Ms. Kaiser began working for the Wisconsin Energy Conservation Corporation in March of 2013. As part of her employment, Ms. Kaiser was eligible for long-term disability coverage through United. The effective date of coverage was April 1, 2013.
The Disability Policy
The disability policy contained the following pre-existing condition exclusion:
We will not provide benefits for any Disability caused by, attributable to, or resulting from a Pre-Existing Condition which begins in the first 12 months after You are continuously insured under the Policy.
Pre-existing condition was defined as any injury or sickness for which the insured received medical treatment, advice or consultation, care or services, including diagnostic measures, or had drugs or medicines prescribed or taken in the 3 months prior to the day the insured became insured under the policy (the “look-back period”).
Ms. Kaiser’s Claim
During the look-back period, Ms. Kaiser sought treatment for her shoulder which she believed she injured while shoveling snow. Her treating doctor believed her shoulder pain was due to rotator cuff and bicipital tendonitis triggered by repetitive action. She was prescribed anti-inflammatories and referred to physical therapy.
After the look-back period, Ms. Kaiser started seeing a new doctor. This doctor sent Ms. Kaiser for an MRI of her shoulder. Based on this scan, the doctor became concerned that Ms. Kaiser may have some metastatic disease stemming from undiagnosed cancer. A later X-ray revealed Ms. Kaiser had Stage IV lung cancer.
No longer able to meet the demands of her job, Ms. Kaiser filed a claim for LTD benefits. Because this claim was filed within 12 months after the effective date of her coverage, United performed a pre-existing condition review.
United denied Ms. Kaiser’s benefits claiming she treated for lung cancer during the look-back period when she saw doctors for her shoulder pain. When her appeal was denied, Ms. Kaiser filed a lawsuit against United.
The Court’s Review of Ms. Kaiser’s Case
The question for the court was whether Ms. Kaiser’s visit for shoulder pain, prescription of pain medication, and referral to physical therapy, was considered treatment for her lung cancer. The court held it was not.
Reviewing other court decisions, the court here found that although a diagnosis of cancer during the look-back period was not needed to invoke the pre-existing condition exclusion, there must have been at least some suspicion, during the look-back period, that her symptoms (shoulder pain) were caused by cancer.
During the look-back period, Ms. Kaiser’s doctors did not suspect cancer. As the court put it, a “cancer diagnosis was not even on the radar screen.” Therefore, the court found that Ms. Kaiser could not have been treated for her disabling condition during the look-back period. The court ruled in Ms. Kaiser’s favor finding United acted unreasonably.
Dabdoub Law Wins Pre-existing Disability Lawsuit
This law firm knows how to win disability benefits lawsuits involving pre-existing denials. TRead about our win in the federal court of appeal involving a pre-existing denial.
Help from an Attorney with Expertise in Disability Insurance
Disability insurance law is complicated, especially when dealing with a pre-existing condition denial. If your claim for disability benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in disability law.
Our lawyers specialize in disability insurance;
Our lawyers have won tough disability insurance lawsuits;
Our lawyers have recovered millions in disability benefits for clients who were wrongly denied.
Because federal law applies to most disability insurance claims, we do not have to be located in your state to help.
Dabdoub Law Firm represents clients nationwide with:
Submitting a disability insurance claim;
Appealing a short-term or long-term disability denial;
Negotiating a lump-sum settlement; or
Filing a lawsuit against your disability insurance company.
Call to speak with a disability insurance attorney. No fees are costs unless clients are paid.