Was LINA (Life Insurance Company of North America) Right to Reject Long-Term Disability Claim on Prexisting Condition?
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Oral Argument: Was detached retina caused by earlier posterior vitreous detachment?
Claimants who have been denied long-term disability benefits will benefit from listening to this in-court argument about how the pre-existing condition clause in a long-term disability insurance policy are interpreted by insurance companies and courts.
Does the disabling condition have to have been caused in full or does it need to be only “related” to an earlier diagnosis?
When someone has long-term disability insurance, there is a special rule called the “pre-existing condition clause.” This rule says that if a person gets sick or hurt from a condition they already had before their insurance started, the insurance might not pay for their disability benefits.
For example, let’s say someone started having eye problems and saw a doctor a few months before their insurance started. If this eye problem gets worse and leads to them not being able to work, the insurance might say this was a pre-existing condition. This means the condition was there before the insurance started, so they might not cover it.
The big question is how closely related the condition diagnosed earlier has to be to the disabling condition. If the first condition directly leads to the second, the insurance company might not pay. But, if the first condition is only slightly related or not related at all to what finally causes the person to be unable to work, then the insurance might still cover it. It depends on what the doctors say and how the insurance company looks at the rules. Typically, courts have said that there must be a substantial relationship between what was going on before the claimant became insured and what eventually took the claimant out of work.
A Deep Dive Into The Medical Issues
In this case a truck driver employed by McLane Company, Inc., experienced a drastic change in his health starting in December 2014, when he began to notice cloudy and foggy vision. Concerned, the driver consulted Dr. Kenneth Van Amerongen, who diagnosed him with posterior vitreous detachment (PVD) in his right eye.
Posterior vitreous detachment (PVD) is when the jelly-like substance inside your eye, called the vitreous, shrinks and pulls away from the back part of the eye. This usually happens as people get older. When the vitreous pulls away, you might see floaters, which look like tiny specks or cobwebs moving around in your vision. You might also see flashes of light. PVD is common and often doesn’t cause serious problems, but it’s important to see an eye doctor to make sure it hasn’t caused any damage to your retina, the part of the eye that helps you see.
Despite this condition, Dr. Amerongen found no immediate severe complications such as bleeds or tears and advised the driver to return to work, with a recommendation to consult a retinal specialist should his condition deteriorate.
The situation worsened, and later, the driver sought the expertise of Dr. Justin Kanoff, a retina specialist, who diagnosed him with a macula-off retinal detachment in his right eye.
Macula-off retinal detachment is a serious eye condition where the retina, a thin layer at the back of the eye, comes loose. The macula, which is the part of the retina that lets you see fine details clearly, also gets detached. This can cause a sudden loss of sharp, central vision, making it hard to read or see faces. It’s like a part of a wallpaper peeling off the wall. If you have this problem, it’s very important to see an eye doctor quickly because it needs to be treated to prevent permanent vision loss.
Despite undergoing three surgeries aimed at correcting this issue, the driver suffered permanent vision loss, rendering him unable to perform his job duties as a truck driver.
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LINA Denied the Claim
The claimant challenged this denial through an administrative appeal to LINA, providing additional medical opinions. Dr. Kanoff argued against the insurance company’s conclusion, clarifying that while PVD could be a risk factor for retinal detachment, it was not the direct cause of the visual impairment. Furthermore, Dr. Ronald Wise supported this stance by noting that PVD is not recognized as a direct risk factor for rhegmatogenous retinal detachments according to the literature from the American Academy of Ophthalmology.
Despite these expert opinions and a subsequent appeal providing further medical clarification, LINA upheld their decision, asserting that the retinal detachment, which directly resulted in vision loss, was indeed initiated by the earlier PVD event. This interpretation was supported by their independent peer reviewer, Dr. George Yanik, who maintained that retinal detachments commonly begin with a PVD, leading to tears and eventual detachment.
The turning point in the quest for long-term disability (LTD) benefits came with the application of the Pre-Existing Condition limitation outlined in his insurance policy. The policy clearly stated that no benefits would be provided for disabilities caused or contributed to by conditions for which medical treatment or diagnostic measures had been taken within three months prior to the effective date of the insurance.
LINA (Life Insurance Company of North America), the insurer, denied the claim for LTD benefits. They based their denial on the treatment he received from Dr. Amerongen on December 4, 2014, for symptoms directly tied to his later-diagnosed condition. LINA concluded that the PVD diagnosed in December was related to the retinal detachment that ultimately caused his vision loss, positioning it within the pre-existing condition exclusion timeframe.
This complex case, woven with medical intricacies and the nuances of insurance policy limitations, illustrates the challenges faced in disputing the application of pre-existing condition clauses in disability insurance claims. After these arguments the court ruled in favor of LINA.
Ben Glass leads the long-term disability team at BenGlassLaw.
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