Case Review Corner: Victory for Claimant in ERISA Pre-Existing Condition and Disability Determination Case

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Welcome to the "Case Review Corner" at Dorian Insurance Law PC. Today, we're examining a recent case out of the United States District Court for the Northern District of Illinois, Eastern Division, presided over by Judge Andrea R. Wood. The case of Jessica Krueger v. Reliance Standard Life Insurance Company, Case No. 23-cv-02493, decided on March 10, 2025, offers valuable insights into ERISA long-term disability claims, particularly concerning pre-existing conditions and the evaluation of disability.

The Facts of Krueger v. Reliance Standard

The plaintiff, Jessica Krueger, was employed by Cooper's Hawk Intermediate Holdings, LLC ("Cooper's Hawk") as a human resources employee. While working at Cooper's Hawk, Ms. Krueger, a resident of Wheeling, Illinois, began experiencing symptoms that were eventually diagnosed as postural orthostatic tachycardia syndrome ("POTS"). Due to the severity of her symptoms, Ms. Krueger became unable to work and applied for long-term disability benefits under a policy ("Policy") underwritten by Reliance Standard Life Insurance Company ("Reliance").

Ms. Krueger's long-term disability insurance coverage with Reliance Standard became effective on August 1, 2021. Her last day of work at Cooper's Hawk was December 31, 2021. She filed her claim for benefits on March 25, 2022, listing January 3, 2022, as her first date of disability. Her primary diagnosis was POTS, with symptoms including visual changes, vertigo, headaches, profound weakness, and the inability to stay upright.

Reliance Standard denied Ms. Krueger's claim, asserting that her POTS was a pre-existing condition excluded from coverage under the Policy. The Policy defined a "Pre-Existing Condition" as any sickness or injury for which the insured was diagnosed or treated within the three months immediately prior to the effective date of insurance. Reliance argued that Ms. Krueger had received treatment for symptoms associated with POTS (specifically, inappropriate sinus tachycardia and migraines) during this "lookback" period.

After exhausting her administrative appeals with Reliance Standard, Ms. Krueger filed a lawsuit under the Employee Retirement Income Security Act of 1974 ("ERISA"), seeking a court order for Reliance to pay her the disability benefits she believed she was owed. The case was ultimately decided on Ms. Krueger's motion for judgment under Federal Rule of Civil Procedure 52, essentially a "trial on the papers" based on the administrative record.

The Legal Issue: Pre-Existing Condition Exclusion and De Novo Review under ERISA

The central legal issue in this case revolved around Reliance Standard's application of the pre-existing condition exclusion. Under ERISA, the standard of review for a denial of benefits is typically de novo when the benefit plan does not grant the administrator discretionary authority, as was the case here. This means the court makes an independent decision about the claimant's entitlement to benefits, without deferring to the insurance company's determination.

Judge Wood thoroughly analyzed the pre-existing condition clause in light of Seventh Circuit precedent, including cases like Estate of Blanco, Bullwinkel, and Pitcher. The court distinguished these cases and applied the framework established in Lawson ex rel. Lawson v. Fortis Ins. Co., which focuses on whether the treatment received during the lookback period was "for" the specific condition that caused the disability.

The Court's Findings:

Judge Wood ultimately sided with Ms. Krueger, granting her motion for judgment. The court found that Reliance Standard failed to prove by a preponderance of the evidence that Ms. Krueger's tachycardia and migraines during the lookback period were early manifestations of POTS. The court emphasized that Ms. Krueger's doctors had diagnosed and treated her for inappropriate sinus tachycardia and migraines as separate conditions, and one neurologist even specifically noted "no syncope or evidence of POTS."

Furthermore, the court rejected Reliance Standard's argument that the presence of "tachycardia" in the name of POTS automatically linked her prior diagnosis to the later one. Judge Wood noted the lack of medical evidence supporting this assertion and highlighted that inappropriate sinus tachycardia and POTS are distinct conditions, even if they can be comorbid. Similarly, the court found that while migraines can be a symptom of POTS, they can also be associated with other conditions and Ms. Krueger experienced improvement in her migraines while still suffering from other POTS symptoms.

The Court's Analysis of Total Disability:

As an alternative argument, Reliance Standard claimed that Ms. Krueger failed to adequately prove she met the Policy's definition of Total Disability, arguing that her evidence was primarily subjective. Judge Wood rejected this argument as well. Under de novo review, the court found that the Policy language regarding "satisfactory proof of Total Disability" was ambiguous and should be construed in favor of the insured.

The court emphasized that it could not reject Ms. Krueger's claim solely because her proof was predominantly subjective, especially given the nature of POTS symptoms. Judge Wood considered the ample evidence Ms. Krueger provided, including her repeated attempts to seek medical care from multiple physicians, their consistent documentation of her significant functional limitations, the objective autonomic testing suggestive of POTS, and the corroborating witness statements from her mother and sister.

The court found the opinion of Reliance Standard's independent reviewing physician, who never met Ms. Krueger and dismissed her limitations as subjective, unpersuasive. Judge Wood noted that this physician even downplayed the objective findings from a dysautonomia physical therapy evaluation.

