In a recent case, Horneland v. United Of Omaha Insurance Company,
No. 16-16935, __F.App'x__, 2017 WL 5508496 (11th Cir. Nov. 17, 2017), the Eleventh Circuit Court of Appeals reversed a federal district court's grant of summary judgment to United of Omaha ("UOO") in an ERISA governed disability insurance claim. Approximately fourteen (14) years prior to becoming employed as a real estate manager for Thornton Real Estate, Kristian Horneland fractured his thoracic spine in a slip and fall accident. With rehabilitation and pain management, following the accident Kristian was able to live a largely pain free existence. After becoming employed at Thornton Real Estate, Kristian became covered under a long-term disability policy with UOO which excluded Pre-Existing Conditions that manifest within a certain period of time and defined this as:
"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 ("Pre-existing Look Back Period")."
As an real estate manager, Kristian was required to o drive approximately 15-20 hours per week. A few months following his employment, Kristian began to suffer from significant back pain and muscle spasms, for which he began taking mediation. Shortly thereafter, the Pre-Existing Look Back Period began. At this time, Kristian began experiencing sharp and stabbing pain over his mid back and sought treatment from his physician, who prescribed refills of his pain medication. Approximately five (5) months after the Pre-Existing Look Back Period ended, Kristian's symptoms progressed and he filed a claim for long-term disability under his policy with UOO.
UOO denied Kristian's claim, asserting that he was not disabled and alleging that even if he was disabled, Kristian's claim was barred by the Pre-existing Conditions Exclusion. Kristian appealed the decision and submitted evidence supporting that his disability was due to significant lumbar spine issues and not the result his thoracic spine issues. UOO denied Kristian's appeal and he filed suit. The district granted UOO's motion for summary judgement, finding that Kristian's muscle spasms and back pain were pre-existing conditions and excluded from coverage.
The Eleventh Circuit provided that it was UOO's burden to prove that the Pre-Existing Condition Exclusion applied. The Eleventh Circuit noted that when applying the plain meaning of the policy terns, the question is whether Kristian had a Pre-existing Condition that caused, contributed to, or resulted in his disability. The Eleventh Circuit determined that based on the Policy's definition of Pre-existing Condition, Injury, and Sickness, a Pre-existing Condition must be an accidental bodily injury, a disease, a disorder, or a condition and that back pain and muscle spasms do not fall into any of these categories. The Eleventh Circuit explained that back pain and muscle spasms are merely symptoms for which an accidental bodily injury, a disease, a disorder, or a condition might be the cause.
Accordingly, the Eleventh Circuit determined that summary judgment was inappropriate and remanded the matter to the district court. The court explained that to prevail, Kristian must establish "(1) that he was disabled by a lumbar condition (2) that arose before his insurance policy ended and (3) that was not caused by an earlier thoracic injury that manifested itself during the look-back period."