200 W. Madison St. | Suite 2670 | Chicago, IL 60606 | Resource Links | Directions

Call Now 312-702-1842
800-237-5182 Toll Free
We Return Calls The Same Day.

Is taking prophylactic measures a pre-existing condition?

Can taking vitamins recommended by a physician trigger a pre-existing condition exclusion in a disability insurance policy?  That was the holding in Kutten v. Sun Life Assur.Co. of Canada, 2014 WL 3562784 (8th Cir. July 21, 2014) where the court found that taking Vitamin A constituted "medical treatment" sufficient to allow an insurer to avoid paying disability benefits to an executive who became disabled due to retinitis pigmentosa.  The policy contained the following exclusion:

 

No LTD benefit will be payable for any Total or Partial Disability that is due to:

6. a Pre-Existing Condition.

Pre-Existing Condition means during the 3 months prior to the Employee's Effective Date of Insurance the Employee received medical treatment, care or services, including diagnostic measures, or took prescribed drugs or medicines for the disabling condition.

 

 

The court found that even though the vitamins were not prescribed, the recommendation that Kutten take vitamins constituted "medical treatment" and thus excluded his coverage.

Judge Kermit Bye dissented, asserting that it was "unreasonable for Sun Life to conclude that the use of a vitamin supplement constituted medical treatment."  He called this "a simple case of an insurer issuing a poorly-drafted policy and then going to significant lengths to evade its terms."  Because the use of vitamin supplements does not require interaction with a medical professional, Judge Bye would have found that taking vitamins is not "medical treatment" and expressed concern about the implication of the majority's ruling, pointing out that so long as a medical professional offers a recommendation: 

 

"Even simple things such as getting eight hours of sleep a night, brushing one's teeth, exercising thirty minutes a day, or taking an aspirin for a headache would be encompassed by this interpretation.  Judge Bye accused the majority of "essentially ignor[ing] the policy language and, instead, apply[ing] its own definition of what should be included within the Pre-Existing Condition clause."  

 

 

Judge Bye appears to have articulated the more logical analysis.  The negative implications of this ruling are profound.  Using the analogies raised by the plaintiff, someone with a history of melanoma who is urged to use sunscreen and later develops a recurrence of the cancer would be deemed to have received medical treatment under the majority's view.  Likewise, someone successfully treated for colon cancer who is advised to eat a high fiber diet, yet later develops new tumors would also be excluded under Sun Life's interpretation.  Similarly, it is common after treatment of breast cancer for the patient to be placed on prophylactic medication even though disease-free.  That, too, would be excluded, as would an individual with cardiac abnormalities who is urged to take an aspirin a day.  The ERISA law, which was enacted to protect the plan participants, suffered a deep blow from this ruling.

No Comments

Leave a comment
Comment Information

DeBofsky, Sherman & Casciari, PC