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Plaintiff Favorable Preexisting Condition Decision Reversal- 9th Cir.

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  • Plaintiff Favorable Preexisting Condition Decision Reversal- 9th Cir.

    In a brief opinion out of the Ninth Circuit, the court reverses the decision of the lower court that upheld Defendant's denial based on a preexisting condition.
    To apply an exclusion for a disability that is “caused or contributed by” a preexisting condition—such as the exclusion here—the insurance provider must show that the disability was “substantially caused or contributed by” the preexisting condition. Dowdy v. Metro. Life Ins. Co., 890 F.3d 802, 809–10 (9th Cir. 2018); see also McClure v. Life Ins. Co. of N. Am., 84 F.3d 1129, 1136 (9th Cir. 1996) (per curiam).1 A mere “philosophic” or “insignificant cause” is insufficient. Dowdy, 890 F.3d at 809. Under this standard, Hartford bears the burden of establishing that Haddad’s left-sided symptoms were substantially caused or contributed to by his right-sided herniated disk. See id. at 810. Hartford has not met its burden.
    In relevant part, the court reasoned as follows:
    First, the exclusionary language here is less expansive than in Dowdy. In Dowdy, the exclusion expressly excluded coverage “for any loss caused or contributed by . . . physical . . . illness or infirmity, or the diagnosis or treatment of such illness or infirmity.” Id. at 805–06 (emphasis added) (omissions in original). The exclusion here contains no language referring to diagnosis or treatment. Instead, it applies only if the disability “results from, or is caused or contributed by, a Pre-existing condition” (emphasis added). So for the exclusion to apply, Hartford must show that Haddad’s preexisting condition itself (i.e., the right-sided herniated disk) substantially caused or contributed to his left-sided symptoms. This requirement affects the point at which the connection between the preexisting condition and the disability becomes too attenuated for the condition to be deemed a substantial cause of the disability.

    Second, to determine whether a cause is substantial, “there must be some evidence of a significant magnitude of causation.” Id. at 809. The record contains little explanation regarding the causal relationship between Haddad’s preexisting right-sided condition and his new, debilitating left-sided symptoms. The only meaningful discussion of how the left-sided symptoms resulted is found in a letter from Haddad’s surgeon, Dr. Bobby Tay, which notes only that the symptoms were “caused by and related to the surgery” (emphasis added). The letter does not discuss whether the manner in which the surgery caused the symptoms was reasonably foreseeable from the existence of the preexisting condition, or relatively uncommon and so not reasonably foreseeable. The only reference to the physiological mechanism by which Haddad’s symptoms arose is Dr. Tay’s letter, which states that “[t]he appearance of these left side symptoms is documented on [a medical scan] which shows a left side C6 lesion.”
    The full opinion is attached below.
    Attached Files