An undiagnosed pre-existing condition will not result in denial of long-term disability benefits

On November 4, 2009, a ruling was handed down in the Sixth Circuit Court of Appeals that will surely have insurance companies looking at how they define “pre-existing condition”. Ruth Mitzel is certainly happy that the court affirmed the lower court’s decision that Anthem Disability Insurance Company, her employer and insurer, had wrongfully denied her long-term life insurance benefits.

When Mitzel was diagnosed on June 18, 2004 with Wegener’s granulomatosis (WG), an auto-immune disease that is life-threatening. Her diagnosis came just five days after she qualified for her employer’s long-term disability plan. She continued working until her condition required hospitalization on June 3, 2005, just shy of a year later.

She applied for short-term disability leave from work first, which she exhausted. Mitzel then filed a claim with Anthem Life Insurance Company (“Anthem”) on Nov. 1, 2005 for long-term disability. Anthem denied Mitzel’s claim on May 18, 2006, claiming that Mitzel had a pre-existing condition as defined by the LTD Benefit Booklet.

In the denial letter, Anthem cited three visits to her doctor in the three months before her coverage began. The company claimed that this look-back proved that Mitzel had “a sickness or injury for which” she had “received medical care or services (including doctor visits, prescriptions and diagnostic tests) during the three months prior to” her “effective date of coverage.” The words “for which” would prove pivotal in the court’s decision.

The problem for Anthem arose from a discrepancy between different documents defining the conditions for long-term disability benefits. One 35-page document known as the LTD Benefit Program excluded anyone with a pre-existing condition from coverage whose disability began less than 12 months after the effective date of coverage. The definition of a pre-existing condition in this document was a sickness or injury “for which you received treatment, or where symptoms were present to the degree that an ordinarily prudent person would seek treatment” within the three months before “your effective date of coverage.”

Anthem provided policy holders with two additional resources: 1) Descriptions of Anthem’s Flexible Benefits Plan and Summary Plan Description (“Summary Plan Description”), a condensed summary of the plan on the internet and 2) Long-Term Disability: 2005 Benefit Booklet” (“LTD Benefit Booklet”), an 11-page booklet. The definition of pre-existing condition in the LTD Benefit Booklet was not as sweeping as that in the LTD Benefit Program document. Anthem claimed that the disclaimer on the last page of the LTD Benefit Booklet deferred any conflict to the plan document.

Mitzel appealed the denial of long-term disability on June 8, 2006, claiming that she had not been under treatment for a known ailment. Anthem hired a physician to evaluate Mitzel’s medical history. His conclusion was that Mitzel was already ill and under a doctor’s treatment for the symptoms of WG and thus was disqualified from receiving benefits under her employer’s long-term disability insurance plan. Her appeal was denied.

Submitting letters from the two physicians who had treated her, Mitzel made one final appeal. Both physicians noted that at the time they were treating her they had no idea that her symptoms were in any way related to WG. One physician suspected lupis, and the other an injured ligament.

Anthem hired another physician to review this new information. His conclusions supported Anthem’s original denial. On February 1, 2007, Anthem denied Mitzel’s final appeal.

Mitzel filed a lawsuit in the US District Court for the Northern District of Ohio against Anthem on July 3, 2007, seeking a reversal of her disability claim denial. On July 14, 2008, the magistrate judge overruled Anthem’s denial of Mitzel’s long-term disability benefits, finding that Anthem’s interpretations of “pre-existing condition” were arbitrary, capricious and contradictory. Anthem appealed the decision to the Sixth Circuit Court of Appeals.

The case was reviewed by a three judge panel. The primary focus was on the definition of “pre-existing condition” as this had been the basis of the lower court’s decision. The Court applied a rule that has arisen from numerous cases; this rule construes any ambiguities against the drafting parties. Anthem wanted the Court to rule that a pre-existing condition is “a sickness or injury for which [Mitzel] received medical care or services.”

No one disputes that Mitzel was under treatment in the three months prior to qualifying for coverage, but her doctors did not know what they were treating. Both of the primary policy documents, while listing what treatment consisted of, assumed that doctors would be treating a specific condition. Thus, she was not being treated “for” a condition, even though she was under treatment.

