Ninth Circuit Affirms Guardian’s Denial of Long-Term Disability Benefits Due to Claimant’s Pre-Existing Condition

In Roeder v. Guardian Life Ins. Co., No. 22-56226, 2024 WL 1612256 (9th Cir. Apr. 15, 2024), Plaintiff-Appellant Jacqueline Roeder appealed the district court’s de novo review of Guardian Life Insurance Company’s denial of her claim for long-term disability benefits under a policy governed by ERISA on the basis of the policy’s pre-existing condition exclusion. The Ninth Circuit found no errors of law or clearly erroneous factual findings and affirmed the judgment of the district court.

Roeder became disabled from work due to severe neck pain from a degenerative cervical spine condition. Because she stopped working within twelve months of employment, Guardian analyzed her claim to determine whether her disability was caused by a pre-existing condition. The policy excludes coverage for any disability occurring within the first twelve months of employment if the claimant “suffered from a physical … condition, whether diagnosed … which caused symptoms within three months before the effective date of [the applicant’s] insurance … for which a prudent person would usually seek medical advice or treatment … [and which] caused or substantially contributed to” the disability. During the policy’s three-month look-back period, Roeder’s medical records showed that she went to urgent care complaining of sinus pain and neck pain. She received treatment including antibiotics, and trigger point injections and electrical stimulation in her neck. Though her degenerative cervical spine condition was not diagnosed or suspected during the look-back period, the district court found that it caused symptoms of neck pain for which she sought treatment.

Roeder challenged the district court’s decision on three bases: (1) the notes from the urgent care visit do not contain a specific diagnosis; (2) the notes suggest that her sinus pain and intravenous antibiotics could have been related to an infection; and (3) the record as a whole fails to prove that her symptoms during the look-back period were related to her later-diagnosed degenerative cervical spine condition. The Ninth Circuit disagreed with Roeder. The court explained that the exclusion does not require a diagnosis during the look-back period. Second, the urgent care notes support the conclusion that Roeder suffered symptoms and received treatment for two separate complaints. The court found no clear error in the district court’s conclusion based on the record as a whole.