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5th Cir. – Very Plaintiff Friendly Pre-Existing Condition Opinion

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  • 5th Cir. – Very Plaintiff Friendly Pre-Existing Condition Opinion

    Here’s a new case out of the Fifth Circuit entitled Marcia L. Smith v. United of Omaha Life Insurance Company; Mutual of Omaha Insurance Company. In this matter, Mutual of Omaha denied the plaintiff’s claim for disability benefits due to a pre-existing condition. United acknowledges that Smith was not diagnosed with metastatic ovarian cancer until 3 months after the pre-existing condition exclusion period had ended. However, the parties agree that the medical records so show that she received treatment during the look-back period for a recurrent right pleural effusion, which was a symptom of the ovarian cancer. Plaintiff argues that since the condition which caused her disability is not pleural effusion, but rather metastatic ovarian cancer and that she did not receive medical treatment advice, consultation, care or services including diagnostic measures, or have drugs or medicines prescribed or taken for metastatic ovarian cancer during the look-back period, her claim was wrongly denied. The court agrees.

    Here, it is clear that Smith received “medical treatment, advice or consultation, care or services, including diagnostic services” for the pleural effusion during the look-back period. But the condition that caused her disability was not pleural effusion; it was metastatic ovarian cancer. This is the condition for which she must have had treatment, care, or services to trigger the pre-existing condition exclusion. Although it is undisputed that Smith’s pleural effusion was caused by the metastatic ovarian cancer, pleural effusion can be caused by any number of conditions, her symptoms were non-specific to metastatic ovarian cancer, and the medical records do not indicate that her medical providers believed the pleural effusion was likely caused by metastatic ovarian cancer. Thus, United could not reasonably have concluded that she received treatment “for” metastatic ovarian cancer during the look-back period. Mitzel v. Anthem Life Ins. Co., 351 F. App’x 74, 84 (6th Cir. 2009) (finding it “unreasonable” to deny a disability claim when the doctor during the look-back period “did not suspect, diagnose, or treat the specific disability for which she eventually applied for benefits.”). United’s conclusion to the contrary is arbitrary and capricious.
    This is a very plaintiff friendly pre-existing case. The opinion is attached below.
    Attached Files