Published by The Pellegrin Firm January 29, 2020

In a ruling dated January 13, 2020, Judge Sarah Vance of the U.S. District Court for the Eastern District of Louisiana sided with a claimant in a dispute over the applicability of a pre-existing condition exclusion to a long-term disability claim.

The insurer, MetLife, argued that since the claimant had struggled with back problems before, it was not obligated to pay him long-term disability benefits due to a new back injury. The judge found that MetLife, and the nurse consultant it hired to examine the file, applied the wrong standard in evaluating the claim. The policy states that disability resulting from a pre-existing condition is excluded from coverage. However, the nurse consultant could state only in her report that the new back pain was “related” to the previous back pain. While this may be true, this is not what the pre-existing condition exclusion says, and courts have generally not applied such exclusions so strictly. For example, Judge Vance cited the U.S. Court of Appeals for the Ninth Circuit’s decision in Haddad v. SMG Long Term Disability Plan, 752 F.App’x 493 (9^th Cir. 2019), in which the court rejected an insurer’s argument that right-sided back pain caused or contributed to left-sided back pain and thus the new left-sided back pain amounted to a pre-existing condition.

The case is Meche v. Metropolitan Life Insurance Co., No. CV-18-3995, 2020 WL 133284 (E.D. La. Jan. 13, 2020).