In Johnson v. Reliance Standard Life Insurance Co., No. 23-13443, 2025 WL _ (11th Cir. Nov. 21, 2025), the United States Court of Appeals for the Eleventh Circuit ruled in favor of an insured who was denied long-term disability benefits on the basis of her group policy’s “pre-existing” condition exclusion.

The claimant was diagnosed with scleroderma, an autoimmune disorder that impacts the skin and internal organs. Before making the claim, she had symptoms later attributed to the disease. However, she was not diagnosed during the policy’s pre-existing condition “lookback period.” Months later, once the policy was in force, her health declined and doctors finally confirmed the diagnosis. When the illness eventually prevented her from working, she filed a claim for long-term disability benefits under an employer-sponsored plan insured by Reliance Standard Life Insurance Company.

Reliance Standard denied the claim by invoking the policy’s pre-existing condition exclusion. This provision barred benefits for disabilities caused by a condition for which the insured received medical treatment during the three months prior to the policy’s effective date. The insurer argued that because the claimant’s earlier medical visits occurred within this lookback period and involved symptoms later associated with scleroderma, the exclusion applied.

The appellate court reversed a district court decision upholding the denial. Its analysis centered on the specific phrasing of the policy, noting that the exclusion only applied if the claimant received treatment “for” the condition during the lookback period. In common usage, the court explained, treatment “for” a disease implies medical care specifically directed toward that particular illness. The medical records in this case showed a different reality. While physicians were attempting to diagnose various symptoms during the lookback period, the actual diagnoses only came later.

The Pellegrin Firm is a Metairie, Louisiana law firm that represents long-term disability claimants in ERISA cases involving wrongful denials, benefit terminations, and procedural violations by insurance companies. The Pellegrin Firm represents clients throughout the New Orleans area and across Louisiana and can be reached at (504) 405-3245 or by email at info@pellegrinfirm.com.