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11th Cir. – Unpublished – Symptoms are Not Pre-Existing Conditions

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  • 11th Cir. – Unpublished – Symptoms are Not Pre-Existing Conditions

    Here’s a new case out of the Eleventh Circuit, unpublished, entitled Kristian Horneland v. United of Omaha Insurance Company. This matter deals with the application of a pre-existing condition exclusion. The court, performing a de novo review, first states the issues of the case as follows:

    Altogether, Defendant twice denied Plaintiff long term disability benefits based on the Pre-existing Conditions Exclusion because Plaintiff received treatment for “back pain and muscle spasms” during the look-back period—the same symptoms that Plaintiff ultimately claimed, just a few months later, to be so debilitating as to render him disabled and unable to work. In doing so, Defendant relied on the fact that Plaintiff was prescribed, and refilled prescriptions for, Vicodin and Tramadol for back pain during the look-back period in March 2013. In its ruling for Defendant, the district court agreed and found that Plaintiff “treated with his primary care physician before, during, and after the look-back period for back pain, and had prescriptions for pain medicine filled during the look-back period.”

    But back pain and muscle spasms are not by themselves necessarily Pre-Existing Conditions under the Exclusion. To interpret the plan and the Pre-existing Conditions Exclusion, we look first to the plan’s text, and we give the plan’s terms their plain and ordinary meaning. See Alexandra H. v. Oxford Health Ins. Inc. Freedom Access Plan, 833 F.3d 1299, 1307 (11th Cir. 2016). The Exclusion states that Defendant “will not provide benefits for Disability: (a) caused by, contributed to by, or resulting from a Pre-existing Condition; and (b) which begins in the first 12 months after [the policyholder is] continuously insured under this Policy.” The record shows, and the parties do not dispute, that (b) is satisfied.2 The only question then is whether Plaintiff had a Pre-existing Condition that caused, contributed to, or resulted in his disability.
    The court concludes that symptoms themselves are not subject to the pre-existing condition exclusion.

    Back pain and muscle spasms are not by themselves an accidental bodily injury, a disease, a disorder, nor a condition. Back pain and muscle spasms are the symptom for which an accidental bodily injury, a disease, a disorder, or a condition might be the cause. At no point in Defendant’s denial letters or in its brief does Defendant assert that back pain and muscle spasms are, in and of themselves, an accidental bodily injury, a disease, or a disorder.

    At most, Defendant occasionally refers to Plaintiff’s “disabling condition” as back pain and muscle spasms. But the plain text of the plan expressly defines pain as being a “symptom,” not a “condition.” The plan defines “Self-Reported Symptoms,” in part, as “manifestations of [the policyholder’s] condition.” (Emphasis added.) And “Examples of Self-Reported Symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness, and loss of energy.” (Emphasis added.) So pain is the “manifestation,” or symptom, of a condition; it is not a condition itself. Under the plan’s plain text, Plaintiff’s back pain is a symptom, not a condition.

    And this same logic dictates that muscle spasms cannot by themselves constitute a Pre-existing Condition. Muscle spasms are, like pain, soreness, or stiffness, a symptom of some underlying injury, disease, disorder, or condition. Muscle spasms are not a condition, nor are they an accidental bodily injury, a disease, or a disorder. Because a Pre-existing Condition must be either an accidental bodily injury, a disease, a disorder, or a condition, the Pre-existing Conditions Exclusion cannot apply to Plaintiff’s back pain and muscle spasms.
    The court then remands to the District Court to determine what the actual underlying condition causing the symptoms was. The opinion is attached below.
    Attached Files
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