Julissa Bradshaw v. Reliance Standard Life Insurance Company
707 F. App'x 599
| 11th Cir. | 2017Background
- Bradshaw purchased long-term disability coverage effective May 1, 2013, while a few weeks pregnant; her pregnancy was uncomplicated during the three-month look-back period (Feb 1–May 1, 2013).
- In November 2013, after delivery, Bradshaw developed preeclampsia and on Nov. 17 suffered a massive cerebellar stroke, resulting in permanent deficits and a claim for long-term disability benefits.
- The policy excluded benefits for disabilities "caused by," "contributed to by," or "resulting from" a pre-existing condition if the insured received treatment in the three months immediately preceding the effective date (the look-back period).
- Reliance denied benefits, reasoning pregnancy during the look-back period was a pre-existing condition and that pregnancy/preeclampsia contributed to the stroke; its independent reviewer agreed preeclampsia contributed to the stroke but conceded preeclampsia was not present or predictable during the look-back period.
- The district court granted summary judgment for Reliance; the Eleventh Circuit reviewed de novo whether the administrator’s interpretation was reasonable under the arbitrary-and-capricious standard (with conflict-of-interest as a factor) and reversed, ordering benefits awarded.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the pre-existing-condition exclusion applies when the insured received pregnancy-related care during the look-back period but had no symptoms of preeclampsia or hypertension then | Bradshaw: exclusion does not apply because she received no treatment for preeclampsia, hypertension, or stroke during the look-back period; a healthy pregnancy did not substantially contribute to her later stroke | Reliance: pregnancy during the look-back period is a pre-existing condition and pregnancy/preeclampsia contributed to the stroke, so the exclusion bars coverage | Court: exclusion must be limited to conditions that substantially contributed to the loss; Bradshaw's healthy pregnancy did not substantially contribute, so Reliance's denial was unreasonable; benefits must be awarded |
| Whether appellant waived arguments on appeal by not citing certain cases below | Bradshaw: she preserved the core legal claims and may advance new arguments/cases on appeal related to those preserved claims | Reliance: failure to cite cases to the district court amounts to waiver | Court: arguments were preserved; 11th Cir. considered new authorities because issues were preserved and involve pure legal questions; no waiver |
Key Cases Cited
- Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350 (11th Cir.) (articulating six-step ERISA benefits-review framework)
- Dixon v. Life Ins. Co. of N. Am., 389 F.3d 1179 (11th Cir. 2004) (adopting a "substantially contributed" test limiting exclusionary causation language)
- Fought v. UNUM Life Ins. Co. of Am., 379 F.3d 997 (10th Cir. 2004) (rejecting overly broad but-for causation for pre-existing-condition exclusions)
- Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (2008) (recognizing conflict-of-interest by a payor/administrator is a factor in abuse-of-discretion review)
- Highmark Inc. v. Allcare Health Mgmt. Sys., Inc., 134 S. Ct. 1744 (2014) (a decision based on an erroneous view of law is an abuse of discretion)
- Adkins v. Reliance Standard Life Ins. Co., 917 F.2d 794 (4th Cir. 1990) (criticizing overly strict "directly and from no other causes" construction and supporting a limiting approach)