Denial of Long Term Disability claim based on an inapplicable “pre-existing condition” provision.
At the time his claim arose, Gerald L. was a 62 year old bus driver. He had a long-standing history of chronic obstructive pulmonary disease, emphysema and hypertension. But none of these conditions prevented him from working at his job. But one the day he suffered a severe, life-threatening heart attack. He was transported by paramedics to a hospital emergency room. His admission diagnosis was “Acute Cardiopulmonary Arrest”. He was discharged five days later. The hospital discharge summary stated: “Discharge Diagnosis: 1. Acute inferolateral wall myocardial infarction, aborted by thrombolytic therapy first then acute percutaneous transluminal coronary angioplasty later. 2. Severe malignant cardiac arrhythmia secondary to #1. . ..” At no time prior to that day had he ever been diagnosed or treated for heart disease.
Following his heart attack, Gerald was never able to return to work. He submitted a claim for Long Term Disability benefits, based on severe coronary artery disease. His claim was denied by the insurer based on a “pre-existing condition” exclusion in the insurance policy. This made no sense in light of the simple fact that a no time prior to his heart attack had he ever been diagnosed or treated for heart disease. But the insurer took the position that since he had a pre-existing history of hypertension, that was a good enough reason to deny the claim.
The insurer’s reviewing doctor found that Gerald’s pre-existing hypertension was "related to" his then current condition of coronary artery disease. (And thus, it too was considered a pre-existing condition). No evidence supported this ridiculous “related to” finding. In fact, Gerald’s hypertension had been well under control for years. But the insurer’s doctor pulled out two blood pressure readings (166 / 138 and 184 / 111) that were both taken on a single day two years before to justify the causal connection. The reviewing doctor ignored the other blood pressure readings over the ensuing two years, all of which were within normal limits. Even the blood pressure readings taken 10 days before and after his heart attack confirmed that his blood pressure was normal. Gerald’s family history was far more relevant in determining the cause of his heart disease. His father had died of coronary artery disease at the relatively young age of 56.
Even if there had been evidence that his hypertension was “related to” his heart disease, it still would not have been relevant. Nowhere in the plan did it state that a “pre-existing condition” included any condition that might be “related to” the disabling condition. The stated plan definition of a “pre-existing condition” was very clear. It was as follows: “means a condition for which you received medical treatment, care or services, including diagnostic measures or taken prescribed drugs or medicines for your condition during the given period of time as stated in the plan”.
Result: The case was resolved satisfactorily without litigation.