Friday, May 21, 2010
Ind. Decisions - One Indiana opinion today from 7th Circuit
In Estate of Norman Blanco v. Prudential Insurance (SD Ind., McKinney), an 11-page opinion, Judge Evans writes:
The phrase “preexisting condition” was frequently in the news as efforts to enact national health care reform were debated over the last year. And although our case today involves a preexisting condition exclusion, there is a twist. The clause in this case is not one that denies coverage for health care expenses. Instead, it’s in an ERISA plan (the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 101 et seq.) promising to pay long term disability benefits to an employee who can no longer do his job. The case is a sad one as the employee, Norman Blanco, died after he struck out in the district court. His estate, which was substituted to fill his shoes, has carried on with this appeal from the judgment of the district court. * * *
If Blanco’s heart attack had occurred anytime after May 4, 2006 (i.e., 282 days after it actually hit), the preexisting exclusion clause in the plan would not have kicked in. Because his disability occurred when it did, Blanco had to get past two roadblocks to receive benefits. The plan’s preexisting exclusion clause defeats a claim for LTD benefits if an employee like Blanco:
A. received treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines, or followed treatment recommendation in the 3 months prior to the effective date of coverage, or
B. had symptoms for which an ordinarily prudent person would have consulted a health care provider in the 3 months prior to his effective date of coverage. * * *
The purpose of the policy is to exclude from coverage a person who is aware of something—be it a sign or symptom—for which a reasonably prudent person should seek treatment. Since Dr. Bobzien told Blanco of his extraordinarily high blood pressure and recommended hospitalization, Blanco’s hypertension was a preexisting condition under subsection (b) of the policy. Therefore, Blanco is not eligible for LTD because his disability—in particular his CHF and dilated cardiomyopathy—was due to this preexisting condition.
For these reasons, the judgment of the district court is AFFIRMED.
Posted by Marcia Oddi on May 21, 2010 12:54 PM
Posted to Ind. (7th Cir.) Decisions