The First Circuit Court of Appeals held Boston Mutual Life Insurance Company (“Boston Mutual”) wrongfully applied the pre-existing condition exclusion to deny Massachusetts man’s long term disability benefits.
Background
In November of 1987, Mr. Hughes became an employee of the University of Massachusetts. Through his employment, he was eligible for long term disability benefits through Boston Mutual. The effective date of coverage was February 1, 1998.
After being diagnosed with multiple sclerosis (“MS”), Mr. Hughes could no longer handle the demands of his occupation. Therefore, he filed a claim for LTD benefits on July 06, 1988. Boston Mutual denied Mr. Hughes’s claim. It did not dispute his disability, but instead claimed his disability was excluded under a pre-existing condition exclusion in the policy.
The Disability Policy
The disability policy contained the following pre-existing condition exclusion:
- The Policy will not cover and Disability caused or contributed to by, or results from a pre-existing condition which begins in the first 12 months after the insured’s effective date of coverage.
- Pre-existing condition was defined as any sickness or injury for which the insured treated for during the 6 months prior to the insured’s effective date of coverage (the “look-back period”).
- Mr. Hughes filed a claim for benefits within the first 12 months after the effective date of his long-term disability coverage. Thus, if he was treated for multiple sclerosis during the look-back period, he would not be eligible for benefits.
Mr. Hughes’s Claim
The only treatment Mr. Hughes received during the look-back period was for numbness in both lower extremities. He was never diagnosed with MS during the look-back period. His doctors testified that the symptoms he treated for during the look-back period would not alone create a suspicion of MS.
Still, Boston Mutual denied his claim arguing that in order to trigger the pre-existing condition exclusion Mr. Hughes need only have received treatment for symptoms which in hindsight appear to be a symptom of MS. Here, that symptom was numbness in the lower extremities.
On the other hand, Mr. Hughes argued that the exclusion requires some awareness on the part of the physicians that Mr. Hughes was treating for multiple sclerosis during his visit in the look-back period.
The court held that both views were possible interpretations, making the policy ambiguous. Because of this ambiguity, the court interpreted the policy language against Boston Mutual and in favor of Mr. Hughes.
Dabdoub Law Wins Pre-existing Disability Lawsuit
This law firm knows how to win disability benefits lawsuits involving pre-existing denials. Read about our win in the federal court of appeal involving a pre-existing denial.
Help from an Attorney with Expertise in Disability Insurance
Disability insurance law is complicated, especially when dealing with a pre-existing condition denial. If your claim for disability benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in disability law.
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Dabdoub Law Firm represents clients nationwide with:
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