In the instant case, Julissa Bradshaw (“Bradshaw”) was a medical biller for Pyramid Healthcare Solutions, Inc. (“Pyramid”). She held a policy through Reliance Standard Life Insurance Company (“Reliance”) for both short-term and long-term disability coverage. Her coverage under this policy began on May 1, 2013. When Bradshaw was hired by Pyramid, she was several weeks into a pregnancy. She was later diagnosed with “mild preeclampsia” on November 4, 2013, and had elevated blood pressure. On November 8, 2013, Bradshaw had a baby girl. She soon left the hospital on November 10 and maintained steady blood pressure.
By November 17, 2013, she had begun to experience nausea, headache, and dizziness. After an MRI, it was determined that Bradshaw had experienced a stroke. Bradshaw’s discharge summary from the hospital stated that “[h]ypertension” was “contributory to [Bradshaw’s] stroke” and “[t]here was likely some residual deficit from her preeclamptic childbirth.” Thereafter, she submitted a long-term disability claim because she was unable to work due to coordination issues, anxiety, confusion, pain, dizziness, and forgetfulness. A neurologist, Dr. Ajay Arora stated that because of her issues with dizziness, balance, and coordination, Bradshaw was unable to go back to work.
Because Bradshaw’s application for disability came within her first twelve months on the job, Reliance needed to investigate whether her condition was pre-existing. The policy states the following:
PRE-EXISTING CONDITIONS: Benefits will not be paid for a Total Disability:
- caused by;
- contributed to by; or
- 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.
Additionally, the policy provided:
“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.
Sickness is further defined as including pregnancy.
Bradshaw’s three-month period ran from February 1, 2013, to May 1, 2013. This time frame is called the “look-back period” wherein Reliance can determine if a pre-existing condition was present. Reliance denied Bradshaw’s claim for benefits on June 2, 2014, because it alleged that her stroke came from the “pre-existing condition” of pregnancy.
Bradshaw appealed her claim on November 26, 2014, stating that she did not have any issues with stroke, headaches, or high blood pressure during the look-back period. Reliance then asked Dr. Jason Pollock, a doctor of obstetrics and gynecology, to review Bradshaw’s records. He stated that her stroke and pregnancy were connected because “[p]regnancy is required for preeclampsia to develop, and certainly preeclampsia contributed to if not caused her neurovascular accident. . . .” He further opined, however, that “preeclampsia was in no way present nor could it have been effectively predicted” during the three-month period.
Reliance then denied Bradshaw’s appeal because “preeclampsia is a condition related to pregnancy” and that condition contributed to her stroke. Bradshaw then filed the instant suit. The court considered the main issue of the suit to be whether Reliance reasonably interpreted the policy’s exclusion for a pre-existing condition.
The court determined that – in order for the interpretation of the policy exclusion to be consistent with jurisprudence – the loss had to be substantially caused by, substantially contributed to, or substantially resulting from a pre-existing condition. Reliance attempted to show that if it were not for Bradshaw’s pregnancy, she would not have had high blood pressure, and if not for the high blood pressure, she would not have had preeclampsia, and if not for her preeclampsia, she would not have suffered the stroke. Through that line of reasoning, Reliance believed that if it were not for the pregnancy, Bradshaw would not have become totally disabled. However, there were several stages linking the pregnancy and the total disability.
When examining the look-back period, all the record showed was that Bradshaw had a healthy pregnancy. As such, the court believed that Bradshaw’s pregnancy could not have substantially contributed to her resulting total disability. The court determined that there were no signs of complications throughout the record of the look-back period. This included a lack of signs of high blood pressure, stroke, and preeclampsia. Further, during the look-back period, there was no mention of the possibility that Bradshaw was susceptible to developing any of those conditions. Additionally, being pregnant is not necessary to have a stroke, and having a stroke is not usually associated with healthy pregnancies.
The court found that the chain of links between the healthy pregnancy leading up to the stroke and total disability contained too many links. Basically, the court believed that Reliance is reaching too far to try and show that Bradshaw’s healthy pregnancy was a substantially contributing factor to her total disability. As such, the court held that Reliance should not have used Bradshaw’s pre-existing condition exclusion of the policy in this instance.
In further support, Dr. Pollock’s statements reflected his opinion that preeclampsia contributed to Bradshaw’s stroke and total disability. Yet, there was no sign of preeclampsia during the look-back period. Dr. Pollock specifically stated that “The consultation for pregnancy was underway during this time frame but at this point there was no clinical evidence suggesting a neurovascular or hypertensive disorder.” Because of this, it appears that Dr. Pollock’s statements do not indicate that he believed Bradshaw had a neurovascular or hypertensive disorder during the look-back period.
Overall, for the above reasons, the court held that Reliance improperly used the pre-existing condition exclusion of its policy to deny Bradshaw’s claim. The court also held that Bradshaw’s pregnancy was not a pre-existing condition that led to her total disability because of the number of links it took to connect the pregnancy to the disability. Therefore, the court chose to remand this decision back to the district court which shall make an award of Bradshaw’s ERISA benefits.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: