ERISA Disability Insurers Frequently Try to Deny Claims Because of Alleged "Pre-Existing Conditions"It happens all too often - an individual is unable to work because of a disabling condition, they fill out a disbility claim form, provide supporting medical documentation, and wait for the decision of the disability insurance company. Then when the decision letter from the disability insurance company finally comes, the insurance company denies the claim because they say the claimed disability was actually caused by a pre-existing condition that was either before employment started or before the effective date of the policy. There are only two choices for an individual in this situation: (1) give up and do nothing; or (2) appeal the decision to deny the disability claim. If it is option number 2, then the individual should get a disability insurance attorney to handle the appeal. If the cost of an attorney is a concern, then it shouldn't be. The ERISA attorneys at Harris & Engler only collect a fee if you win your appeal or lawsuit. If you don't win, you don't pay anything. An individuals chances of success in appealing a denial decision is exponentially greater by hiring an attorney experienced in ERISA disability insurance denials.
Examples of Disability Insurance Denials for Pre-Existing Conditions in the Sixth Circuit and in OhioHaving diabetes is a somewhat common reason for disability insurance companies to deny a later occurring more serious injury. In the Sixth Circuit case of Collins v. Unum Life Insurance Company of America (2017), an individual had diabetes and one day tripped in his employers parking lot. He fell and broke an ankle. His foot later had to be amputated. Unum Life Insurance Company denied his claim for long term disability coverage because they said it was his history of poorly maintained diabetes that was the reason his foot had to be amputated.
Unum denied coverage due to their disability insurance policy provision excluding from coverage any "accidental losses caused by, contributed to by, or resulting from ... disease of the body."
That case was similar to an Ohio disability case in Morgan v. United Omaha Life Insurance Company (S.D. Ohio, Mar. 11, 2001), where a few days after an individual stepped on a screw, the disability claimant went to the emergency room, where they were diagnosed with "diabetic foot infection," and their foot ultimately had to be amputated. That disability insurance policy provided that the injury "must result in loss independently of sickness and other causes." United Omaha Life Insurance Company denied the claim for disability insurance benefits claiming that the loss was not independent of sickness or other causes. United Omaha ignored that there were infection issues after the initial surgery that led to the need to amputate the foot.
Another Sixth Circuit case that applies to Ohio disability insurance cases is Clark v. Metropolitan Life Insurance Company, 67 F.3d 299 (6th Cir. 1995). In that case, the disability claimant filed a claim for disability insurance after having a left hip replacement. Metlife denied the claim because they found a notation in a medical chart that the patient had pain in their left thigh for the past 4 -5 years. Metlife said that because the pain in the thigh and hip was pre-existing before the surgery, that it was a pre-existing condition. Metlife had a pre-existing condition clause that read:
"Expenses incurred as a result of an injury, illness, or pregnancy, as diagnosed by a physician or covered provider, which existed prior to the effective date of insurance are not covered by this plan, until twelve months from the effective date of your coverage of the plan, whether the condition was diagnosed before or after the effective date of insurance and whether or not the condition resulted in any symptoms prior to the date of insurance."
The Court did not side with Metlife in that case because the Metlife denial letter simply restated the medical names for the disability claimant's hip conditions, such as enthesopathy of the hip, traumatic arthropathy and osteoarthritis, and then just concluded that they were "pre-existing conditions." The Court said that Metlife was required by statute and regulations to give the disability claimant specific reasons why it considered those conditions to be pre-existing. See 29 U.S.C. Sec. 1133, and 29 C.F.R. Sec. 2560.503-1(f).