Opinion ID: 164970
Heading Depth: 3
Heading Rank: 3

Heading: Pre-existing Condition Review

Text: 39 Ms. Allison contends that UNUM unreasonably sought her medical records dating back to 1996—long before the July 1, 1997, start date of Ms. Allison's six-month pre-existing condition exclusion period. She argues that UNUM, upon discovering it applied the incorrect time frame for calculating her coverage, should have asked for records only since July 1, 1997, consistent with its previous request. Ms. Allison contends that UNUM was dissatisfied with its initial analysis, having concluded that she did not seek treatment for MEN-I from August 1, 1997 through February 1, 1998. See id. at 118 (Pre-Existing Condition Medical Review, dated Nov. 7, 1999) (No evidence of treatment for related problems during the dates in questions of 8/1/97 to 1/31/98); id. at 95 (in its initial review, UNUM states Ms. Allison was treated by Dr. Johnson on 1/30/98 for a condition which caused, contributed to or resulted in the condition for which [she is] now claiming disability). She contends that UNUM's request backtracks from this conclusion and is essentially a fishing expedition without foundation. At oral argument, appellate counsel also emphasized that the blanket medical release authorization Ms. Allison completed in June 1998 was identical to the newly requested release form. 40 In support of its argument, UNUM, in turn, relies upon various references to treatment from other doctors that appear in the medical records, as well as Ms. Allison's somewhat confusing responses in her disability applications. UNUM points out that Ms. Allison received treatment for MEN-I related conditions, including the removal of her parathyroid, which predated her coverage period by nearly two years. Furthermore, Dr. Schiller's February 3, 1998 report stated that she had been previously diagnosed with MEN-I. 41 UNUM stresses that Ms. Allison's failure to include Dr. Robert Gagle, who treated her in June 1998, on her LTD claim form as a treating physician was a deliberate omission. UNUM states that [t]he preponderance of the medical evidence indicated that Plaintiff was diagnosed with MEN-I years before her claim for disability, Aple's Br. at 23, and implies that this condition may have been captured by the pre-existing condition exclusion. 42 UNUM repeatedly insists that Ms. Allison has been deceitful by providing misleading information. Id. at 22. For example, UNUM asserts that she claimed that she had pancreatic tumors which were inoperable and that her condition was terminal. Id. at 22-23. UNUM also casts aspersions upon Ms. Allison, stating that she apparently changed jobs in 1997, and her health insurance did not become effective until January 1, 1998. As soon as Plaintiff received coverage, she sought treatment for her MEN-I related symptoms. Id. at 23. 43 We cannot draw the same conclusions as UNUM: Although the malignancy of the tumors had been disproved at the time Ms. Allison completed her short-term disability claim, see Aplt's Supp.App. vol. II, at 265 (Disability Claim dated June 25, 1999), a Physician's Statement that post-dated Ms. Allison's claim also indicated she suffered from pancreatic abnormalities and pancreatic tumors. Id. at 219 (Physician's Statement dated August 19, 1999). UNUM appears to fault Ms. Allison for confusing inoperable pancreatic abnormalities with inoperable pancreatic tumors. We also note that Ms. Allison's LTD disability claim form no longer referenced the pancreatic lesions. 44 Based upon the above, without more, we might be unable to conclude that UNUM could have justified a denial of benefits based on the record before it, especially noting its own miscalculations of the pre-existing condition exclusion period. However, because UNUM diligently sought information to round out its pre-existing condition inquiry, we must also analyze this section of the Plan's language.