Northern District of Illinois determines the exception to The Standard’s “limited conditions” provision does not apply when plaintiff failed to provide current positive MRI evidence of a herniated disc

It is very common for group disability policies to contain provisions limiting LTD benefits to 12 or 24 months for conditions involving the cervical or lumbar spine as well as soft tissue injuries. It is important to be familiar with your policy language and its limitations prior to filing a claim for benefits, especially if your policy contains a limitation for certain medical conditions. It is often times possible to get around these limitations if you are able to provide objective medical support of a condition falling under one of the exceptions provided in the plan. If you are suffering from one of the limited conditions in your plan, it is extremely important to address this issue with your treating physicians in order to determine whether additional testing may provide evidence of one or more of the possible exceptions to this limitation.

An example of this exact issue was addressed in an April of 2014 decision, out of the Northern District of Illinois, Zaccone v. Standard Life Insurance Company. The LTD Plan at issue contained the following limitations:

Payment of LTD Benefits is limited to 12 months during your entire lifetime for a Disability caused or contributed to by any one or more of the following, or medical or surgical treatment of one of the following:

3. Other Limited Conditions.

Other Limited Conditions means… chronic pain conditions… arthritis, diseases or disorders of the cervical thoracic, or lumbosacral back and its surrounding soft tissue…

However, Other Limited Conditions does not include… herniated discs with neurological abnormalities that are documented by electromyogram and computerized tomography or magnetic resonance imaging, scoliosis, radiculopathies that are documented by electromyogram, spondylolisthesis, grade II or higher, myelopathies and myelitis, traumatic spinal cord necrosis, osteoporosis, discitis, Paget’s disease.

Plaintiff Fails to Provide Recent Objective Proof of Neurological Condition

In an effort to get around the “Other Limited Condition” provision in his plan, Zaccone provided the Standard with an MRI from 1992 which revealed a herniated disc. According to Zaccone, this MRI was sufficient evidence of a “neurological abnormality that is documented by MRI.” However, according to the Standard and the Court agreed, the 1992 MRI was insufficient objective proof of his lumbar condition. The Court reasoned that Zaccone underwent a lumbar laminectomy and discectomy in 1992, after the MRI was done, which were both successful as described by his neurosurgeon. Since 1992, there had been no additional evidence on MRI or otherwise to indicate the plaintiff had a herniated disc or any tests such as a positive EMG indicating radiculopathy. The Plaintiff argued that the plan was ambiguous as it does not specify the time frame in which the evidence must date back to. The Court disagreed, holding that the plaintiff is disabled due to degenerative disc disease, but without more recent objective proof, his claim is limited to 12 months.

The Zaccone case is a prime example of why it is pertinent to be familiar with the exclusions and limitations in your plan, to ensure that your treating physicians are aware of these as well and to request that your physicians order all possible objective tests including MRI’s, CT scans, EMG’s in order to provide recent objective evidence of your disability due to a cervical or lumbar condition.

The law firm of Dell & Schaefer did not handle the Zaccone case, but our firm represents many clients with disabilities similar to Zaccone, who are faced with the challenge of refuting the limitations contained in their LTD policies. When representing our clients, it is our goal to help ensure that he or she is receiving the proper medical care, the proper tests have been ordered by their doctors and most important, that the client and his or her physicians have an understanding of the limitations contained in their policy.

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There are 2 comments

  • Rich,

    Unfortunately, depending on applicable plan language that may preclude payment of benefits beyond a certain period a person may not be entitle to additional benefits.

    Stephen JessupDec 19, 2014  #2

  • So those of us who have had prior surgeries – repairing fractures, herniations – which have not resolved pain and have led to diagnosis of failed back syndrome are out of luck?

    RichDec 18, 2014  #1