Fill and Sign the Declaratory Judgment Insurance Form

IN THE UNITED STATES DISTRICT COURT FOR THE ____________ DISTRICT OF ___________ ___________________ DIVISION NAME OF PLAINTIFF )       ) ) V. ) NO.       ) ) NAME OF DEFENDANT )       ) ) COMPLAINT FOR DECLARATORY JUDGMENT The Plaintiff, ___________, (hereinafter referred to as "__________" or the "Plaintiff') files its Complaint for Declaratory Judgment against the Defendant, __________ (hereinafter referred to as "___________" or the "defendant") as follows: I. JURISDICTION 1. This Court has jurisdiction over the claims set forth in this Complaint by virtue of diversity of citizenship, 28 U.S.C. Section 1332, and pursuant to the Declaratory Judgment Act, 28 U.S.C. Section 2201. 2. The Court possesses original jurisdiction over this matter, as the Plaintiff and the Defendant are citizens of different states, and the amount in controversy exceeds $75,000.00, exclusive of interest and costs. 3. Venue in this district is appropriate pursuant to 28 U.S.C. Section 1391. This Court has jurisdiction over the Defendant, as he resides in _______________, __________ County, State of _____________. II. PARTIES 4. ______________ is incorporated under the laws of the State of _________ and maintains its principal place of business in ____________, _____________. 5. The Defendant, _______________, is a citizen of the State of _____________ and resides at _____________, _____________, _____________ ______. The Defendant can be served with process at this address. III. FACTS 6. On or about ________________ __, ____, the Defendant was issued a variable life insurance policy from ___________ ("_________") policy number _____________ for the face amount of $__________.00. 7. On ______________ __, ____, _________ merged into __________ and __________ now stands in the shoes of __________. 8. On or about ______________ __, ____, the Defendant was issued a whole life insurance policy from ___________, policy number __________, for a face amount of $__________.00. 9. The owner of both policies is ____________. The beneficiary of both policies is Mr. __________'s wife, ___________. 10. On both policies, the Defendant sought and received a "__________," which entitles the owner to have his premiums waived for that policy upon proof of "total disability," as defined in each policy. 11. Total disability is defined in both policies as the "Insured's complete inability, because of bodily injury or disease, to perform all of the substantial and material duties of his or her regular occupation. However, after 24 consecutive months of such disability, total disability will mean the Insured's complete inability to engage in any gainful occupation for which he or she is reasonably fitted by education, training or experience." 12. On or about __________ __, ____, the Defendant suffered a myocardial infarction (heart attack) and underwent open-heart surgery with angioplasty and coronary artery bypass graft. Thereafter and upon recovery from the surgery, he was allegedly diagnosed with "major depression." ____________ remained under the treatment of Dr. _____________, his attending psychiatrist. 13. In _______________, ____, the Plaintiff received ___________'s "insured's statement of claim for disability benefits" dated ____________ __, ____, and signed by Mr. ___________’s treating physician, __________, M.D. This form alleged that the Defendant was totally disabled as defined in the policies. 14. This statement, and subsequent statement, represented that the Defendant was totally disabled as defined in each policy as a result of "major depression," for his regular occupation as well as any occupation. Furthermore, it was represented that the Defendant ceased work because of this alleged disability on _____________ __, ____. 15. Based on representations from the Defendant and the statements of disability from his attending physician, the Defendant was approved for waiver of premiums beginning on or about __________ __, ____, for both policies. 16. At periodic intervals, the Plaintiff requested and received further statements of disability from Defendant and his attending physician. Each time the Plaintiff received statements representing that the Defendant continued to suffer from major depression, which resulted in a total disability as defined in the respective policies. 17. The statements of disability received by the Plaintiff further represented that the Defendant was incapable of performing any duties of his job for an indeterminate time period and further stated that the Defendant was not suitable for further rehabilitation services nor could his job be modified to allow for handling with impairment. 18. Throughout this period, the Defendant, himself, also represented through numerous correspondence that he continued to remain totally disabled and unable to engage in any gainful occupation for which he was reasonably fitted by education, training or experience. 19. The Defendant has received loans based on the cash value of these policies, which continued to generate equity even though no premiums were being paid. In other words, __________ was paying the Defendant's premiums during this period and building up the cash value of the respective policies. The Defendant then withdrew those finds. The total amount of loans the Defendant has currently outstanding for the two policies in question is $_________.00. 20. Beginning in _____________, ____, the Plaintiff requested and received authorization to release medical information to the Plaintiff concerning his alleged disability. Upon receipt of medical records from the Defendant's treating physicians, it became apparent that the Defendant was indeed working and had been earning a substantial income throughout the premium waiver period. 21. Additional investigations were performed and the Defendant's FICA earnings were investigated. The information and documentation verified that the Defendant had been receiving substantial income since ____, which steadily increased each year. 22. The total premiums waived by the Plaintiff on ___________ and the former ____________ policy is $________._______, as of ____, which continues to increase. IV. REQUEST FOR DECLARATORY RELIEF 23. Based on the foregoing, an actual controversy exists between ___________ and the Defendant, that is ripe for resolution by this Court and declaration of the rights of these parties regarding the obligation of _____________ to continue to waive ___________'s premiums under the terms of the policies. 24. ________________ accordingly requests that the Court afford it the following declaratory relief: (a) issue a declaratory judgment that any and all obligations on behalf of __________ to continue to waive the premiums on policies ___________ and __________, issued to _____________, are hereby terminated, and issue a declaratory judgment and/or injunction which finds and adjudicates the Defendant liable for the return of all improperly waived premiums on the respective policies. (b) issue a declaratory judgment and/or injunction that declares that the Defendant is not entitled to retain any portions of the policy loans he has received which were due to improper accumulation of equity or cash value of the policies through the wrongful representation of his disability status, and to require and direct the prompt return of such funds. (c) issue any further relief that is necessary or proper in the Court's determination after a hearing on this matter. WHEREFORE, PREMISES CONSIDERED, _______________ respectfully requests that the Court issue the declaratory relief and/or other relief requested by it in this Complaint, including attorney's fees, taxing all costs to the Defendant. Respectfully submitted, ______________________________