This was a contested point, with one of the judges favoring Anthem’s broader definition of pre-existing condition. The other two judges argued that because Mitzel’s physicians were not treating her for a diagnosed disease, Anthem’s denial of benefits based on the fact that she had been under treatment for “a” sickness was arbitrary and capricious. By of vote of two to one the United States Court of Appeals for the Sixth Circuit Court affirmed the Northern District of Ohio’s decision, therefore awarding benefits to Ms. Mitzel.

If you have been denied long-term disability insurance benefits under similar circumstances, contact a disability insurance attorney today. In claims for disability benefits, a claimant should always be aware that an insurance company will always look for pre-existing medical conditions as an excuse to deny benefits. The laws related to pre-existing condition clauses are not the same in every state.

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There are 11 comments

  • Pat,

    Please feel free to contact our office in the event that Unum’s decision is unfavorable.

    Stephen JessupJun 5, 2015  #11

  • Yes, I have. Waiting to here from Unum now.

    PatJun 4, 2015  #10

  • Pat,

    For purposes of appeals the most important information is the actual medical documentation. Providing or arguing case law could potentially backfire as the company could find a way to fashion an answer that would get around similar cases. Have you already submitted your appeal?

    Stephen JessupMay 31, 2015  #9

  • During my appeal process would it benefit me to refer to court cases such as Lafferty v/s Unum Life Ins Co of America and or McLoud v/s Hartford Life Ins Co. as the case scenario is virtually the same.

    PatMay 30, 2015  #8

  • Pat,

    Pre-existing condition arguments are difficult as the language governing these provisions are often very broad in scope. As you have already appealed your decision it will be a matter of waiting to see what the answer is. In the event the claim is denied we will be more than willing to review the information.

    Stephen JessupMay 25, 2015  #7

  • In July 2014, just days after I had enrolled in STD with the employer paying the LTD premiums. I went to play golf with my husband and another couple. On the first hole, I bent over to place the ball on the tee and upon raising I experienced significant back pain. By the second hole I could not bend over to place the ball on the tee so I quit. Several days passed and the pain just wouldn’t go away. I went to the ER for eval and was Dx with a collapsed vertebrae of the T7. I under went kyphoplasty shortly thereafter and then I had a bone density scan as per recommendation of my FMD. The Dexa scan noted I was osteoporotic. I then had Reclast IV for aide with bone formation. I have been unable to return to work since the injury. I was granted STD without a problem, and was deemed disabled for LTD by the Insurance company and was given 4 months back pay in a lump sum amount under provisions that they were investigating to see if I had LTD coverage under my prior policy before taking out the current policy. (note: I was working as an RN for small community hospital who merged with a Large well known hospital. I was covered by another insurance company for STD but did not elect LTD coverage. When the companies merged July 1st, I signed up for all new benefits which included STD coverage with the hospital covering the LTD premiums).

    In March of 2014, I was seen by my FMD for a c/o pain and numbness in my left arm and hand. He referred me to a neurologist. The neurologist did not feel it was Carpel tunnel syndrome, so he ordered some labs as he was concerned for compression palsy with diffuse peripheral neuropathy. This lab included a Vit D level. The level indicated I was deficient in Vit D, so he order OTC supplement along with a prescription dose of 50,000 IU weekly x 4. Within 2 weeks from taking one dose of 50,000 IU plus a daily dose of 1000IU my endocrinologist ordered a recheck of lab value. The Vit D level had significantly improved and was WNL. I continued on the same Plan of Care and was rechecked again approx. 4 months later and I was super-therapeutic so the 50,000 IU weekly was discontinued and I was advised to continue on the 1000IU daily. (note: too much Vit D is just as bad as not enough). The endocrinologist who was following me for post graves disease which was DX in 2006 and treated with thyroid hormone replacement therapy once I became hypo. was attempting to find out the cause for my osteoporotic bones ordered a PTH level. The level confirmed that I had hyperparathyroidism. Therefore a parathyroid scan was ordered. The scan was scheduled for Feb 6th. The Insurance company was fully aware of everything that I was having done. On Feb 6th the insurance company closed the claim and stated I had a pre-existing condition that caused or contributed to my vertebral fracture for which I claiming disability from. The parathyroid scan did not detect any adenoma’s but did pick up a breast mass. The mass was identified as invasive ductal carcinoma. I underwent a segmental mastectomy, followed by radiation and anti-hormonal treatment for which I have to take for the next five years.

