Cheriese Johnson purchased a long-term disability insurance policy from Reliance Standard Life Insurance Company in October 2016. The policy included a preexisting condition exclusion that denied benefits if the disability resulted from a sickness for which the insured received medical treatment during the three months prior to the policy's effective date. During that lookback period, Johnson sought medical care for a wide array of symptoms including fatigue, nausea, vomiting, and joint swelling. Her doctors diagnosed her with various conditions such as fibromyalgia and reflux, but no one suspected or diagnosed scleroderma, a rare autoimmune disease, until four months after the lookback period ended. When Johnson filed a disability claim based on scleroderma, Reliance Standard denied it, arguing that because her symptoms were consistent with scleroderma, she had received treatment for that condition during the lookback period. The district court agreed with the insurer and granted summary judgment. Johnson appealed, arguing that she could not have been treated for a condition that no one knew she had.
The Eleventh Circuit applied its unique six-step framework for reviewing ERISA benefit denials. At the first step, the court determined the insurer's decision was de novo wrong because it misinterpreted the policy's plain language. The policy defined a preexisting condition as a sickness 'for which' the insured received treatment. The court emphasized that the word 'for' connotes intent, purpose, or aim. Since neither Johnson nor her physicians knew or suspected she had scleroderma during the lookback period, they could not have treated her 'for' that specific disease. The court rejected Reliance Standard's broader view, which would treat any symptom consistent with a later-diagnosed condition as treatment for that condition. The court reasoned that such an interpretation would absurdly allow insurers to deny coverage for a brain tumor if a patient was treated for headaches, or for tuberculosis if a patient was treated for the flu, simply because the symptoms were not inconsistent with the eventual diagnosis. At the third step, even though the insurer had discretionary authority, the court found its interpretation unreasonable and arbitrary and capricious. The court distinguished prior cases like Bullwinkel, noting that those involved specific concerns about a known disease, whereas Johnson's case involved vague, non-specific symptoms with no suspicion of the underlying condition. The court also clarified that its unpublished decision in Ferrizzi did not require a formal diagnosis but did not support the insurer's position when there was no suspicion of the condition.
The decision limits the scope of preexisting condition exclusions in ERISA-governed disability plans within the Eleventh Circuit. Insurers can no longer deny claims simply because a patient received treatment for symptoms that are later found to be consistent with a specific disease, unless there is evidence that the patient or doctor suspected that specific disease at the time of treatment. The case is remanded to the district court to determine Johnson's entitlement to benefits consistent with this interpretation. The ruling leaves open the question of how to handle cases where symptoms are highly specific and strongly indicative of a condition, distinguishing them from the vague symptoms in this case.