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The 11th U.S. Circuit Court of Appeals, reversing a decision by the U.S. District Court for the Middle District of Florida, has rejected a disability insurer’s decision denying disability benefits to a woman who suffered a stroke days after giving birth on the ground that her pregnancy amounted to a “pre-existing condition.”

The Case

Julissa Bradshaw was a few weeks into a healthy pregnancy and had no other pre-existing medical conditions when she obtained short-term and long-term disability insurance coverage through her employer, through a policy administered by Reliance Standard Life Insurance Company. About six months after her coverage became effective — which was nine days after she gave birth to her daughter — Bradshaw suffered a debilitating stroke.

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Bradshaw filed a claim for long-term disability benefits with Reliance. Because she had filed an application for disability benefits within the first 12 months of her employment, Reliance investigated.

It denied her claim, citing Bradshaw’s pregnancy at the time she purchased her policy and asserting that it qualified as a pre-existing condition that had “contributed to” Bradshaw’s stroke.

Bradshaw sued Reliance, alleging violations of the Employee Retirement Income Security Act of 1974, as amended (ERISA).

Reliance moved for summary judgment, and the district court granted its motion, concluding that Reliance’s decision denying benefits was reasonable.

Bradshaw appealed to the 11th Circuit, arguing that Reliance had incorrectly and unreasonably interpreted the policy by applying the pre-existing-condition exception to deny her long-term disability benefits. In Bradshaw’s view, the exception did not apply because she had not received treatment for a stroke during the “look-back period.”

For its part, Reliance claimed that it had reasonably applied the policy’s exclusion for a pre-existing condition because Bradshaw had not been employed for a full year, was pregnant during the “look-back period,” and her pregnancy “played a part in producing” the stroke. More specifically, Reliance justified its denial of Bradshaw’s claim because it viewed her pregnancy as having “contributed to” her stroke.

The Reliance Policy

The Reliance policy provided:

PRE-EXISTING CONDITIONS: Benefits will not be paid for a Total Disability:

(1) caused by;

(2) contributed to by; or

(3) resulting from

a Pre-existing Condition unless the Insured has been Actively at Work for one (1) full day following the end of twelve (12) consecutive months from the date he/she became an Insured.

 Blood pressure reading (Photo: Thinkstock)

(Photo: Thinkstock)

According to the policy:

“Pre-Existing Condition” means any Sickness or Injury for which the Insured received medical Treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines, during the three (3) months immediately prior to the Insured’s effective date of insurance.

The policy noted that the term “Sickness” includes pregnancy.

The 11 Circuit’s Decision

The circuit court reversed and remanded the case to the district court for it to award ERISA benefits to Bradshaw.

In its decision, the circuit court explained that the policy permitted Reliance to deny long-term disability benefits for a total disability that was “caused by,” “contributed to by,” or “resulting from” — terms not defined in the policy — a pre-existing condition unless the insured had been actively at work for a full year. It then ruled that Reliance’s interpretation of the pre-existing-condition clause and, in particular, the phrase “contributed to,” was “unreasonable as a matter of law and at odds with the goals of ERISA.”

The circuit court explained that the exclusion of coverage for a loss “(1) caused by; (2) contributed to by; or (3) resulting from a Pre-existing Condition,” strictly construed, “purport[ed] to preclude coverage if any pre-existing health conditions in some way – no matter how remote – might have contributed to the loss.”

In other words, the circuit court continued, the Reliance policy would essentially require a claimant “to be in perfect health” at the time of obtaining the policy before the policy would benefit the claimant during the succeeding 12 months, “and that, of course, [was] a condition hardly obtained, however devoutly to be wished.”

The 11th Circuit then ruled that the language “caused by; contributed to by; or resulting from a Pre-existing Condition” excluded coverage for only those losses “substantially caused by, substantially contributed to by, or substantially resulting from a pre-existing condition.” In the circuit court’s view, this interpretation of the policy language advanced ERISA’s “clear purpose to provide greater coverage to beneficiaries.”

The circuit court rejected Reliance’s argument that but for Bradshaw’s pregnancy, she would not have developed high blood pressure; but for her high blood pressure, she would not have developed preeclampsia; but for her preeclampsia, she would not have suffered a stroke; and, finally, but for her stroke, she would not have become totally disabled. Connecting Bradshaw’s healthy pregnancy during the look-back period to her ultimate disabling condition required four links, the 11th Circuit said, which were “too many.”

The circuit court concluded that the “only condition” that Bradshaw had during the “look-back period” was a healthy pregnancy, and her pregnancy could “not be said to have substantially contributed to her total disability.”

The case is Bradshaw v. Reliance Standard Life Ins. Co., No. 16-11125 (11th Cir. Aug. 31, 2017).

— Read Children Entitled to Annuity Proceeds, Not Widow, Louisiana Court Determines on ThinkAdvisor.


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