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Hartford attempts to deny store clerk’s claim for disability benefits on the basis of a pre-existing multiple sclerosis condition

McLeod v. Hartford Life and Accident Ins. Co., 372 F.3d 618 (US Court of Appeals Third Circuit 06/22/2004)

On January 26, 1998, Shirley McLeod (hereinafter “McLeod”) was hired by Valley Media to stock video cassettes in its warehouse. Subsequent to her hire date, McLeod signed up for disability insurance under the Valley Media Plan (hereinafter the “Plan”). The Plan’s administrator was Hartford Life and Accident Insurance Company (hereinafter “Hartford”).

Not too long after McLeod started working, she applied for long-term disability benefits. Hartford denied McLeod’s claim for long-term disability benefits on the grounds that her disabling condition, multiple sclerosis, was a pre-existing condition for which long-term disability benefits were not payable under the Plan. Even though McLeod’s diagnosis of multiple sclerosis was not made until August 1999, four months after her effective date of coverage, April 1, 1999, Hartford concluded that McLeod had “received medical [care] for manifestations, symptoms, findings or aggravations relating to or resulting from multiple sclerosis during the 90 day period prior to [her] effective date of coverage. After exhausting her administrative remedies, McLeod sued Hartford, claiming that she had not received treatment for multiple sclerosis during the 90 day look-back period because the multiple sclerosis had not yet been diagnosed at that time. The district court ruled in favor of Hartford and McLeod appealed.

The Third Circuit ultimately reversed the district court’s ruling, holding that “despite language in the benefit plan aimed to cast a broad net as to what constitutes receiving medical care for a ‘pre-existing condition,’ McLeod did not receive treatment ‘for’ such a pre-existing condition prior to her effective date of coverage because neither she nor her physician knew or suspected that the symptoms she was experiencing were in any way connected with multiple sclerosis.” The Court held that McLeod was entitled to receive disability benefits.



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