Insurance Benefits Denied for Pre-Existing Condition

appealed that decision under the appeal provisions of the policy. leave of absence policy other than the family and medical leave act (fmla). the a message stating she would not return to work on september 8. on this record, jones jones argues that unum's decision is entitled to less deferential review because * appeal from the united states provision under: 1. the unum plan; or 2. the prior carrier's plan, if in the district court nor included in her statement of issues on appeal. see al-zubaidy month, jones filed a long-term disability claim with unum, based upon a recurrence app. 1997), which held that an employee scheduled to work full-time was covered condition coverage on the insured employer's relationship with an employee. some was unambiguous. only when the other policy is ambiguous will discretion to disagree. unlikeindividualdisabilityinsuranceplans,employer-providedgroupplans further argues that unum's interpretation of the fortis policy violated numerous condition clause because she received psychiatric treatment within the three months (2008), this conflict does not change the standard of review but may be relevant in was not an issue while she was receiving long-term disability benefits. no doubt for deference when the erisa administrator has sought advice from the other insurer as recovered from a long-term disability, the clause expressly provided that * lapsed. as of no later than august 26, jones had stopped active work and was no or illness would lose coverage and be subject to the pre-existing condition provision lapse in coverage. the fortis claims agent who handled jones's prior disability claim conclude that coverage under the fortis policy lapsed more than six weeks prior to returned to work full-time in october. during the first twelve consecutive months of being insured under the policy. unum insurance coverage ends when a person "stops active work" or is no longer in an continuing long-term disability without further investigation. she did not pursue employee be `actively working' in order to be eligible." id. at 87. see also lickteig 1 looked to the coverage provisions in the fortis policy and concluded that her coverage jones argues that a literal interpretation of the thirty-hour requirement would defendant - appellee. * before resolving jones's appeal, unum contacted fortis about the apparent later. under these circumstances, the fortis plan plainly provides that of an eligible class when her disability ended and she failed to return to full-time * district of minnesota. opined that coverage lapsed on june 8. unum sent fortis a confirming letter. unum unum provident corporation, * upon returning to work. but neither fortis nor unum applied either policy in this thirty hours per week, and active work means working full-time for the decision may change" if fortis changed its position. jones apparently contacted jones further argues that unum erred by ignoring the continuance of insurance * the judgment of the district court is affirmed. august 26 decision that jones was no longer disabled, and did not resume until she v. ge group life assur. co., 541 f.3d 1002 (10th cir. 2008); tester v. reliance (8th cir. 1977). but others provide narrower coverage. the fortis policy provided "eligible class," defined as being "an active full-time employee." coverage for jones fabyanske firm changed group disability insurance providers from fortis to unum. because the policy granted unum discretion "to determine your eligibility for 5-5- began, not when it ended, and the plan at issue "did not specifically require that an minnesota statutes. we decline to consider these issues because they were not raised summary judgment de novo, we affirm. see jessup v. alcoa, inc., 481 f.3d 1004, would return to work. on september 3, jones "stopped in to the office to say that she conclude that coverage continued when jones returned to work part-time on june 28, 2 this reason, the policy did not address the issue. the record suggests that the between june 8 and october 4, 2004: fabyanske firm continued to classify jones as a full-time employee who was on 4-4- determining whether the insurer abused its discretion, for example, "where an to include active full-time employees, full-time means working at least not challenge that decision. rather, the dispute turns on unum's application of the abuseitsdiscretionindeterminingthatjones'scoverageunderthefortispolicylapsed full-time work in october, consistent with coverage having lapsed. grantedsummaryjudgmentdismissingherclaim. jonesappeals,arguingunum would be attempting to return to work on wednesday, september 8." she later left unum first determined that jones did not satisfy the unum policy's pre-existing our decision in this case is not affected by the erisa standard of review. premiums -- rather than lapsing coverage -- while jones received long-term disability jones's claim. see walke v. group long term disability ins., 256 f.3d 835, 839 (8th based on the extensive record compiled during unum's thorough investigation, we before loken, chief judge, hansen and melloy, circuit judges. unum and the fortis policies. applying the abuse-of-discretion standard. benefit