Pre-existing Condition Exclusion

In Genoff v. United of Omaha Life Ins. Co., 2012 U.S. Dist. Lexis 124402 (E.D. Mich. Aug. 31, 2012), the plaintiff suffered a stroke a few weeks after becoming covered under his employer’s LTD plan.  His claim was denied by the defendant under the preexisting condition exclusion found in the Policy. The Policy defined preexisting condition as “any injury or sickness for which you received medical treatment, advice or consultation, care or services including diagnostic measures, or had drugs or medicines prescribed or taken in the the three months prior to the day you became insured under this policy.”  The Court reviewed the denial applying the de novo standard of review.

The Court noted that there was nothing in the record to indicate that the plaintiff had received any treatment for a stroke before the effective date of coverage:  “To the contrary, the symptoms for which Genoff sought treatment were determined to be caused by an ear infection. Thus, United’s denial of Genoff’s claim simply because he presented symptoms that could be associated with a later-diagnosed disease and consulted with a doctor during the look-back period in connection with those symptoms cannot stand.  Plaintiff’s treating physician did not diagnose or treat the specific disability that resulted in Plaintiff’s long term disability.”

Advertisements