Court Ruling On Mutual Of Omaha Pre-Existing Denial Of Benefits

In the case of Horneland v. United of Omaha Insurance Company, the eleventh circuit reversed the United States District court for the Middle District of Florida’s decision finding for the defendant. In the case, Horneland sued United of Omaha Life Insurance Company under ERISA, due to the fact that United of Omaha Life Insurance Company denied Horneland’s long term disability. Horneland began to work as a real estate manager for Thornton’s Inc. as part of the employment, Horneland received short term and long term disability coverage.

However, per United of Omaha Insurance Company’s insurance plan, long term disability coverage begins on the day following completion of 12 months of Active employment. The long term disability benefits also include a Pre-existing conditions exclusion. That exclusion states that the insurance company will not provide benefits for disability (a) caused by, contributed to by, or resulting from a Pre-existing Condition; and (b) which begins in the first 12 months after the individual is continuously insured under the policy. The eleventh circuit defines the term pre-existing as any injury or sickness for which the individual received medical treatment, advice or consultation, care or services including diagnostic measures, or had drugs or medicines prescribed or taken in the 3 months prior to the day they become insured under the policy.

Mutual of Omaha Short-Term Disability Pre-Existing Conditions

The Pre-Existing exclusion includes a look-back period. That is, that a sickness or injury is deemed a pre-existing condition only if it was treated in the three months before Plaintiffs long-term disability coverage begins. Fifteen years before Horneland became a real estate manager, he hurt his back in a slip and fall accident. He managed to live pain free for the 14 years following the accident as a result of successful pain management and rehabilitation. Being a real estate manager consist of driving for most part of the week. Consequently, his pain and muscle spasms worsened. Horneland returned to his doctor complaining about the severe pain and muscle spasms, which was causing him to have difficulty in walking; medication no longer helped. Evidently, he stopped working as a real estate manager and claimed to be disabled the following day.

Horneland went to the first doctor an explained to him that he had pain in his back that became worse as a result of his increased driving required for his job. After Physical examination, the doctor determined that Horneland’s back was affected. The following moth, Horneland had an MRI done of his lumbar spine. He visited a second doctor and reported to him that he first hurt his back 15 years prior, but that he lived pain free. The doctor determined after physical examination and studying the MRI that the plaintiff’s lumbar spine was normal. He determined that the plaintiff was suffering from “pain in the thoracic spine” and advised him to get an MRI done of his thoracic spine.

Horneland, submitted a Short Term Disability Benefits claim to United of Omaha Life Insurance Company. He was examined by doctors who found everything to be normal, but due to his constant pain, assessed Horneland as suffering from pain in the thoracic spine. He did not stop there. Horneland, as he awaited the decision of his short and long term disability benefits, continued to get opinions from varies other doctors. The doctor after reviewing his medical records and performing a physical examination on Horneland, determined that “with a reasonable degree of medical probability, Horneland’s employee obligation, requiring long hours of prolonged driving have exacerbated and/or aggravated his preexisting condition.” However, both his short term and long term disabled benefit claim were denied due to insufficient evidence probing that Horneland was in fact disabled. As to his Long Term Disability Benefits claim, United of Omaha Life Insurance Company, determined that Horneland was being treated for his back pain and muscle spasms during the look back period and even if he were disabled, he would not be eligible for long term disability claims as per the Pre-existing Conditions Exclusion.

Horneland appealed United of Omaha Life Insurance Company denial of short term disability benefits. He provided a statement from the doctor proving that his time driving for work contributed to the pain which Horneland was having that day. Defendants, however, determined that plaintiff still did not prove his disability and denied the short term disability benefits. Horneland went on to appeal the long-term disability benefits.

As to the pre-existing condition Exclusion, Horneland stated that he had one single treatment during the look-back period. After seeing a few more doctors, and the doctors determined that he did in fact have back problems, one of the doctors, Dr. Gelia, submitted a statement asserting that plaintiff was unable to work due to his extensive lumbar issues. A second doctor, Dr. Kalin, determined that (1) Horneland’s preexisting condition was aggravated by prolong driving, (2) the prolonged driving caused addition compression to his back that resulted in the recent back pain, and (3) that Horneland was unable to work due to extensive decompensation in the lumbar spine.

On appeal, United of Omaha Life Insurance Company determined that plaintiff was not disabled as of the day which he filed the claim and that there was reasonable medical evidence finding that the symptoms Horneland were treated for during the look-back period was the same as the ones in his disability claims. Therefore, the long-term disability claim under appeal was again denied.

Horneland sued United of Omaha Life Insurance Company for denying both his long term and short term disability claims. They both came to a mutual understanding for the short term disability claim and determined that the only question for the court was whether the Pre-existing Condition Exclusion applied. Cross-motions for summary judge were filed and the district court found in favor of United of Omaha Life Insurance Company.

Using the Standard of Review, de novo, the eleventh circuit reversed the district courts decision and claimed that there was a genuine issue of a material fact and the district court granting the defendants summary judgment was incorrect. The eleventh circuit explained that as per the definition of the policy, a Pre-existing condition is “any injury or sickness for which the policyholder received medical treatment, advice or consultation, care or services including diagnostic measures, or had drugs or medicines prescribed or take in the 3 months prior to the day the policy holder because insured under the policy.

Injury is defined in the policy as an accident bodily injury and sickness is defined as a disease, disorder or condition. Put together, the court determined that a “Pre-existing condition must be an accident bodily injury, a diseased, a disorder, or a condition. They determined that muscle spasms are neither, but rather a symptom. The policy’s “Self-Reported systems” definition further proves the circuit courts findings, w which defines symptoms and the definition included the term pain. SO pain is a symptom of a condition and the Pre-existing Condition exclusion cannot apply to Horneland’s back pain and muscle spams.

The eleventh circuit however determined that there was evidence precluding the entering of summary judgment for either party. Horneland would have to prove that (1) he was disabled by a lumbar condition (2) that arose before his insurance policy ended and (3) that was not caused by an earlier thoracic injury that manifested itself during the look-back period. Due to the genuine issue of material fact on both sides, the eleventh circuit reversed the district courts decision for the defendants and affirmed Horneland’s denial for summary judgment. The case was remanded back to the district court for further proceedings.

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