Opinion ID: 164315
Heading Depth: 3
Heading Rank: 3

Heading: Illustrative cases

Text: 85 The few cases that have focused on the application of proximate cause to exclusions for pre-existing conditions are not inapposite. In Cash v. Wal-Mart Group Health Plan, 107 F.3d 637 (8th Cir.1997), the plaintiff was diagnosed with diverticular disease. He later developed diverticulitis. The Eighth Circuit held the denial of benefits was reasonable, because the diverticulitis was a complication and secondary condition of the presence of diverticula in the wall of the colon. Id. at 643. In other words, the diverticular disease was a necessary precursor to the later illness of diverticulitis. Id. Here, in contrast, Mr. Fought's coronary condition was not a prerequisite to the onset of the staph infection: There is no necessary precursor link. 86 Similarly, in Holsey v. UNUM Life Ins. Co. of Am., 944 F.Supp. 573, 579 (E.D.Mich.1996), relied upon by the district court, [Plaintiff's] blindness was caused by, contributed to by or resulted from diabetes where blindness was related to diabetes and glaucoma was a well-known complication of diabetes; preexisting condition exclusion enforced. Aplt's App. at 14. Holsey, like Cash, clearly describes a situation where an insurer denied coverage for the results of diabetes, not for the complications from treatment or surgery for diabetes. Blindness certainly is a well-known complication of diabetes. Staph infections are not, so far as we are aware, a well-known complication of coronary artery disease. The district court also cited to Currie v. Metropolitan Life Ins. Co., No. CIV-A-1665, 1998 WL 214761, at - (E.D.La. April 29, 1998), and noted the Currie court reject[ed the] argument that plaintiff was suffering from a different sickness or injury when she received treatment within the pre-existing period; all treatment stemmed from prior car wreck; preexisting condition exclusion enforced. Aplt's App. at 14. The plaintiff in Currie was disabled because of back pain. She had been treated for back pain after a car accident that had occurred before she was covered by the insurance policy, so the insurer denied coverage for a pre-existing condition. She tried to claim that she was at that point suffering from a different kind of back pain, whereas the back pain for which she had received treatment was from a different cause; but the court held that all of the back pain had arisen from the car accident. This scenario, however, has nothing in common with Ms. Fought's case. The question is not whether her disability arose from a different surgery or a different form of heart disease but simply whether the causal connection between the disease and the disability is insufficiently proximate. 87 Next, in Reinert v. Giorgio Foods, Inc., 15 F.Supp.2d 589 (E.D.Pa.1998), the plaintiff, Ms. Giorgio, suffered from three pre-existing conditions before she became eligible for plan benefits: diabetes, Charcot joint disease, and diabetic neuropathy. She later suffered from a series of ulcerations on her left foot. Two of the ulcerations were manifestations of her pre-existing conditions. A third ulceration developed from an insulin needle that became embedded in the plaintiff's foot. The needle ulceration was a separate and distinct injury which was aggravated by those underlying conditions. Id. The court found improper the denial of benefits for the treatment of this injury. 88 The court recognized, however, that the distinction between the ulcers was subtle. Ulcerations similar to those suffered by Ms. Giorgio were frequently caused by continuing deterioration of the bones and tissue in her foot, which was in turn caused by the diabetes, Charcot joint disease, and diabetic neuropathy. Thus, applying a strict arbitrary and capricious standard, with no conflict of interest present, the court determined that the improper denial of benefits as to the third ulcer was not arbitrary and capricious. 89 Here, UNUM cannot point to such nuances. The staph infection was a separate and distinct injury, not a manifestation of the underlying coronary disease. 90 Finally, and most importantly, in Vander Pas v. UNUM Life Ins. Co. of Am., 7 F.Supp.2d 1011 (E.D.Wis.1998), the plaintiff had suffered from a pre-existing heart condition for which he took the drug Coumadin. Coumadin puts a patient at risk for a subdural hematoma. The patient did suffer a subdural hematoma, and UNUM attempted to deny coverage on the theory that the pre-existing heart condition had caused him to take Coumadin, which had then caused the hematoma. The district court in Vander Pas described the chain of causality as attenuated: [T]he plaintiff's atrial fibrillation caused him to take Coumadin, which brought about his subdural hematoma, which produced his disability. Id. at 1018. The court faulted UNUM for not providing a proximate cause analysis, among other failings. Id. The district court therefore denied UNUM's motion for summary judgment. 91 UNUM attempts to distinguish Vander Pas by asserting that the court did not actually rule against UNUM on the basis of lack of proximate cause, but because UNUM had not set forth that, or any, explanation of a chain of causation. Aple's Br. at 15 (bold-faced type in original). This misreads Vander Pas. The court clearly based its decision on UNUM's failure to explain how the treatment itself, Coumadin, was the pre-existing condition. Vander Pas, 7 F.Supp.2d at 1018. In other words, the district court properly required UNUM to show that the proximate cause of the disability (taking Coumadin) pre-existed. That the patient would not have been taking Coumadin but for the pre-existing heart condition did not make the pre-existing condition the cause of the disability. See id. ([T]he proposition that Coumadin played a part in causing plaintiff's subdural hematoma ... is not equivalent to a studied conclusion that plaintiff's use of Coumadin satisfies the definition for `pre-existing condition,' or that his disability was `caused by, contributed to by, or result[ed] from' the use of Coumadin.). Similarly here, UNUM must demonstrate that the proximate cause of the disability, here, the staph infection, was a pre-existing condition.