    I filed an appeal and asked for reconsideration of the claim, advising that I was not treated for osteoporosis, as I had not been diagnosed with this condition until after the effective date of coverage and post kyphoplasty. Also the Endocrinologist had advised that Hyperparathyroidism could be the causative factor for the osteoporosis. She could not determine whether it was primary or secondary to Vit D deficiency as I was under tx for breast cancer and she could not do surgery to remove glands if need was indicated. I would have to wait until radiation therapy was completed. I am scheduled to see her the end of June. She also stated that my Vit D level could be low because of my recent diagnosis of breast CA. Note: I had a routine mammogram less than 12 months ago, which did not detect s/s of cancer. The Vit D level was also initially checked during the winter months when on average your levels at the lowest. The recheck with robust elevation with treatment was done in August which is in the season where your levels are on the rise from the summer sun exposure.

    The appeal for reconsideration was denied, so therefore it is currently back with the Appeal officer for review.

    Do you think that I have a chance to win this case. Obviously I didn’t know I was going to have a fracture simply by bending over and that my bones were so osteoporotic that I am subject to have recurrent fractures. I am limited to lifting no greater than 2 quarts of milk at a time, I have great difficulty bending, sitting or standing for any significant length of time. I have continuous pain daily and if I take any narcotics for pain control I can not think or function, just want to sleep. Muscle relaxants unfortunately do the same thing. Pain patches are not covered by my insurance and I can not afford them out of pocket. I have gone from the ability to make 70,000 plus annually to zero income. I am virtually struggling to stay a float. If it were not for my husbands income and my savings, I would have lost everything I own. The stress from pain, breast cancer and loss of income is becoming overwhelming. I need advise on how to win this case or what to do next! I have applied for SS disability as well, unfortunately I had to hire an attorney because even though SS recognized that I have a disability, they felt that since I worked as a Director of Nursing in the past I could return to that type of work since their survey of job responsibilities for DON “did not require beside nursing”. Wrong answer, you are a nurse as long as you are on duty! If someone falls you help get them up, if someone codes you help to bring them back to life. Do they really think I am just a paper pusher? Also I quit being a DON in November of 2013, because it was a 24 hour, seven day a week job. The stress is unbelievable. I went to work at the hospital as a QA/Education Coordinator, however, I have to pull call and fill in on the floor when other nurses call out….. Nursing is no joke!

    Please advise.
    Thanks
    Pat

    PatMay 24, 2015  #6

  • The pre-existing clause states: if received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 6months just prior to your effective date of coverage and the disability begins in the first 12 months after your effective date of coverage (07/01/2013).

    My diagnostic testing was 01/29/2014 and diagnosed and discussed on 03/20/2014.

    MarieMay 7, 2014  #5

  • Marie,

    Without knowing how the pre-existing provision is defined in your policy I would not be able to provide any suggestions. Please feel free to contact our office.

    Stephen JessupMay 7, 2014  #4

  • I had lumbar surgery in June 2012 in which there was pain as I improved. I continued to see my neurologist without any pain nor muscle relaxants. On February 26, 2013, I saw the neurologist and he noted the pain but my weight gain was causing the pain in legs and back. Once I lost the weight there weren’t anymore problems. So in July 2013, I decided to enroll in the Short Term Disability on the job but not before clarifying the pre-existing clause of the policy. It was the year for promoting the Short Term Disability Policy to employees so I received incorrect and vague information. I continued to push until they stated the surgery in 2012 wouldn’t be considered pre-existing. December 2013, there was something different and was credited to physiological stage of aging. January 29, 2014, my doctor ordered MRI which reflected the physiological stage of aging but the Specialist denied the claim. She stated it is pre-existing condition. Although it was in the cervical and back as previously, it was different levels not from the 2012 surgical procedure.

    Would this be considered pre-existing? I am appealing the denial with them now.

    MarieMay 6, 2014  #3

  • Guy,

    You should definitely appeal. If you fail to appeal then you will have no further recourse against the disability insurance company.

    Gregory DellOct 26, 2012  #2

  • I started a new job and one week later had to go see the doctor. He gave me meds, and said it was maybe swollen nerves. I got better and then, seven months later, I was changing a tire which caused a bulging disc. I had to have back surgery. The insurance company denies my claim, it said it was a preexisting condition. The surgeon said they were no not related. Should I appeal?

    Guy BoisclairOct 25, 2012  #1