A former Engineer Director for Bon Secours, with the help of his Pennsylvania Disability Attorney, were forced to file a federal ERISA lawsuit after Unum repeatedly denied his claim for Long Term Disability Benefits under a disability policy he was covered under through his employment with Bon Secours. After filing Cross Motions for Summary Judgment, the Court ultimately ruled in favor of the claimant and against Unum.
While most Courts seem inclined to uphold most disability insurance decisions to deny benefits because of a pre-existing condition, in the case of Robert L. v. UNUM Life Insurance, that wasn’t the case. Evidently, the Court felt that Robert L.’s claim for disability benefits as a result of cardiac disease did not constitute a pre-existing condition even though Robert L. had been taking aspirin for hypertension and hypercholesterolemia during the “look back” period (the three-month period before the “effective date of” a disability insurance policy). Consequently, in Robert L. v. UNUM, the United States District Court for the Middle District of Pennsylvania found that UNUM abused its discretion when it denied Robert L. disability benefits due to an alleged pre-existing condition.
The question that the Pennsylvania Court had to answer in deciding a ruling on the cross motions for summary judgment in this case was whether or not treatment of a medical condition to prevent another more serious one and then having the more serious condition present itself is the same as already having the condition. This would make all preventative measures taken by a physician for the symptoms of some undiagnosed disease suspect and thus, very few disability benefits claimants would escape having a pre-existing condition.
ERISA Claim is Examined for Abuse of Discretion on the Part of UNUM
Per the Employee Retirement Insurance Security Act of 1974 (ERISA), the Court must review a plan administrator or fiduciary review using an abuse of discretion standard of review. That means that the Court can take into consideration any conflict of interest that would have been present at the time of the decision, but the primary determining factor in whether or not the Court upholds the insurer’s decision is whether or not the decision was made “without reason, unsupported by substantial evidence or erroneous as a matter of law,” per case law, Doroshow v. Hartford Life and Accident Ins. Co.
In Robert L.’s case, he and his disability lawyer alleged that Robert L. was entitled to long term disability and asked the Court for the following.
- An order that UNUM pay Robert L. long term disability benefits;
- Prejudgment interest on the award through the date of judgment;
- Attorney’s fees and costs; and
- “Other and further relief as the court deems just and proper.”
Background of the Case
Robert L. was an engineering director for Bon Secours when he ceased work due to the implantation of an ICD (implantable cardioverter-defibrillator). He had worked for the firm since November 2008. The implantation of the device to treat congestive heart failure was performed in September 2009 and rendered Robert L. totally disabled from performing the duties of his job in that the presence of an ICD caused Robert L. to be unable to be in close proximity to any type of electrical machinery. Because of this, Robert L. filed a Unum disability application for long term disability benefits. Initially, UNUM denied Robert L.’s disability claim and continued to deny his claim throughout the insurer’s appeal process, and in October 2010, UNUM sent Robert L. a letter issuing its final denial of disability benefits stating that Robert L.’s congestive heart failure and need for an ICD device was a pre-existing condition. With the administrative remedies exhausted, Robert L. was forced to file this lawsuit against Unum.
UNUM Reviewer’s Reasoning Doesn’t Impress the Court
Unum’s reviewer reasoned that since Robert L. was taking aspirin and receiving treatment for hypertension and high cholesterol and had had coronary bypass surgery during the look back period, he was in effect receiving treatment for an underlying coronary disease (in this case congestive heart failure) and thus, had a pre-existing condition for which the insurer owed no coverage. Robert L.’s attorney pointed out in their complaint that Robert L. was not taking high cholesterol and hypertension medications to combat coronary disease, but was taking those medications as well as aspirin for the “effects of the heart surgery he had in 1999.” It wasn’t unit 2009, some eight months after the effective date of his insurance coverage, that Robert L. was diagnosed with congestive heart failure.
The District Court Finds In Favor of the Claimant
Quoting several examples of case law on the subject of pre-existing conditions and the awarding of disability insurance benefits, the Court, in its Memorandum, pointed out that per two medical reviewers who were hired by UNUM, the two doctors agreed that “congestive heart failure and coronary artery disease are two separate conditions, with two very different types of treatment programs. And, that Robert L. was being treated for coronary artery disease to prevent development of heart failure, not as a treatment for heart failure. Consequently, Robert L.’s doctors did not diagnose him with heart failure during the look back period, nor did he have a pacemaker installed during that time. In addition, no tests were performed during the look back period with regard to suspicion of a heart condition, all leaving the Court with little choice but to rule that Robert L.’s congestive heart failure was not a pre-existing condition.
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