After being diagnosed with throat cancer, Mr. Langdon applied for both short term and long term disability benefits with Principal Life Insurance Company. Principal agreed to pay the short term benefits, but denied the long term claim. They alleged that the throat cancer was a preexisting condition and thus excluded under the relevant policy.
The preexisting condition provision in the policy stated that benefits would not be paid to any individual who suffered from an illness for which they had either (1) received medical treatment or (2) had taken prescribed medications for in the three months prior to becoming insured.
During the relevant three month period, also called the look back period, Mr. Langdon saw several doctors who examined and treated him for swelling in his neck. At no point during the three month period was he diagnosed with throat cancer. However, Principal denied his claim alleging that “preexisting condition” includes all related conditions. They claimed that the neck swelling was a condition related to the throat cancer.
Other Courts have faced a similar issue and have come up with a general rule regarding the pre-existing condition provision. While a patient need not be definitively diagnosed with a condition during the look-back period, there must be at least some concern or suspicion at that time that the observed symptoms were caused by the particular condition.
In this case, the court found that none of Mr. Langdon’s treating physicians suspected throat cancer during the relevant time period. Rather, the court found that while the doctor’s may have treated the swelling and recognized the potential for a serious diagnosis, they did not indicate any suspicion of cancer. It was not until after the look-back period that cancer became a possible diagnosis. Ultimately, the court ruled in favor of Mr. Langdon and found that he did not receive medical treatment for throat cancer during the relevant time period because none of the doctors knew of or suspected throat cancer.