Kristian Horneland v. United of Omaha Insurance Company
16-16935
| 11th Cir. | Nov 17, 2017Background
- Horneland worked as a real-estate manager beginning March 12, 2012; long-term disability (LTD) coverage began March 12, 2013 and contained a 12‑month pre‑existing condition exclusion with a 3‑month look‑back (Dec 12, 2012–Mar 12, 2013).
- He had a 1998 thoracic spinous‑process fracture (T6–T8) that was largely asymptomatic until increased driving in late 2012 triggered recurrent mid‑back pain and muscle spasms.
- During the look‑back period he refilled prescriptions (Vicodin, Tramadol) and saw Dr. Gelia for upper/mid‑back pain; after the look‑back period his pain worsened, he stopped work Aug 2, 2013, and filed for disability Sept 2013.
- Early imaging (2013 lumbar and thoracic MRIs) showed no significant abnormalities; later testing (2015 EMG and MRI) demonstrated lumbar radiculopathy and other lumbar findings.
- Defendant denied LTD benefits twice, relying on (1) insufficient objective evidence of disability and (2) application of the pre‑existing condition exclusion because Horneland received treatment/prescriptions during the look‑back period.
- The district court granted summary judgment for the insurer; the Eleventh Circuit reversed that grant (affirmed denial of plaintiff summary judgment) and remanded, finding material factual disputes.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the pre‑existing condition exclusion bars coverage | Horneland: prescriptions/refills during look‑back were for symptoms (pain/spasms), not a "condition"; symptoms alone do not satisfy the plan’s definition of a Pre‑existing Condition | United of Omaha: treatment and medication for back pain during the look‑back show the disabling condition was pre‑existing and exclusion applies | The court held that pain and muscle spasms are symptoms, not a defined "Injury" or "Sickness" under the plan, so the exclusion does not automatically apply; but genuine fact disputes remain about the underlying condition and causation, precluding summary judgment for either party |
| Whether Horneland was actually disabled within policy period | Horneland: medical statements and progression show disability from mid/late 2013 attributable to spinal pathology aggravated by driving | United of Omaha: insufficient objective evidence in 2013 to show disability; later lumbar findings are new and post‑date the claim | Court found disputed evidence (conflicting diagnoses, imaging, timing) — disability is a factual question for further proceedings |
| Whether the underlying pre‑existing ‘‘condition’’ (if any) caused or contributed to the claimed disability | Horneland: his 1998 thoracic injury was aggravated by work driving and caused later disability (possibly via thoraco‑lumbar decompensation) | United of Omaha: later lumbar radiculopathy is a new condition unrelated to look‑back treatment; thus exclusion applies if the look‑back treatment matches the disabling condition | Court: record contains conflicting medical opinions about diagnosis, timing, and causal relationship — genuine issues of material fact exist |
| Proper remedy at summary judgment stage | Horneland: summary judgment should be denied to insurer and remand to decide disability if exclusion not triggered | United of Omaha: summary judgment in insurer’s favor because exclusion applies as a matter of law | Court: reversed grant for insurer, affirmed denial of Horneland’s summary judgment, remanded for factfinding; plaintiff’s motion to amend findings is moot |
Key Cases Cited
- Melech v. Life Ins. Co. of N. Am., 739 F.3d 663 (11th Cir.) (standard of review for ERISA benefits denial)
- Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350 (11th Cir.) (multi‑step framework for judicial review of ERISA benefit denials)
- Capone v. Aetna Life Ins. Co., 592 F.3d 1189 (11th Cir.) (de novo review when administrator has no discretion)
- Horton v. Reliance Std. Life Ins. Co., 141 F.3d 1038 (11th Cir.) (burden on administrator to show exclusion applies)
- Alexandra H. v. Oxford Health Ins. Inc. Freedom Access Plan, 833 F.3d 1299 (11th Cir.) (plan terms given plain meaning)
- Gagliardo v. Connaught Lab., Inc., 311 F.3d 565 (3d Cir.) (muscle spasms characterized as a symptom)
- Smith v. Kmart Corp., 177 F.3d 19 (1st Cir.) (pain and spasms are symptoms)
- Herr v. Sullivan, 912 F.2d 178 (7th Cir.) (same)
- Preston v. Sec’y of Health & Human Servs., 854 F.2d 815 (6th Cir.) (same)
- Smith v. Office of Pers. Mgmt., 784 F.2d 397 (Fed. Cir.) (same)
- Taylor v. Heckler, 742 F.2d 253 (5th Cir.) (same)