Ultimately, the court concluded that Ms. Krueger had presented sufficient evidence to demonstrate that her POTS symptoms prevented her from performing the material duties of her job as a Senior Human Resources Manager at Cooper's Hawk, which involved significant cognitive demands.

What Ms. Krueger Did Correctly:

• Persisted Through the Administrative Process: Ms. Krueger diligently pursued her administrative appeals with Reliance Standard, providing additional medical records and witness statements.

• Sought Ongoing Medical Treatment: Her consistent engagement with multiple medical professionals provided a detailed record of her symptoms and limitations.

• Obtained Objective Testing: The autonomic testing that suggested POTS provided objective medical evidence supporting her diagnosis.

• Provided Corroborating Evidence: The statements from her family members offered valuable insights into the impact of her condition on her daily life.

• Ultimately Filed a Lawsuit: When her administrative appeals were denied, Ms. Krueger took the necessary step to file a lawsuit under ERISA to protect her rights.

What Ms. Krueger Could Have Done Better (and Lessons for Claimants):

• While Ms. Krueger ultimately won her case, claimants can learn from this: It's crucial to ensure that medical records thoroughly document the functional impact of your symptoms on your ability to perform your specific job duties. While Ms. Krueger did provide this information, emphasizing these limitations clearly and consistently with her treating physicians from the outset could potentially have strengthened her initial claim.

• Consider Consulting an ERISA Attorney Earlier: While it's not clear when Ms. Krueger sought legal counsel, engaging with an experienced ERISA attorney like those at Dorian Law PC earlier in the claims process can provide invaluable guidance on the type of documentation needed and the best strategies for building a strong claim from the beginning. This could potentially help avoid unnecessary denials and appeals.

For Legal Professionals: De Novo Review and the Nuances of Pre-Existing Condition Exclusions Under ERISA

The Krueger v. Reliance Standard decision was reviewed under the de novo standard, as agreed upon by the parties and consistent with the absence of a discretionary clause in the plan. The court explicitly cites Schultz v. Aviall, Inc. Long Term Disability Plan, 670 F.3d 834, 836-37 (7th Cir. 2012), for this standard, emphasizing the court's independent decision-making authority akin to a contract dispute, where "what happened before the plan administrator is irrelevant," as noted in Dorris v. Unum Life Ins. Co. of Am., 949 F.3d 297, 304 (7th Cir. 2020).  

The court's analysis of the pre-existing condition exclusion relies heavily on Seventh Circuit precedent, distinguishing Estate of Blanco v. Prudential Ins. Co. of Am., 606 F.3d 399 (7th Cir. 2010), and Bullwinkel v. New England Mutual Life Insurance Co., 18 F.3d 429 (7th Cir. 1994), from the facts of Krueger's case. The court found the reasoning in Pitcher v. Principal Mutual Life Insurance Co., 93 F.3d 407 (7th Cir. 1996), more applicable, particularly the distinction between being monitored for a pre-existing condition versus being treated for the specific disabling condition during the lookback period. Ultimately, the court adopted the framework from Lawson ex rel. Lawson v. Fortis Ins. Co., 301 F.3d 159, 166 (3d Cir. 2002), emphasizing that treatment during the lookback period must be "for" the particular condition that caused the disability.

The Lesson: This case highlights the critical importance for practitioners litigating ERISA claims under de novo review to focus on the precise language of the pre-existing condition exclusion and to meticulously analyze the medical record to demonstrate whether the treatment received during the lookback period was truly "for" the disabling condition. Under this standard, the court will not defer to the insurer's interpretation. Claimants' counsel should emphasize the distinctions between symptoms and diagnoses, as well as the evolution of the claimant's medical condition. Insurers must present clear medical evidence linking the pre-lookback treatment directly to the later disability, especially when alternative diagnoses or explanations exist.

Conclusion:

The case of Jessica Krueger v. Reliance Standard Life Insurance Company serves as a significant reminder of the complexities of ERISA long-term disability claims, particularly concerning pre-existing conditions and the importance of a thorough and well-documented record. Judge Wood's meticulous analysis underscores the court's role in independently evaluating the evidence under de novo review and the limitations of relying solely on subjective complaints when those complaints are consistent and supported by medical evidence. This case highlights the importance for claimants in Los Angeles, California, and elsewhere, to work closely with their medical providers and understand their rights under their disability insurance policies.

Facing a denial from Reliance Standard or another insurance company on your long-term disability claim, perhaps even involving a pre-existing condition? As you saw in the case of Jessica Krueger, navigating these ERISA regulations and effectively presenting your case can be challenging. At Dorian Law PC, we have extensive experience representing claimants in Los Angeles, California, and across the country in disability insurance disputes, including those involving Reliance Standard. If you're struggling to understand your rights or believe your claim has been unfairly denied, don't hesitate to contact us for a free confidential consultation. We can help you understand the nuances of ERISA law and strategize the best approach to secure the benefits you deserve.

Disclaimer: The information provided here is for general knowledge and informational purposes only, and does not constitute legal advice. You should consult with a qualified lawyer for advice regarding your specific situation.