Our client, Mr. M, formerly worked as a trade consultant for an international accounting firm. In May 2017 a large lumbar disc herniation forced Mr. M to stop working and submit his claim for disability benefits first under his employer’s STD policy, which paid full benefits, then under its Long-Term Disability (“LTD”) Policy which was administered and funded by Hartford. Under the employer’s disability policy Mr. M would be considered totally disabled if he was prevented from performing one or more of the essential duties of his occupation unless his injury or sickness was subject to the policy’s pre-existing condition limitation. Under that provision, Hartford would not pay a benefit for a disability that “results from, or is caused or contributed to by… any manifestations, symptoms, findings, or aggravations related to or resulting from” his disabling condition “for which [he] received medical care” during the 180 consecutive day period ending the day before his effective date of coverage.
Hartford denied benefits in January 2018 on the basis that Mr. M allegedly was not eligible for benefits under the Policy. Specifically, Hartford “determined that [his] condition was Pre-Existing and is excluded by [the] Policy.” After receiving the denial, Mr. M contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Hartford’s denial letter and in the evidence it relied on and agreed to prepare and submit Mr. M’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of Hartford’s short-comings and reasons for denial, with a special focus on Mr. M’s disabling condition versus the pre-existing condition referenced by Hartford. More specifically, Hartford’s denial letter incorrectly stated that Mr. M was claiming benefits under the Policy due to diagnosis of low back pain and orthopedic aftercare following a Rhizotomy and anterior spinal fusion with a disability date in May 2017. While this may have been true of his claim under the STD policy, which does not have a pre-existing condition limitation, Mr. M’s LTD claim, which did not begin until November 2017, was based on restrictions and limitations associated with rhBMP-2 osteolysis, which is an extremely rare complication he suffered following the fusion surgery and which was not diagnosed until July 2017. In fact, Mr. M made this point very clear to his Hartford claims examiner during a telephone call in November 2017.
The appeal made clear that courts across the country agree that where a Policy excludes coverage for disabilities caused by pre-existing conditions, the carrier may not attempt to apply its Policy as if it excludes coverage for disabilities caused by complications from surgery for pre-existing conditions. Courts recognize that surgery is not, itself, a pre-existing condition, but at most a necessary consequence of a pre-existing condition. Thus, the question is where to draw the line on chain of causation. In Mr. M’s case the chain of causation contained five very attenuated stages, including a decision by Mr. M’s health insurer to reject an initially recommended course of treatment. Hartford’s acceptance of that extremely attenuated causal link effectively rendered meaningless the notion of the pre-existing condition clause by distending the scope of the exclusion. Courts have rejected such an attenuated and long chain of causal links, with unanticipated intervening causes, and instead have held that the disabling condition must be substantially or directly attributable to the pre-existing condition. Courts have also made the distinction that well-known complications from a disease may trigger the pre-existing condition exclusion but, as here, rare, unrelated and unanticipated complications from treatment or surgery would not.
Several months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, Hartford overturned its denial and referred the claim back to the claims examiner for a disability determination. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.