District judge denies injured doctor's disability claims

By Jim Boyle | Oct 14, 2014

A judge at the U.S. District Court for the Eastern District of Pennsylvania granted

summary judgment in favor of an insurance company using the doctrine of collateral estoppel, denying a disability claim for a Montgomery County doctor who claimed a workplace injury.

The claim's rejection was based on findings from a separate workers' compensation board that ruled the injury did not occur at the hospital, providing preclusive evidence to rule for the defendants at the federal court.

According to the original claim, Dr. Joseph Hayes said he sustained severe injuries when a door at Montgomery Hospital in Norristown, Pa., struck his head in November 2001. He filed for disability claims from U.S. Life Insurance Company and received payments of $4,000 per month for the first several years.

In May 2006, he received notice that surveillance of his activities showed Hayes performing functions that were restricted by his physician and that future benefits payment would stop. He filed the suit claiming breach of contract and fiduciary duties against the insurance company in 2009.

The discovery process showed that the work place injury was also the subject of a previously adjudicated workers’ compensation claim. The workers’ compensation judge reviewed and considered the record in its entirety, conducted two hearings, and gave the plaintiff opportunity to testify and to present witness testimony and documentary evidence in support of his position.

Ultimately, however, the workers’ compensation judge found the plaintiff to be not credible and denied his claim, holding that the accident never happened. This decision was upheld on appeal by the Workers’ Compensation Appeal Board, which "found no error”in the holding that the plaintiff failed to sustain his burden or proof.

Attorneys representing U.S. Life used the previous decision as evidence in the federal case, claiming collateral estoppel barred all of Hayes' claims based on the alleged accident. The plaintiff argued that collateral estoppel did not apply because the “identical issue” element of the doctrine was not met.

Hayes argued that the cause of the disabling condition was immaterial and should be ignored, as the civil action’s issue was whether the plaintiff was disabled, not whether the accident occurred. The court disagreed with the plaintiff, saying the workers compensation claim and the civil suit were both filed as a result of the accident.

"Plaintiff’s position ignores the facts and history of his claims. If he were disabled for some reason other than the Work Accident, that would be contrary to his Insured’s Statement seeking disability benefits under the Policy, not to mention the testimony he gave under oath in the workers’ compensation hearing, and to his Complaint in this civil action," wrote magistrate Judge Elizabeth Hey. "I cannot simply ignore the fact that Plaintiff seeks disability benefits in this action as a result of the Work Accident when a prior court has determined that the Work Accident never happened."

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