UNUM's decision to deny disability benefits on the basis of a pre-existing condition for primary lateral sclerosis is reversed on appeal
Glista v. Unum Life Ins. Co. of Am., 378 F.3d 113 (US Court of Appeals First Circuit 08/11/2004)
On July 15, 1999, Bernard Glista (hereinafter “Glista”) was hired by Ezenia, Inc. to serve as its vice president of worldwide sales. As an employee of Ezenia Inc., Glista was given long-term disability insurance, for which, Unum Life Insurance Company of America (hereinafter “Unum”) served as its administrator.
Shortly after commencing his employment with Ezenia Inc., Glista, in the summer of 1999, applied for long-term disability benefits. Unum denied Glista’s claim for long-term disability benefits, citing that his disabling condition, Primary Lateral Sclerosis (hereinafter “PLS”), was a pre-existing condition for which long-term disability benefits were not payable under the plan. Unhappy with Unum’s decision to deny benefits, Glista brought suit against Unum claiming unlawful denial of benefits.
Glista argued that Unum was incorrect in denying his long-term disability benefits on the basis that he had received treatment for PLS during the look-back period. Glista states that he could not have received treatment for PLS during the look-back period because the PLS had not yet been diagnosed. Additionally, Glista motioned the court to allow the inclusion of documents from Unum’s computer-based “risk management reference” guide concerning the interpretation of the pre-existing provisions, and Unum’s training materials on applying pre-existing condition clauses and related deposition testimony in the administrative record.
Unum in response, moved for judgment on the administrative record, arguing that because Glista had received treatment for a condition that was caused by PLS, he was prohibited from receiving benefits under the Treatment Clause of the pre-existing condition exclusion. The district court ultimately granted Unum’s motion and denied Glista’s motion. Unsatisfied with the courts decision, Glista appealed.
The 1st Circuit ultimately held “that based on the insurer’s own internal guidelines and training manuals, the treatment clause of the pre-existing condition exclusion applied only where there is a clear and direct relationship between the symptoms and treatment in the pre-existing period and the disabling condition. Furthermore, the Court held that “the plan administrator’s failure to cite the plan’s symptoms clause of the pre-existing condition exclusion as a reason for denying benefits will preclude the administrator from using such plan language in a later court action as a justification for denial.
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