District Court Affirms Insurer’s Application of ERISA Disability Policy’s Pre-Existing Condition Exclusion

In Tunkle v. Reliastar Life Insurance Company, No. 2:23-CV-10-SPC-NPM, 2024 WL 3638011 (M.D. Fla. Aug. 2, 2024), on cross-motions for summary judgment, a Florida Middle District Judge granted Defendant Reliastar’s motion, and denied Plaintiff’s motion, finding that Plaintiff was not actively employed for a period immediately prior to his claim for long-term disability benefits, and thus the pre-existing condition exclusion applied under his new coverage when he stopped working two months later.

Plaintiff was a general surgeon employed by 21^st Century Oncology. In January 2020, Plaintiff underwent left shoulder joint-reconstructive surgery due to an injury. In March 2020, Plaintiff began to struggle and worked reduced hours (below the policy’s required 30-hour per week for “active employment status”) due to a tremor that had developed in his left hand. Plaintiff treated with a neurologist, and he resumed working full-time in May 2020 continuing until July 30, 2020. At that time Plaintiff’s neurologist placed him off work stating that given his profession as a surgeon and the level of tremor, Plaintiff could not continue to operate, and it would not be an option going forward.

Reliastar denied Plaintiff’s claim finding that Plaintiff’s coverage ceased when he was no longer “actively employed” in March 2020. When he returned to work in May 2020, this became Plaintiff’s new effective date under the policy. Reliastar concluded that Plaintiff’s tremors were, thus, a preexisting condition excluded from coverage.

The Court agreed finding that the administrative record left little room to second-guess Reliastar’s conclusion. Under a de novo standard of review, while Plaintiff bears the burden of proving entitlement to benefits, the insurer must prove that a policy exclusion prevents coverage. The Court found that all documentation from the employer indicated Plaintiff was not actively employed from March 15^th to May 23^rd. Plaintiff’s employer repeatedly confirmed it had no record to support either full-time work or an approved leave of absence during the relevant time period. Hourly logs showed that Plaintiff worked only 9.5 hours each pay period during those two months. The Appointment Productivity Reports also reflected that Plaintiff spent far less than thirty hours each week in appointments. While Plaintiff insisted he was constantly researching, making phone calls, traveling to medical facilities, completing medical records, preparing for surgery or conducting post-operative visits with patients, as well as being “on call” 24/7, Plaintiff provided no evidentiary support for these assertions – no call logs, redacted medical records, invoices, mileage receipts, or calendar appointment entries. The Court found Plaintiff’s declaration (and that of his colleague) were uncorroborated and insufficient. Plaintiff did not explain why all this additional work was not logged by his employer, particularly given it was the company’s explained business practice to do so.

The Court concluded that Reliastar’s reliance on documents from the employer was reasonable, especially given the absence of any contrary evidence. As such Plaintiff was not actively employed from March 15^th to May 23^rd. Further, Plaintiff conceded that his hand tremors were a preexisting condition. As such, the Court affirmed Reliastar’s decision.

If Reliastar or your insurer has denied or otherwise limited your life or disability insurance claim, contact us for assistance.