Opinion ID: 4521051
Heading Depth: 2
Heading Rank: 1

Heading: Pre-existing Conditions Limitation

Text: The plan document’s pre-existing conditions limitation provides that Defendant will not pay benefits for a “Total Disability” caused by, contributed to by, or resulting from “a Preexisting Condition unless the Insured has been Actively at Work for one (1) full day following the end of twelve (12) consecutive months from the date he/she became an Insured.” (Admin. R., R. 42-1 at PageID #751.) A “Pre-Existing Condition” includes “any Sickness or Injury for which the Insured received medical Treatment, consultation, care or services, . . . or took prescribed drugs or medicines, during the three (3) months immediately prior to the Insured’s effective date of Insurance.” (Id. at #752.) The facts before us do not permit us to determine if this pre-existing conditions limitation provision applies. Neither Plaintiff nor Defendant contest that Plaintiff’s medical condition qualifies as a “Sickness” or “Injury” under these definitions. But Defendant and Plaintiff disagree as to the Plaintiff’s effective date of insurance. Defendant contends it was April 7, 2013, the date that Plaintiff returned from her initial medical leave, while Plaintiff contends it was January 1, 2013, the “Effective Date” of the policy. The applicability of the transfer of insurance provision is dispositive as to this issue. (See Def. Br. at 32 (“The Transfer of Insurance provision in the Group Policy allows for the individual coverage effective date to coincide with the effective date of the Group Policy”).) As will be discussed below, additional factfinding is required to determine whether that provision applies, and so this Court cannot conclusively determine Plaintiff’s effective date of insurance. No. 18-2316 Wallace v. Oakwood Healthcare, et al. Page 13 Moreover, the district court did not make a factual finding as to when Plaintiff began receiving medical treatment for her condition. We do not make such a finding now, as it is more appropriately the province of the district court to address that question on remand. The district court did find that Plaintiff did not work after May 12, 2013, and we agree. (Op. & Order Granting Pl.’s Mot. J. & Den. Def.’s Mot. J., R. 50 at PageID ##1228, 1236.) This was less than twelve consecutive months after either January 1, 2013 or April 7, 2013. Therefore, if the facts on remand show that Plaintiff did receive medical treatment for her condition in the three months prior to her effective date of insurance, as determined based on the applicability of the transfer of insurance provision, Plaintiff would potentially be subject to the pre-existing conditions limitation.