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10th Cir. – Pre-Existing

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  • 10th Cir. – Pre-Existing

    Here’s a new case out of the Tenth Circuit, Michael Green v. Life Insurance Company of North America. The court first turns to LINA’s conflict of interest in its dual capacity as both the administrator and funder of the plan. The court finds that LINA properly dealt with their conflict of interest.

    Here, LINA properly dealt with its conflict of interest in its dual capacity role by twice referring Mr. Green’s case to independent peer reviewers. In Mr. Green’s initial appeal, LINA consulted Dr. Kamjoo, upon whose opinion it was able to state that Mr. Green’s PVD “was highly likely to have caused a retinal tear and was the initial event that led to a retinal tear which subsequently led to the development of the retinal detachment and vision loss.” Aplt. App. at 1108. When Mr. Green appealed to LINA a second time, LINA consulted Dr. Yanik, another independent peer reviewer, whose analysis was the same. Id. at 1142.

    Having dealt with its conflict of interest, LINA made a reasonable and good faith determination that Mr. Green had a pre-existing condition (PVD) that caused or substantially contributed to his vision loss. As the district court’s well-reasoned opinion points out, LINA relied on five doctors’ opinions, two of whom were Mr. Green’s own doctors, and all of whom agreed that PVD was a highly probable link to Mr. Green’s ultimate vision loss. See Green, 2017 WL 4337675, at *5.
    The court then concludes that Mr. Green’s disabling condition was pre-existing.

    Mr. Green argues that the causal relationship between PVD and his vision loss is too tenuous. He points us to Fought v. Unum Life Ins. Co. of Am., 379 F.3d 997, 1003 (10th Cir. 2004), a case in which we held that a pre-existing condition “cannot merely [] be one in a series of factors that contributes to the disabling condition; the disabling condition must be substantially or directly attributable to the pre-existing condition.” But PVD was not part of a long chain of ailments that eventually led to Mr. Green’s vision loss; it led directly to his seeking further treatment and surgeries. The medical experts all agree that PVD was a cause of Mr. Green’s vision loss. Indeed, Mr. Green’s only reason for seeking a diagnosis of his PVD was vision difficulties. A condition need not be the ultimate cause of a person’s claim for LTD benefits to qualify as a pre-existing condition.

    Mr. Green’s argument that LINA impermissibly rewrote the Plan is also without merit. The Plan provides that “a ‘Pre-existing Condition’ means any Injury or Sickness for which you incurred expenses, received medical treatment, care or services including diagnostic measures, or took prescribed drugs or medicines within 3 months before your most effective date of insurance.” Aplt. App. at 22 (emphasis added). Mr. Green contends “nothing in the Record demonstrates that [he] incurred expenses, received medical treatment, or took prescribed drugs” during the Pre-Existing Condition Look-Back Period. Id. at 1352. But Mr. Green admits that he visited Dr. Amerongen after experiencing cloudy and foggy vision in December 2014. And Dr. Amerongen referred Mr. Green to a retinal specialist if Mr. Green’s condition worsened (which it apparently did).
    The relatively short opinion is attached below.
    Attached Files
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