Opinion ID: 4521051
Heading Depth: 2
Heading Rank: 3

Heading: Pre-Existing Conditions Limitation Credit

Text: Defendant contends that even if Plaintiff is covered under the plan document’s transfer of insurance provision, the pre-existing conditions limitation still applies, unless Plaintiff meets the terms of the pre-existing conditions limitation credit. We agree. That provision states that “[i]f an employee is an Eligible Person on the Effective Date of this Policy, any time used to satisfy the Pre-existing Conditions Limitation of the prior group long term disability insurance plan will be credited towards the satisfaction of the Pre-existing Conditions Limitation of this Policy.” (Id. at #742.) Our previous analysis as to whether Plaintiff was an eligible person also applies here. Thus, the applicability of this provision turns on whether Plaintiff was a full-time employee. If so, this provision applies, and her time used to satisfy any pre-existing conditions limitation of the Hartford policy should be credited towards the twelve months of work she was required to perform after her effective date of insurance in order to avoid the application of the pre-existing conditions limitation. (Id. at #751 (requiring that Plaintiff be “Actively at Work for one (1) full day following the end of twelve (12) consecutive months from the date he/she became an Insured” for provision not to apply).) But the district court also made no factual finding as to how much time Plaintiff had earned under Hartford’s pre-existing conditions limitation, which required a participant to work for Oakwood for a year before she could avoid its application. (Am. Compl., Ex. 2, R. 16-2 at PageID #187.) While we note that Plaintiff had been employed with Oakwood continuously during at least two years when Hartford insured the plan, we think it appropriate to allow the district court to consider this question in the first instance. (Id. at #176; Admin. R., R. 42-1 at PageID ##768, 824.) Thus, while we find that Plaintiff may have been covered under the transfer of insurance and pre-existing conditions limitation credit provisions, the facts before us do not permit us to make a definitive finding that she was. Accordingly, further factfinding is required as to the following points: (1) when Plaintiff began receiving medical treatment for her condition; (2) whether Plaintiff was a full-time employee required to work more than thirty hours during No. 18-2316 Wallace v. Oakwood Healthcare, et al. Page 22 her regular work week; (3) whether Plaintiff was insured with Hartford as of the date of transfer; (4) whether Plaintiff’s initial leave lasted through the elimination period; (5) whether Plaintiff remained totally disabled after May 27, 2014; and (6) what credit Plaintiff had earned under Hartford’s pre-existing conditions limitation. Accordingly, we vacate the district court’s judgment on the record and remand for further factfinding on these six questions. On remand, the district court may make what additional findings of fact it can based on the administrative record, but it may not look beyond the administrative record. Hoover, 390 F.3d at 809. If the district court remands the case to the plan administrator, in view of the court’s familiarity with the record, it may wish to retain jurisdiction over future proceedings should the case subsequently return. See, e.g., Bowers v. Sheet Metal Workers’ Nat’l Pension Fund, 365 F.3d 535, 537 (6th Cir. 2004). III. Award of Benefits