An appellate court panel has ruled in favor of an insurance company accused of wrongly denying a trucker disability benefits. The truck driver filed for the benefits after he lost his vision. However, the insurance company argued that a pre-existing condition caused the vision loss, disqualifying the driver from any benefits.
On Sept. 26, the U.S. Tenth Circuit Court of Appeals affirmed a lower court’s decision denying disability benefits for Colorado truck driver Michael Green. Both courts agreed with Pennsylvania-based Life Insurance Company of North America’s (LINA) assessment that resulted in the denial of benefits.
Problems for Green began in December 2014 while he was driving for McLane Company. At that time, Green began experiencing cloudy and foggy vision, which would be diagnosed as posterior vitreous detachment (PVD) in his right eye. A doctor released Green back for work.
In February 2015, Green saw a retina specialist, who gave him a diagnosis of retinal detachment that required three surgeries. All three surgeries were unsuccessful, leaving Green with permanent vision loss. Consequently, Green could no longer drive a truck.
After Green’s short-term benefits expired, the former driver filed for long-term disability benefits. LINA denied Green’s claim, stating that his diagnosis with a doctor in December 2014 rendered the subsequent diagnosis and surgery as a pre-existing condition. LINA’s long-term disability policy states the following limitation:
“We will not pay for benefits for any period of disability caused or contributed to by, or resulting from, a pre-existing condition. A ‘pre-existing condition’ means any injury or sickness for which you incurred expenses, received medical treatment, care or services including diagnostic measures, or took prescribed drugs or medicines within 3 months before your most effective date of insurance.”
Green submitted an administrative appeal by producing medical documentation that noted that “while a posterior detachment is certainly a risk factor for developing a retinal detachment, (PVD) was not the ultimate cause of (Mr. Green’s) visual loss,” according to the complaint. However, an independent peer reviewer hired by LINA disagreed, upholding the denial.
Upon a second administrative appeal, Green provided a report from a doctor who found that PVD “was not the cause of Mr. Green’s vision loss in his right eye, but rather was an event prior to presumably the retinal tear, which to a reasonable degree of medical probability led to the rhegmatogenous retinal detachment.” The report noted that PVD is not listed as a risk factor for retinal detachment.
The doctor who diagnosed Green with retinal detachment also disagreed with LINA’s assessment, noting PVD “was not the cause of (Green’s) vision loss; the retinal detachment was the cause of the patient’s vision loss.”
Despite the evidence presented, LINA denied Green’s second administrative appeal, pointing again to their hired peer reviewer’s analysis. Green brought the case to court, which he lost at the district court level.
In his legal appeal, Green brought up LINA’s conflict of interest in its dual role as both plan administrator and funder of long-term disability benefits. However, the appellate court ruled that LINA properly dealt with its conflict of interest by twice referring the case to independent peer reviewers.
“Having dealt with its conflict of interest, LINA made a reasonable and good faith determination that Mr. Green had a pre-existing condition (PVD) that caused or substantially contributed to his vision loss,” the appellate court opined. “As the district court’s well-reasoned opinion points out, LINA relied on five doctors’ opinions, two of whom were Mr. Green’s own doctors and all of whom agreed that PVD was a highly probable link to Mr. Green’s ultimate vision loss.”
Green argued that the causal relationship between PVD and his vision loss was weak. He referred to a previous Tenth Circuit court ruling which held that a pre-existing condition “cannot merely be one in a series of factors that contributes to the disabling condition; the disabling condition must be substantially or directly attributable to the pre-existing condition.” However, the panel in Green’s case determined PVD was not part of a long chain of ailments that led to vision loss. Rather, it led directly to his seeking further treatment and surgeries.
Lastly, the court ruled that the condition occurred during the look-back period, qualifying it as a pre-existing condition.
More specifically, Green must have received treatment for PVD within three months before his most effective date of the plan for it to be considered pre-existing. The plan became effective Jan. 1, 2015, putting the look-back time frame between Oct. 1 and Dec. 31, 2014. Green sought treatment on Dec. 4, 2014, within the look-back period.
Consequently, the condition was deemed pre-existing, allowing LINA to properly deny Green of long-term disability benefits.
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