Treatment For Heart Condition Met Pre-Existing Condition Exclusion
ESTATE OF BLANCO v. PRUDENTIAL INSURANCE CO. (May 21, 2010)
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Norman Blanco was hired by Porsche Engineering Services in April of 2005. After one month of employment, he was covered by Porsche's benefit plan. The plan included both short and long term disability benefits. Blanco suffered a heart attack in July and, by the end of August, was no longer able to work. The long-term disability plan had a pre-existing condition exclusion. It precluded coverage for conditions for which the beneficiary, in the three months prior to his coverage effective date, had either a) received care or took medication or b) had symptoms for which a prudent person would have sought care. Pursuant to the pre-existing condition exclusion, Prudential denied Blanco's claim for long-term benefits. Blanco filed an ERISA suit. Judge McKinney (S.D. Ind.) granted summary judgment to Prudential.
In their opinion, Judges Cudahy, Flaum, and Evans affirmed. Before addressing the core issue, the Court noted that a) Blanco had a long history of heart problems, including congestive heart failure (CHF), for which he was being treated and b) pre-existing condition exclusions were regularly upheld. On the merits, the Court found that he failed to qualify under either prong of the exclusion. He was taking heart medication. The fact that he was taking it for hypertension as well as CHF does not matter. Even if it did, the hypertension and CHF are related and taking medication for the hypertension would disqualify him. The Court also found that Blanco was excluded under the second prong of the policy. He had an episode of high blood pressure for which a prudent person would have sought treatment.
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Elizabeth Black was the executive director of the Milwaukee World Festival, Inc., the organization that operates an annual summer music festival in Milwaukee. In early 2001, she had surgery to repair two aneurysms. She returned to work after several weeks and was well enough to run the festival that summer. Although her contract was not scheduled to expire until the end of 2003, she sought a renewal after the 2001 festival. The organization deferred a decision until 2002. When that time came, many of her relationships with coworkers had deteriorated. She complained, and had several doctors support her complaints, that the stress and abuse of her job was harmful to her health. In July of 2003, the organization elected not to extend her contract. Within a month, Black claimed that she was disabled and could no longer work. She filed a disability claim with the organization's plan. The plan denied the claim, based on a review of the records she submitted. After an administrative appeal, the plan’s underwriter consulted four physicians and a psychiatrist, each of whom reviewed her records and concluded that she was not disabled. The underwriter denied the appeal. Black appealed to the district court, which granted summary judgment to the plan. Black appeals.
Nancy Love had worked at National City for over twenty years when she was diagnosed with multiple sclerosis. After almost 3 years of receiving long-term disability benefits, the Plan told her she no longer fit their definition of "disabled." The controlling definition, after two years of long-term disability, is that a claimant must not be able to perform any job for which she is or could be qualified. The Plan's assessment concluded that, although she probably suffered from multiple sclerosis, she had never suffered an attack nor exhibited clinical signs. Love appealed the determination. She supported her appeal with several medical reports concluding that she had limited functional ability. The Plan denied her appeal, citing its doctor's conclusion that Love was able to do certain simple jobs. Love sued the Plan under ERISA. The district court granted summary judgment to the Plan. Love appeals.
Although Paul Krolnik ceased working because of a hernia and back pain, he failed to return to work because, at least in part, of his depression. Prudential paid him long-term disability benefits for two years. It stopped the benefit stream after two years because the policy at issue caps the benefit at two years if the inability to work is caused, even in part, by a mental illness (including depression). Krolnik brought an ERISA suit against Prudential. The court below barred all discovery on medical issues, struck Krolnik's medical affidavits and granted summary judgment to Prudential.
Charles Jenkins went to work for PricewaterhouseCoopers LLP ("PwC") in 1989. He started experiencing health problems related to HIV in 1993. He suffered from fatigue, nerve damage, decreased sensation, dexterity limitations, and infections. By the end of 1993, he was no longer able to work. He filed a claim under PwC’s long-term disability plan. The plan administrator agreed that he met the definition of "total disability" and paid him benefits from 1994 until 2006. Beginning in 2004, the plan administrator began to review Jenkins' file. After two medical record reviews and an independent medical examination, the plan administrator terminated Jenkins' benefits. The more recent reviews concluded that Jenkins' condition was fairly stable and that he may be capable of performing some jobs. In fact, a rehabilitation specialist identified certain specific positions that fit within Jenkins’ limitations. Jenkins' treating physician disagreed with the conclusion and maintained that he was unable to work. After an unsuccessful internal appeal, Jenkins brought an action under ERISA. The district court granted summary judgment to the plan. Jenkins appeals.