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Methicillin-Resistant Staphylococcus Aureus (MRSA)

If pregnancy exacerbates a pre-existing medical condition can your disability claim be denied?

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February 28, 2013 4:51AM

This isn't a yes or no question. See the research. Turn in the claim and see what happens. Is Pregnancy covered under the Disability Plan? When two causes join in causing injury, one of which is insured against, insured is covered by policy. Zimmerman v. Continental Life Ins. Co. (App. 1 Dist. 1929) 99 Cal.App. 723, 279 P. 464.

West's Ann.Cal.Ins.Code § 10320

Although ERISA plan participant's preexisting condition of congenital cataracts might have contributed to extent of his injuries, the preponderance of evidence in the administrative record established that accident, whereby participant tripped in his home and jammed his thumb into his eye socket, was proximate cause of participant's total loss of sight in his eye, and since accident was proximate or predominant cause of participant's total loss of vision in eye, he was entitled to recover from accidental death and dismemberment insurer under the terms of the controlling summary plan description (SPD) which only excluded accidental death and dismemberment due to most natural illnesses or diseases. Employee Retirement Income Security Act of 1974,

Weis v. Accidental Death & Dismemberment Ben. Plan of Kaiser Foundation Health Plan Inc. 442 F.Supp.2d 850 (N.D.Cal.,2006)

The district court found that: 1) McClure's disability was the result of the process of nature and, 2) McClure was entitled to benefits even though he had a preexisting condition, because the accident was the proximate cause of his disability. Under the "process of nature" rule, a claimed disability is considered to have occurred immediately within the meaning of a total disability policy provision when it follows directly from the accidental injury within the time the process of nature takes.

McClure v. Life Ins. Co. of North America 84 F.3d 1129, *1133 (C.A.9 (Nev.),1996)

the existence of a preexisting condition does not bar recovery under an ERISA policy unless the preexisting condition "substantially contributed to the disability or loss," even when the general policy language limits coverage to losses caused by accidents "directly and independently of all other causes.

McClure v. Life Ins. Co. of North America 84 F.3d 1129, *1135 (C.A.9 (Nev.),1996)

Where resultant disability is due entirely to lighting up or aggravation of pre-existing condition by industrial injury, employer is liable to compensate for entire disability, but where disability is partly due to industrial disability from injury, and partly due to normal progress of a pre-existing disease or condition, employer is liable to compensate only for portion or percentage of disability due to injury. West's Ann.Labor Code, § 4663.

Bowler v. Industrial Acc. Commission 135 Cal.App.2d 534, 287 P.2d 562 (Cal.App.1955)

Question whether compensation applicant's permanent disability results from effects of accident, including aggravating effect of accident upon pre-existing disease, or whether disability or part thereof resulted from normal progress of a pre-existing disease is a question of fact for determination by Industrial Accident Commission.

Bowler v. Industrial Acc. Commission 135 Cal.App.2d 534, 287 P.2d 562 (Cal.App.1955)

Where an employee's pre-existing condition is asymptomatic, and an industrial injury causes disability other than death, medical testimony may be resorted to determine whether disability is entirely due to injury, or partially due to a continuance of pre-existing condition.

Bowler v. Industrial Acc. Commission 135 Cal.App.2d 534, 287 P.2d 562 (Cal.App.1955)

An insurer's narrow definition of "injury" as one that is independently caused by an accident does not defeat coverage of an insured whose preexisting condition contributed to his injury unless the policy documents conspicuously set forth this exclusion.

Weis v. Accidental Death & Dismemberment Ben. Plan of Kaiser Foundation Health Plan Inc. 442 F.Supp.2d 850 (N.D.Cal.,2006)

In Saltarelli, we allowed an insured to recover for his medical expenses relating to a preexisting cancer despite an ERISA policy clause excluding coverage for "pre-existing conditions," finding that the exclusion, buried amid definitions in the policy, "was not clear, plain, and conspicuous enough to negate [a] layman['s] ... objectively reasonable expectations of coverage

McClure v. Life Ins. Co. of North America 84 F.3d 1129, *1135 (C.A.9 (Nev.),1996)

Pre-existing Conditions: No payment will be made for services or supplies for the treatment of a Pre-existing Condition during a period of six (6) months following your Effective Date. This limitation does not apply to a child born to or newly adopted by an enrolled Policyholder or enrolled spouse. However, we may apply Creditable Coverage to satisfy or partially satisfy the six (6) month period if the length of time between the ending date of your prior coverage and your Effective Date under this Policy did not exceed sixty-two (62) days. Pre-existing Condition means an illness, injury, disease or physical condition for which medical advice, diagnosis, care or treatment, including the use of Prescription Drugs was recommended or received from a licensed health care provider during the six (6) months immediately preceding the Insured's Effective Date of coverage. ---Blue Cross CA Individual Hospital Plan---