When a “Pre-Existing Condition” Is Not Pre-Existing: What the Eleventh Circuit’s Johnson Decision Means for Disability Claimants

In late 2025, the Eleventh Circuit issued a significant decision that reshaped how disability insurers must interpret pre-existing condition exclusions in ERISA-governed long-term disability policies. The ruling in Johnson v. Reliance Standard Life Insurance Company clarifies a question that affects thousands of claimants: whether ordinary medical visits for nonspecific symptoms can be treated as “treatment for” a condition that had not yet been diagnosed.

The court’s answer was clear. Insurers cannot retroactively label everyday medical care as treatment for a condition that doctors did not yet suspect. This decision strengthens the rights of disability claimants and limits insurers’ ability to use hindsight to deny valid claims.

The Case at a Glance

Cherie Johnson became disabled by scleroderma shortly after her employer-sponsored disability coverage began. Because this occurred within the policy’s first year, her claim was subject to a pre-existing condition review. The insurer argued that Johnson had received treatment for scleroderma during the lookback period, even though no physician had considered, tested for, or treated scleroderma at that time.

Johnson had sought care for routine symptoms, including fatigue, cough, swelling, and nausea. None of her doctors believed these symptoms pointed to a rare autoimmune disease. Despite this, the insurer claimed that these routine visits were enough to trigger the policy’s pre-existing condition exclusion.

The Eleventh Circuit disagreed.

The Court’s Key Holding

The court concluded that a pre-existing condition exclusion applies only when a claimant actually received treatment for the condition during the lookback period. Treatment must be directed at the condition itself. It is not enough that, in hindsight, symptoms could be associated with the disease.

This distinction matters. A doctor cannot treat a condition that no one recognizes. Treating common symptoms is not the same as treating the underlying illness.

The court rejected the insurer’s broad interpretation that any symptom consistent with a later diagnosis automatically becomes “treatment for” the condition. Such an interpretation would allow insurers to deny claims based on pure hindsight, something the court deemed unreasonable.

Why This Decision Matters for Claimants

Before turning to the practical takeaways, it is essential to understand how this ruling affects real people facing disability denials. The decision does more than clarify policy language. It sets a clear standard for how insurers must evaluate medical care during the lookback period and offers claimants stronger protection against hindsight-driven interpretations that unfairly exclude coverage.

• Treatment must be intentional.

The decision confirms that a claimant must have been knowingly treated for the specific condition during the lookback period. Medical care for unrelated or general symptoms does not qualify.

• Insurers cannot rely on hindsight.

Many disabling conditions are not diagnosed quickly. The ruling prevents insurers from retroactively linking early medical visits to conditions that were unknown at the time.

• Claimants with rare or complex conditions are better protected.

People with difficult-to-diagnose diseases often have long periods of unexplained symptoms. This decision ensures those early visits cannot be used to deny coverage unless the condition was actually suspected or treated.

• Insurers must prove their interpretation.

The burden remains on the insurer to show that treatment for the actual condition occurred during the lookback period. Speculation is not sufficient.

What Claimants Should Do After a Pre-Existing Condition Denial

If your insurer has denied your disability claim based on a pre-existing condition exclusion, this decision may provide strong support for challenging the denial.

Consider taking the following steps:

• Review all medical records from the lookback period.
• Determine whether any doctor actually suspected or treated the disabling condition.
• Compare the insurer’s reasoning to the policy language.
• Seek help from experienced ERISA disability attorneys before filing an appeal.

Many denials based on broad readings of pre-existing condition language can be overturned when the facts and policy definitions are carefully analyzed.

A Clear Reminder of the Importance of Legal Guidance

The Johnson decision reinforces a critical point. Disability policies must be applied according to their actual wording, not expanded by hindsight or interpretations that favor the insurer. Claimants who have been unfairly denied benefits may have far more options than they realize.

Protect Your Rights After a Wrongful Disability Denial

If your long-term disability benefits were denied based on a pre-existing condition exclusion, you do not have to accept the insurer’s interpretation. Our attorneys at Disability Insurance Law Group have decades of experience challenging improper denials and holding insurers accountable.

Call 954-989-9000 today or contact us online to schedule a free consultation. Our nationwide disability insurance attorneys can review your claim, explain your rights, and help you pursue the benefits you deserve.