Broffman, M.D. v. Provident Life and Accident Insurance Company et al

Filing 225

FINAL SPECIAL VERDICT FORM. Signed by Judge James Donato on 5/5/2015. (jdlc2S, COURT STAFF) (Filed on 5/5/2015)

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UNITED STATES DISTRICT COURT

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NORTHERN DISTRICT OF CALIFORNIA

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JEFFERY BROFFMAN, M.D.,

Case No. 13-cv-04922-JD

Plaintiff,
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v.

SPECIAL VERDICT FORM

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United States District Court
Northern District of California

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PROVIDENT LIFE AND ACCIDENT
INSURANCE COMPANY, et al.,
Defendants.

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When answering the following questions and filling out this verdict form, please follow the
directions provided throughout the form. Your answer to each question must be unanimous.
Some of the questions contain legal terms that are defined and explained in detail in the jury
instructions. Please refer to the jury instructions if you are unsure about the meaning or usage of
any legal term that appears in the questions below.

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SPECIAL VERDICT FORM

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We, the jury in Broffman v. Provident Life and Accident Insurance Co., Case No. 3:13-cv-04922JD, unanimously agree to the answers to the following questions and return them under the
instructions of this Court as our verdict in this case:

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I.

BREACH OF CONTRACT

United States District Court
Northern District of California

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A.

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Did Provident Life and Accident Insurance Company breach the insurance contract
with plaintiff?

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Answer:

YES _______

NO _______

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(If your answer is “NO,” stop here, answer no further questions, and have the
foreperson sign and date this form.)

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B.

If you answered “YES” to Question A above, state the amount of damages you
award to Dr. Broffman for breach of contract against Provident Life and Accident
Insurance Company:

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1.

Past due total disability benefits: $________________

2.

Past due residual disability benefits: $_________________

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II.

BREACH OF THE IMPLIED COVENANT OF GOOD FAITH AND FAIR DEALING

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A.

Did Provident Life and Accident Insurance Company breach the implied covenant
of good faith and fair dealing?

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Answer:

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YES _______

NO _______

(If your answer is “NO,” stop here, answer no further questions, and have the
foreperson sign and date this form.)

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B.

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Answer:

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United States District Court
Northern District of California

Was Provident Life and Accident Insurance Company’s breach of the implied
covenant of good faith and fair dealing a substantial factor in causing harm to
Dr. Broffman?
YES _______

NO _______

(If your answer is “NO,” stop here, answer no further questions, and have the
foreperson sign and date this form.)

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C.

Do you find that Unum Group was Provident Life and Accident Insurance
Company’s agent?

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Answer:

YES _______

NO _______

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1.

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If you answered “YES,” do you find that Unum Group was acting within
the scope of its authority?:
Answer:

YES _______

NO _______

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2.

Do you find that Unum Group engaged in willful misconduct?

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Answer:

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D.

YES _______

NO _______

What are Dr. Broffman’s damages?

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Mental suffering, anxiety, humiliation, emotional distress: $____________

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Future contract benefits Dr. Broffman would have received: $___________

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III.

PUNITIVE DAMAGES

Answer the question below only if you found that Provident Life and Accident Insurance
Company breached the implied covenant of good faith and fair dealing, and that the breach was a
substantial factor in causing harm to Dr. Broffman. (In other words, answer this next question
only if you answered “YES” to both questions A and B in Section II above.)

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Did Dr. Broffman prove by clear and convincing evidence that Provident Life and
Accident Insurance Company acted with malice, oppression or fraud such as to
warrant an award of punitive damages against it?

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Answer:

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1.

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A.

YES _______

NO _______

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United States District Court
Northern District of California

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If you answered “YES,” enter the amount of punitive damages to be
awarded against Provident Life and Accident Insurance Company:
Answer:

$____________.

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You have now reached the end of the verdict form and should review it to ensure it accurately
reflects your unanimous determinations. The foreperson should then sign and date the verdict
form in the spaces below and notify the courtroom deputy that you have reached a verdict. The
foreperson should retain possession of the verdict form and bring it when the jury is brought back
into the courtroom.

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Dated: May ____, 2015
By: ______________________________
Foreperson

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