Pre-existing condition exclusions can be difficult to apply, especially when addressing whether a new disabling condition relates back to a pre-existing condition.
But this new case shows how a new disabling condition resulting from a "bad surgery" may still be excluded under the pre-existing condition exclusion. Haddad v. SMG LTD and Hartford Life and Accident Ins. Company, 2017 WL 3620143 (E. D. Cal. August 22, 2017).
FACTS: Haddad had a pre-existing condition cervical disk that caused pain/tingling in his right arm. He had surgery to replace the disk. The surgery caused a new, non-pre-existing disabling condition to his left arm. Hartford contended the pre-existing condition exclusion applied to the new, post-surgery left arm condition because it was "caused or contributed to by" his pre-existing right-sided disk condition.
ISSUE: Whether a new disabling condition (caused by surgery to treat a pre-existing condition) is excluded as a pre-existing condition?
DISTRICT COURT HELD: YES. (Applying de novo standard of review.)
- The policy provided up to six weeks of disability benefits "for any Disability that results from, or is caused or contributed to by, a Pre-existing Condition...." Op. at 2.
- The [new] disabling left side pain, parenthesis and neck pain were "caused or contributed to" by Haddad's pre-existing condition—the diseased C5-6 disk. Op. at 9.
- "This conclusion is consistent with district court cases that have addressed this issue on similar facts under similar policy language." Op. at 9.
- "[The decisions from these other district courts] did not necessarily turn on the deferential standard applied. They relied on what a reasonable interpretation of 'caused or contributed to' is, as applied to the conditions that have worsened due to treatment or progression of a disease." Op. at 11.
- The "caused or contributed to" language is broader than "related to or resulting from" language seen in some other pre-existing condition exclusions. Op. at 13-14.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
