What sort of “medical treatment” triggers the pre-existing condition exclusion in an ERISA-governed disability policy?
Can taking over-the-counter vitamin supplements trigger the exclusion? YES.
Here’s the case of Kutten v. Sun Life Assurance Company of Canada, __ F.3d __, 2014 WL 3562784 (8th Cir. July 21, 2014) (pdf).
FACTS: Kutten had a progressive eye disease. In 1994, his doctor directed him to start taking daily 15,000 unit doses of an over-the-counter vitamin A supplement. This could slow, but not cure, this progressive disease which can lead to blindness.
In June 2010 Kutten’s employer bought a new policy for the ERISA-governed disability benefit. This new policy excluded pre-existing conditions, defined as a condition in which the employee “received medical treatment, care or services, …or took prescribed drugs or medicines for the disabling condition” 3 months before the start of the policy. Kutten applied for disability benefits. Sun Life concluded the vitamin A supplements triggered the pre-existing condition exclusion as “medical treatment” and denied the claim. Kutten sued.
ISSUE: Do vitamin supplements constitute “medical treatment” sufficient to trigger the pre-existing condition exclusion?
TRIAL COURT HELD: Plaintiff wins — vitamin A supplements are not a “medical treatment” because such use does not require the same medical intervention as “prescribed drugs or medicines.”
EIGHTH CIRCUIT COURT OF APPEALS: REVERSES (2-1 decision)
- “Drawing a sharp distinction between ‘prescribed drugs or medicines’ and ‘medical treatment’ is a virtually impossible task because ‘prescribed drugs or medicines’…are forms of ‘medical treatment.’” Op. at 5
- “[T]he ordinary meaning of the phrase ‘medical treatment’ would encompass Kutten’s vitamin A supplements. The supplements are ‘medical’ in the sense that they prevented or alleviated the progression of Kutten’s [eye disease and]… constituted a ‘treatment’ because it was the ‘manner,’ in fact the only manner, by which Kutten could ‘care for’ his condition.” Op. at 6.