payments on june 8, advising jones it would review her eligibility and in granting summary judgment, the district court concluded that unum did not and began paying long-term disability benefits after a three-month qualifying period. interpret it be significant. in such cases, a reviewing court may properly grant some the fortis policy lapsed on june 8, 2004, the retroactive effective date of fortis's jones's return to full-time work in october 2004. accordingly, her march 2005 2004, and began working full-time on october 4. effective january 1, 2005, the was absent from her full-time work for one week in november 2004 due to illness. follow-up appointments. she stopped working on july 15, and a new psychiatrist, dr. ___________ prior to that date, unum concluded that benefits would not have been paid under the jones returned to work part-time on june 28. she scheduled initial iii. standard of review ins. co., 94 f.3d 489, 491 (8th cir. 1996); irvine v. reliance standard life ins. co., court1 2009 wl 2231681, at *1-*2 (d. minn. july 24, 2009).2 june 7, 2004. jones notified fortis but advised that she disagreed with dr. jones relies on reese v. brookdale motors, inc., 567 n.w.2d 83, 87-88 (minn. jones argues that, even if unum had discretion to interpret its own policy, the disability. leaving aside the question whether this provision applied after jones at least thirty hours per week. the 2004 billing records reflect that fortis waived extreme manner. for example, the fortis billing records reflect that fortis waived 26, and fortis found her not disabled on august 26, retroactive for benefits purposes benefits suspended but not yet denied, just as coverage would continue for a full-time premium payments for jones until she was "added" as an employee after returning to investigated the claim, both initially and when jones appealed, and its initial and final loken, chief judge. 575, 582 (8th cir. 2008). but jones filed her claim in 2005. unum thoroughly based upon a uniform policy. plaintiff - appellant, * menz v. procter & gamble health care plan, 520 f.3d 865, 868 & n.6 (8th cir. 2008). i. background that was diagnosed or treated during the three months before the claimant became issue by raising it to the district court. accordingly, we decline to consider it. see v. tek indus., inc., 406 f.3d 1030, 1037 (8th cir. 2005). no. 08-3830 for disability benefits under the firm's group long term disability insurance policy benefits would have been paid had that policy remained in force. policy. this is an interesting issue of first impression. but jones did not preserve the benefits, jones asserts, "has no relevance" to continued insurance coverage. we in order to receive a payment you must satisfy the pre-existing condition notified jones that it was denying her long-term disability claim for benefits after june corporation ("unum"). after unum denied the claim and jones's appeal, she for the most part, we agree with this analysis. the fortis policy provided that failed to prove either that her employer requested continued coverage, or that she was ___________ benefits, and neither insurer took the position that jones's coverage lapsed when she first returned to full-time work at fabyanske approximately four months initially determined that jones's coverage under the fortis policy lapsed on august policyholder at the employee's usual place of business. fortis in january 2004, jones was hospitalized for major depression and stopped ___________ ii. the claim at issue eligible for continued coverage because the continuance, if implicitly requested, was v. bus. men's assur. co. of am., 61 f.3d 579, 585 (8th cir. 1995); granite v. 563 f.3d 773, 776 (8th cir. 2009); wakkinen v. unum life ins. co. of am., 531 f.3d insurance company administrator has a history of biased claims administration." submitted: october 22, 2009 part-time on june 28 and full-time on july 26. appointments with two other psychiatrists, who refused to support her claim of from her visits to dr. heefner and the other psychiatrists. on august 26, fortis not appeal this adverse decision. she returned to work part-time on september 20, determined that jones was no longer disabled as of june 8, 2004, and she also explained to jones in a telephone conversation that her benefits were denied condition limitation in the prior group insurer's policy. reviewing the grant of longer in the eligible class of active full-time employees, defined as those who work ___________ her treating psychiatrist, dr. paul richardson, cleared jones to return to work after ______________________________ record further reflects that the fabyanske firm wrote jones on august 13 asking if she coverage. but what happened to that status when jones recovered the ability to based on the fortis policy, suggested that jones contact fortis, and noted that "our coverage for a person unable to perform active work on account of a covered v. * district court for the working as a legal secretary with fabyanske, westra & hart, p.a. she filed a claim filed: march 1, 2010 "[c]ontinuancemustbebased onauniformpolicy,andnotindividualselection."here, employee who is reduced to part-time work during a medical leave. accord weber we note that the issue would be of little if any significance if the other insurer's policy jones stopped working in late february 2005, complaining of an infected dog district court erred in not reviewing de novo unum's interpretation of the fortis united states court of appeals issued by fortis benefits insurance company ("fortis"). fortis found jones disabled prior to the effective date of the unum policy, january 1, 2005, and her disability the district of minnesota. 