{"id":7527,"date":"2020-04-20T16:46:52","date_gmt":"2020-04-20T21:46:52","guid":{"rendered":"https:\/\/www.nickortizlaw.com\/?p=7527"},"modified":"2024-03-27T16:33:57","modified_gmt":"2024-03-27T21:33:57","slug":"smith-v-united-of-omaha-is-it-a-pre-existing-condition-or-unspecified-medical-problem","status":"publish","type":"post","link":"https:\/\/www.nickortizlaw.com\/smith-v-united-of-omaha-is-it-a-pre-existing-condition-or-unspecified-medical-problem\/","title":{"rendered":"Smith v. United of Omaha – Pre-Existing Condition or Unspecified Medical Problem?"},"content":{"rendered":"\n
Marcia L. Smith (“Smith”) worked as a property manager for Arlington Properties, Inc., and starting on March 1, 2016, she was covered under a long-term disability<\/a> plan administered by United of Omaha Life Insurance Company and Mutual of Omaha Insurance Company<\/a> (collectively, “United”). <\/p>\n\n\n\n The plan provided the following as part of its exclusions<\/a>:<\/p>\n\n\n\n \u201cWe will not provide benefits for Disability:<\/p>\n\n\n\n A Pre-existing Condition means any 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 become insured under this Policy.\u201d<\/p>\n<\/blockquote>\n\n\n\n Three months after her coverage start date, Smith was diagnosed with metastatic ovarian cancer<\/a>. This diagnosis involved having to have surgery, including exploratory laparotomy and major tumor debulking, as well as chemotherapy. On June 30, she requested short-term disability benefits, which were granted for twenty-six weeks. When filing for long-term disability benefits, her claim was denied because her “current disabling condition is considered a Pre-existing Condition and excluded under the policy.” Smith filed for an administrative review but was again denied on March 14, 2017.<\/p>\n\n\n\n At that point, Smith filed the instant suit, asking for a judicial review of United’s denial under 29 U.S.C. \u00a7 1132(a)(1)(B) so that she might attempt “to recover benefits due to [her] under the terms of [her] plan, to enforce [her] rights under the terms of the plan, or to clarify [her] rights to future benefits under the terms of the plan.” The district court ruled in favor of Smith and against United, citing abuse of discretion on United’s part. <\/p>\n\n\n\n United then filed an appeal relating to that decision.<\/p>\n\n\n\n Now, the present court seeks to review the district court’s decision de novo. The standard that a court is looking for regarding the abuse of discretion is whether the party acted arbitrarily and capriciously. “When, as here, the language of the plan grants discretion to an administrator to interpret the plan and determine eligibility for benefits, a court will reverse an administrator’s decision only for an abuse of discretion.” “A plan administrator’s decision to deny benefits is arbitrary and capricious when it is made without a rational connection to the facts and evidence.”<\/p>\n\n\n\n\n
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