The Tenth Circuit Court of Appeals reversed Unum’s denial of long-term disability benefits for complications of surgery based on a pre-existing condition exclusion. Shirley Fought stopped working due to severe staph infection following elective heart surgery. The appeals court overturned the lower court’s ruling in favor of Unum, entering an order mandating that Unum pay all benefits due to Ms. Fought.
Unum’s Disability Policy
Prior to enrolling in her employer’s long-term disability plan, Ms. Fought had been diagnosed with and treated for coronary artery disease. She became covered under the long-term disability (“LTD”) plan, which was underwritten by Unum, as of June 1, 1998. The LTD policy contained a pre-existing condition exclusion, which did not pay benefits for any disability that was “caused by, contributed to by, or resulting from” a pre-existing condition.
Unum’s policy did not define the terms “caused by, contributed to by, or resulting from.” A pre-existing condition was defined as a condition for which:
- You received medical treatment, consultation, care or services including diagnostic measure; or
- Took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; or
- You had symptoms for which an ordinarily prudent person would have consulted a health care provider in the 3 months just prior to your effective date of coverage.
If the disability began in the first 12 months after the effective date of coverage.
Ms. Fought’s Disability Claim
About three months after Ms. Fought’s enrollment in Unum’s LTD plan, in August 1998, she underwent angioplasty. Seven months later, in March 1999, Ms. Fought was admitted to the hospital for unstable angina syndrome and underwent elective coronary revascularization surgery. Because of Ms. Fought’s anatomy, the surgeons required a special procedure to close the surgical wound and expected post-operative complications. Six days after the surgery, Ms. Fought was discharged without issue.
Three weeks later, Ms. Fought’s wound split open and she was readmitted to the hospital in April 1999 for wound care and possible infection. She was placed on antibiotics due to a positive culture test and remained in the hospital for five days and then transferred to a skilled nursing facility. Ms. Fought was discharged from the nursing facility on April 19, 1999.
On May 7, 1999, Ms. Fought complained of chest pain and was readmitted to the hospital where doctors found two exposed sternal wires. At this time, Ms. Fought tested positive for a staph infection and was placed in the Intensive Care Unit. For two months Ms. Fought underwent several operative procedures--including wound reconstruction--required intubation, nutritional support, monitoring, and sedation.
Unum’s Claim Denial
Unum denied Ms. Fought’s disability coverage under the LTD plan, claiming her disability was caused by a pre-existing condition: coronary artery disease.
Ms. Fought appealed Unum’s decision and provided letters from three different doctors certifying that the staph infection was (1) not a pre-existing condition and (2) not related to her coronary artery disease. Unum rejected Ms. Fought’s appeal and upheld its denial. Ms. Fought filed a lawsuit under ERISA.
The Court’s Review of Unum’s Decision
Ms. Fought argued before the court that Unum wrongly extended the pre-existing of its LTD policy to exclude coverage for disabilities that result from surgery--not just those that result from pre-existing conditions. Unum’s position was that the pre-existing condition exclusion language did not require that the disabling condition be the sole or direct result of the pre-existing condition.
Although the lower court agreed with Unum, the court of appeals did not. The appeals court noted that Unum sought to exclude coverage for disabilities caused by complications from surgery for a pre-existing condition. Simply put, the appeals court had to determine where to draw the line on the chain of causation. The appeals court found that Unum relied on a classic “but/for” causation: but for Ms. Fought’s coronary artery disease, none of the rest of the chain of medical events would have happened.
For Ms. Fought, however, there were at least five intervening events between her pre-existing coronary artery disease and her disability. According to the appeals court that was too many events and Unum’s interpretation of its pre-existing condition language would render the policy meaningless as the exclusion would swallow up coverage.
The question in this case for Unum was: what condition caused Ms. Fought’s disability?
Unum answered coronary artery disease. The Tenth Circuit Court of Appeals disagreed and ruled in favor of Ms. Fought and determined her disability was caused by a staph infection, which was not pre-existing.
Disability Insurance Companies Have Lawyers. Shouldn’t You?
If you are facing a long term disability claim denial based on a pre-existing condition exclusion, you should consult an experienced disability lawyer. Our law firm had a recent victory at the court of appeals concerning a pre-existing condition denial. We can do the same for you.
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