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Home > Blog > Sixth Circuit Upholds Denial of Benefits under ERISA Plan’s Limitation for Preexisting Conditions

Sixth Circuit Upholds Denial of Benefits under ERISA Plan’s Limitation for Preexisting Conditions

The Sixth Circuit Court of Appeals recently decided Harrison v. Life Insurance Company of North America, No. 20-3337, __F.App’x__, 2021 WL 1530040 (6th Cir. Apr. 19, 2021), a case brought under the Employee Retirement Income Security Act of 1974 (“ERISA”). Plaintiff-Appellant Angela Harrison appealed the district court’s judgment in favor of Life Insurance Company of North America (“LINA”) on the issue of whether her long-term disability benefit claim is payable under LINA’s policy’s exclusion for a disability “caused” or “contributed to by” a preexisting condition. The court affirmed the district court’s determination, finding that Harrison’s depression and anxiety were but-for causes of her inability to work and subject to the policy’s preexisting-condition limitation.

The relevant policy language is the following:

The Insurance Company will not pay benefits for any period of Disability caused or contributed to by, or resulting from, a Pre-existing Condition. A “Pre-existing Condition” means any Injury or Sickness for which the Employee incurred expenses, received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a Physician within 3 months before his or her most recent effective date of insurance.

Harrison worked as a customer service representative for Advance America, Cash Advance Centers. LINA insured Advance America’s long-term disability benefit plan under which Harrison became covered by virtue of her employment. Because of the timing of Harrison’s disability in relation to her coverage effective date, LINA conducted a preexisting condition investigation. It is not in dispute that Harrison was treated for depression and anxiety before she started work for Advance America. It is not in dispute that depression and anxiety affected her ability to work. But it was not until after Harrison left work that she was diagnosed with Right Hemisphere Deficit Syndrome which stemmed from a brain injury at birth, and which has impaired her cognitive functioning. She argues that Right Hemisphere Deficit Syndrome caused her inability to work, and the preexisting-condition limitation did not apply because she had not been diagnosed with it until after she left Advance America. On the other hand, LINA argues that her depression and anxiety were also causes of her disability and there is no evidence that absent these diagnoses that her Right Hemisphere Deficit Syndrome caused an inability to work.

On appeal, the parties raised various legal issues involving the standard of review, who bears the burden of establishing that the limitation applies, and whether the phrase “contributed to by” must be read narrowly to require proof that a condition is a “but-for” cause of an inability to work. The court decided not to reach any of these legal issues because even if it “resolved each of them in Harrison’s favor—that is, even if we (1) applied de novo review to LINA’s decision, (2) placed the burden of proof on LINA to establish that the preexisting-condition limitation applies, and (3) interpreted the phrase ‘contributed to by’ narrowly to require but-for causation—Harrison still must lose.” This is because the evidence in the record shows that depression and anxiety were but-for causes of Harrison’s inability to work.

The court found compelling the following evidence: (1) letters from treating doctors identifying the worsening of Harrison’s depression and anxiety as the source of her inability to work; (2) Harrison’s own statements that her job caused her depression and other symptoms to get worse; (3) nothing in the record suggesting that her Right Hemisphere Deficit Syndrome got worse; she was initially capable of working at the company for over a year before her worsening depression and anxiety caused her inability to work. The court declined to address Harrison’s argument that her Right Hemisphere Deficit Syndrome does not qualify as a preexisting condition because it was diagnosed too late. This is because Harrison’s depression and anxiety were preexisting conditions and caused her inability to work. The district court’s judgment is affirmed.

If you have a denied claim for long-term disability benefits due to a preexisting condition, there may be a way out of the policy’s limitation. Contact us for a case evaluation since these issues are not so cut and dry.

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