The court in Indiana held that breast cancer was not a pre-existing condition under the terms of a health insurance policy. The court held that where pre-existing conditions are excluded from coverage, insurance company’s receipt of routine physical examination and mammogram records prior to the effective date of policy did not constitute treatment for breast cancer. Thus, the policy's pre-existing condition exclusion did not prevent coverage for the insured's breast cancer treatment.
Charlotte Pitcher obtained health benefits through her employer under a group health insurance policy. The policy was underwritten by Principal and contained a provision that excluded coverage for pre-existing conditions.
The policy made it such that “if Pitcher received ‘treatment or service’ for a medical condition existing in the ninety-day period prior to [when she signed up for benefits], that condition would qualify as a ‘pre-existing condition’ under the policy” and not be covered.
Pitcher had a fibrocystic breast condition that led to benign lumps in her breasts, but the condition does not develop into cancer. Prior to her health insurance’s effective date, Pitcher went to her doctor for a routine physical examination where her doctor detected lumps in both breasts. Given her condition, this was not automatically indicative of cancer. At a follow-up appointment prior to her health insurance effective date, the lumps were still present, and she underwent a mammogram.
Results led Pitcher’s doctors to take a breast tissue biopsy. The procedure took place after her health insurance became effective. Biopsy results led to a cancer diagnosis, and treatment ensued. There was a total cost of $24,260. Pitcher sought reimbursement through her employer-sponsored, ERISA governed, health insurance for all cancer-related costs she incurred after her policy’s effective date.
Of the issues examined by the court was whether “Pitcher received a “treatment or service” for breast cancer during the ninety-day period prior to the effective date of coverage . . . and not whether Pitcher actually had breast cancer during this time period.” If the treatment was for breast cancer then it is barred by the policy's pre-existing condition clause.
The Court’s Decision
The court held that the medical treatments Pitcher underwent during the pre-coverage period, including the physician examination, physician follow up, and mammogram, were not services or treatments for cancer, but monitorization for the longstanding fibrocystic breast condition.
Pitcher’s fibrocystic breast condition was “unrelated to cancer, even though it manifests itself in the same area of the body as breast cancer and takes on the form of cysts, masses, and formations of fibrous tissue.”
Furthermore, a mammogram is not a treatment, but rather a service, and in this instance, the mammogram was (1) part of treatment for her breast condition – not cancer; and (2) routine given Pitcher’s age and time since her last mammogram.
Because Pitcher did not receive “treatment or service” for breast cancer in the 90-days before her health insurance became effective, her cancer treatment is not a pre-existing condition. Thus, she may recover the costs incurred after the policy became effective.
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