Haddad v. SMG Long Term Disability Plan

276 F. Supp. 3d 967
District Court, E.D. California·Decided August 23, 2017·No. Case No. 16-cv-01700-WHO·Published

Opinion

ORDER GRANTING DEFENDANT’S MOTION FOR JUDGMENT

William -H. Orrick, United States District Judge

INTRODUCTION

The question in this ERISA denial of disability benefits case is -whether disabling symptoms caused by a surgery to treat a pre-existing condition fall under a limitation of benefits for disabling symptoms “that result[] from, or [are] caused or contributed to by, a Pre-existing Condition.” There is no dispute that: (1) plaintiff Dr. Fadi G. Haddad (Haddad) had a preexisting condition of cervical radiculopathy in the C5-6 cervical disk and that condition caused (prior to the surgery) non-disabling but significant and deteriorating neck pain as well as pain and paresthesia from the top of his right arm down to his right thumb; ■ (2) the surgery he underwent in March 2015 was to alleviate the cervical radiculopathy by replacing the diseased disk, and that he was advised pre-surgery that the operation carried risks of spinal injury and equipment failure; and (3) after that surgery, Haddad’s right -side symptoms improved dramatically (or were totally alleviated) but Haddad started to suffer from non-pre-existing and disabling symptoms on his.left side stemming from the C5-6 disk area. '

Defendant Hartford Life and Accident Insurance Company (Hartford) contends that the post-surgery disabling conditions were “caused or contributed to” by his pre-existing cervical disease because the disabling conditions were the direct result of treatment/surgery to treat the pre-exist-ing condition. Haddad asserts that because the symptoms that disabled him (left-side pain and paresthesia) were not the symptoms that-he sought the surgery for (right-side pain and. paresthesia), his coverage cannot be excluded .by-the pre-existing conditions limitation. I conclude that under the plain language of the Plan, the preexisting condition exclusion applies because the left side disabling symptoms were “caused or contributed to”, by the treatment for the pre-existing degenerative disk disease. Hartford’s motion for judgment is GRANTED and Haddad’s motion is DENIED.

BACKGROUND

I. THE PLAN

Defendant Hartford Life and Accident Insurance Company (Hartford) issued a group life and disability policy (Policy) tothe Trustee of the Health Care Industry Groúp Voluntary Life and Disability Insurance Trust (Trust or policy holder). AR 1064-1167. Hartfofd issued “certificates of insurance” (Certificates) to covered employees, outlining the benefits available. According to Hartford, these Certificates compromise the ERISA plan (Plan). Under the Plan sponsored ‘by plaintiffs former employer Sutter Medical Group .(Sut-ter), short-term disability (STD) and long-term disability (LTD) benefits were available. Haddad became covered by the Plan on July 28, 2014, his first day of employment with Sutter. AR 1058.

To be eligible, for STD. benefits under the Plan, an employee had to be unable to perform their regular or customary work. AR 1079-80. Benefits were payable for up to -22 weeks, but only six weeks if the disability was caused by a pre-existing condition. AR 1071. With respect to pre-exist-ing conditions, the Plan provided:

Pre-Existing Conditions Limitation: Are benefits limited for Pre-existing Conditions?
[970] We will only pay benefits, or an increase in benefits, under The Policy for any Disability that results from, or is caused or contributed to by, a Pre-existing Condition for up to 6 week(s), unless, at the time You become Disabled:
1) You have not received Medical Care for the condition for 6 consecutive month(s) while insured under The Policy; or
2) You have been continuously insured under The Policy for 12 consecutive month(s).
Pre-existing Condition means:
1) any Injury, Sickness, Mental Illness, pregnancy, or episode of Substance Abuse; or
2) any manifestations, symptoms, findings, or aggravations related to or re-suiting from such Injury, Sickness, Mental Illness, pregnancy, or Substance Abuse; for which You received Medical Care during the 6 month(s) period that ends the day before:
1) Your effective date of coverage; or
2) the effective date of a Change in Coverage.

AR 1075 (emphasis added).

The LTD Plan has a 180 days elimination period and provides coverage if the participant is unable to Work in their “own occupation.” AR 1097. The only substantive difference between the pre-existing condition limitation in the LTD and STD Plans is that medical care for a condition pre-coverage must have been within three months under the LTD Plan (as opposed to six month under the STD Plan). AR 1105.1

II. MEDICAL CONDITION AND CLAIM FOR STD

Haddad first experienced neck pain in 2013. AR 1048.2 On July 1, 2014, Had-dad had a cervical spine X-ray and .discussed his neck pain and right thumb numbness with pain with an orthopedic surgeon. AR 940-41, 945-46. The surgeon diagnosed mild right-sided C5-6 disk herniation. AR 940t-41.3

[971] On July 28, 2014, Haddad started working at Sutter as a pediatric gastroenterologist. AR 1058. From August through November 2014, Haddad continued to seek medical care for his cervical radiculopathy that was causing him “mild right-sided C6 symptoms.” Haddad was being evaluated by medical personnel for cervical traction units and treated with physical therapy. AR 936-939, 942. During this time, Had-dad’s symptoms progressed from only neck pain and eventually, included pain and paresthesia from the top of his right arm down to his right thumb. AR 1048. He treated the condition with, physical therapy and anti-inflammatory medicines. Id.. A November 2014 MRI, performed because of Haddad’s “neck-pain with radiculopa-thy,” showed “severe right foraminal narrowing and compression” of the C6 nerve at the C5-6 level and “C5-6 disk herniation.” AR 942, 944.

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Haddad v. SMG Long Term Disability Plan, 276 F. Supp. 3d 967 (E.D. Cal. 2017).

276 F. Supp. 3d 967 (Haddad v. SMG Long Term Disability Plan) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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