2001, and there was no lapse in coverage in 2004 because her employer considered 2-2- resume work? 6-6- court's recent decision in metropolitan life ins. co. v. glenn, 128 s. ct. 2343, 2351 2004, consistent with dr. richardson's limited release-for-work and with long-term income security act of 1974 ("erisa"). see 29 u.s.c. � 1132(a)(1)(b). the district her a full-time employee on medical leave. the fact that fortis terminated disability [t]hefortispolicyprovidesthatacoveredperson'sinsuranceendswhen that insurance ends when a person is no longer an active, full-time employee or stops like the policy at issue in verlo v. equitable life assurance society, 562 f.2d 1034 pre-existing condition clause of the fortis policy, had it remained in force. jones disabled." because coverage did not resume until she returned to full-time work in began during the first twelve months after the effective date of the policy. jones does ___________ to june 7, 2004. in these circumstances, both unum and the district court reasonably pre-existing condition clause in the unum policy: 7, based on her failure to satisfy the test of disability in the fortis policy. jones did 8-8- insured; it denied coverage "for any disability caused by a pre-existing condition" determined, consistent with the informal fortis opinion, that jones's coverage under practices in the decade ending in 2003. see chronister v. unum life ins. co. of am., 26, 2004, the date of fortis's final decision that she was "no longer considered 3-3- october 2004, and because jones received psychiatric treatment within three months insurance policy issued to her employer by an affiliate of unum provident policies provide that insurance does not end until an employee is formally terminated, the honorable joan n. ericksen, united states district judge for pre-existing condition limitation in the fortis policy. both evaluates claims for benefits and pays granted claims. under the supreme john heefner, supported her claim of continuing disability. jones sent fortis records clause in the fortis policy, which provided that the policyholder may continue disability leave, and fortis waived monthly insurance premiums for continued disability claim was not covered because of the pre-existing condition clauses of the guardian life ins. co. of am., 544 f. supp. 2d 833, 848 (d. minn. 2008). jones applying glenn, we have noted that courts heavily criticized unum for unfair claims commencedthisactionforwrongfuldenialofbenefitsundertheemployeeretirement requesting additional medical information. dr. richardson released jones to work a human resources employee advised unum that the fabyanske firm had no "formal" carol jones filed a claim for long term benefits under the group disability work. in denying the appeal on may 24, 2006, unum's appeals department the person is no longer in an eligible class or when the person stops like the unum policy, the fortis policy defined a pre-existing condition as one even though he never worked full-time. but the issue in reese was when coverage carol jones, * lead to absurd results, because any employee taking a day off for vacation, a holiday, 1006 (8th cir. 2007) (standard of review). unum operated under the financial conflict of interest present whenever an insurer can hardly be called an active, full-time employee. accord fink v. union cent. life her insurance ended. decisions were carefully reasoned. the district court did not err for this reason in richardson's decision and was seeking a different psychiatrist. fortis suspended standard life ins. co., 228 f.3d 372 (4th cir. 2000). but here, jones quit work of her major depression and other ailments. unum denied the claim based upon the to the proper interpretation of its policy, as unum did in this case. fortis, because the fortis agent called unum again and confirmed that jones fell out least 30 hours per week." an employee who, like jones, quit work for several months entirely on july 15, contrary to dr. richardson releasing her for full-time work on july active work, defined as working full-time. "full-time" was defined as "working at active work. under the fortis policy, eligible classes are defined in part onappeal,jonesarguesthat her coverage under the fortis policy began in april scratch. the fabyanske firm terminated her employment in mid-march. later that and the court erred in concluding that a lapse in coverage triggered the pre-existing cir. 2001). jones argues the district court erred in applying this standard of review. applied the familiar abuse-of-discretion standard in reviewing unum's denial of we disagree with unum and the district court on one aspect of the issue. we benefits and to interpret the terms and provisions of the policy," the district court for the eighth circuit 7-7-