The federal appellate Court for Florida clarifies what the pre-existing exclusion means when determining if back pain is excluded under United of Omaha’s policy.
Mr. Horneland suffered injuries to his thoracic spine in 1998. Following that he did not have much pain and his injury did not limit his functionality. In late 2012 and early 2013 he sought pain medications from his doctor to deal with some back pain. In March 2013, he began working as a real estate manager. His job required a lot of driving, which exacerbated his back pain. He was forced to stop working in August 2013 due to chronic back pain and muscle spasms.
Under United of Omaha’s disability insurance policy, a pre-existing condition is an injury or sickness for which you 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 you became insured under the policy. In this case, the 3 month “look back period” was from December 2013 thorugh March 2013.
Because Mr. Horneland had obtained a prescription for pain medication for his back pain during the look back period, United of Omaha denied his disability insurance claim as pre-existing.
The Court conducted a thorough analysis on what pre-existing condition means under the terms of the policy. The court determined that a pre-existing condition must be an:
- Accidental bodily injury,
- A disease,
- A disorder, or
- A condition
Mr. Horneland was claiming disability for back pain and muscle spasms. The court concluded those, by themselves, do not constitute a pre-existing condition under the definitions in the policy. They are symptoms of a condition. However, the claim file contained conflicting information regarding the underlying cause of his symptoms.
The court held that more information was needed to determine the underlying cause of his symptoms. With that information, the parties could then apply the court's analysis to determine if he has pre-existing conditions that would be excluded.
This case presents a very interesting and complex issue for disability insurance attorneys. Insurers are quick to deny a claim based on pre-existing conditions. However, there is almost always more to the story.
A person filing for disability insurance and facing a pre-existing review should not just accept what the insurance carrier says. You want someone who understands the complexities of a pre-existing condition analysis helping you with your claim.
Our firm has experience dealing with pre-existing condition issues. We push back against insurance carriers when its analysis is flawed or wrong.
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