA 01608 // . . ,~ ~--t,-,,-~) LlA . Lort;'K Serratelli, Esq. SERRAT LLI, SCHIFFMAN, BROWN , CALHOON, P.C. 2040 Linglestown Rd., suite 106 Harrisburg, PA 17110 (717) 540-9170 Attorney for Plaintiff