Does a Pre-Existing Back Injury to L4-5 Preclude Benefits for an Injury to L2-3?
In Karl Meche v. Metropolitan Life Insurance Co., (MetLife), Plaintiff had worked for about six months as an account manager for Air Liquide USA LLC, when he injured his back at work. On July 20, 2016, he was moving a cylinder for his employer when he heard his “back pop.” He reported the injury to his medical providers.
After receiving short-term disability (STD) benefits from MetLife, Plaintiff’s claim for long-term disability (LTD) benefits was denied. MetLife decided that since Plaintiff had a previous diagnosis of degenerative disc disease (DDD) which resulted in a spinal fusion on L4-5, his injury at L2-3 was due to a pre-existing condition.
On administrative appeal, MetLife again denied Plaintiff’s claim for LTD benefits for the same reason: he had a pre-existing condition. After exhausting his administrative remedies, Plaintiff filed this ERISA lawsuit in the United States District Court for the Eastern District of Louisiana.
Plaintiff presented two main questions to the District Court: 1) Did the policy preclude payment in general for a disability that “results” from a pre-existing condition; and 2) If so, did Plaintiff’s disability result from a pre-existing condition.
After careful analysis of the policy terms and Plaintiff’s medical records, the Court decided in favor of Plaintiff, holding that although the pre-existing condition clause in the policy was valid, his disability was not the result of a pre-existing condition. Therefore, the Court ordered MetLife to pay Plaintiff past and future LTD benefits for the back injury he suffered at work.
The Pre-Existing Conditions Clause in the Policy is Valid
MetLife’s policy identified several instances when an employee would be deemed to have a pre-existing condition. For example, if the employee had received treatment or taken medication for the condition in the 12 months prior to the date the policy went into effect, that would be considered a pre-existing condition. MetLife would pay benefits for a pre-existing condition if the employee became disabled after working for the employer for an entire year after the insurance became effective, or if the employee had not received any treatment for the condition or taken any medication for it for three months following the date the insurance began.
Plaintiff argued this clause should be invalid since it identified when payments would be made for a pre-existing condition but did not articulate when benefits would not be paid. The Court disagreed with Plaintiff and found that since the clause was written “in an ordinary and popular sense as would a person of average intelligence and experience” understand it, it was valid. The Court concluded “that the clause at issue validly permits the denial of benefits based on a pre-existing condition.”
Plaintiff’s Disability Was Not the Result of a Pre-Existing Condition
MetLife did not dispute the fact that Plaintiff suffered a work-related injury. It just argued that since Plaintiff had pre-existing DDD, he was precluded from collecting long term disability (LTD) benefits. An analysis of Plaintiff’s medical record showed that prior to his work injury, Plaintiff had undergone surgeries for DDD at Level L4-5.
Medical testing documented that after his injury, Plaintiff suffered problems related to levels L2-3. This was a new part of his back. There was no evidence in his medical records that indicated Plaintiff had ever had any issues at L2-3 prior to the injury.
Plaintiff’s pain changed after the accident. Before the injury, his pain was localized to his lower spine, around his belt-line, areas known to cause pain due to an L4-5 injury. Plus, prior to the accident, his pain was under control with medication, and he was able to work. In fact, prior to the injury at Air Liquide, he worked as an industrial engineer for 20 years, and was able to walk, play baseball and engage in “an active lifestyle.”
After the injury, that affected L2-3, Plaintiff suffered “with intense, uncontrollable pain.” He lost mobility. He increased his use of painkillers. He could not “tolerate sitting or standing for significant amounts of time.” He could only drive for limited periods of time and on many days, he was unable to get out of bed.
The Court noted, “In sum, therefore, the changes in location, magnitude, and effect of [Plaintiff’s] pain suggest that the pain does not arise from a preexisting condition. And overall, the occurrence of a workplace injury, followed by new anatomical findings, tied to different symptoms, all provide evidence that [Plaintiff’s] disability does not result from a pre-existing condition.”
In addition, MetLife’s consultant used the wrong standard in recommending denying benefits. She stated that Plaintiff’s problems were “‘related’ to the pre-existing condition.” The policy requires the disability to “result” from the pre-existing condition. This phrase requires a “causal relationship between the pre-existing condition and the disability at issue, not mere association.” The Court found that MetLife did not meet its burden to show a causal relationship.
The Court held that “MetLife unlawfully denied [Plaintiff’s] long-term disability benefits. The Court therefore orders MetLife to pay [Plaintiff] past and future long-term disability benefits for his July 20, 2016, back injury.”
Contact Dell & Schaefer
This case was not handled by our office, but we believe it can be instructive to those struggling with an insurance company that is denying them benefits based on a pre-existing condition. For questions about this case, or any question about your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.