The opinion of the court was delivered by: F. STEELE LANGFORD
On March 4, 1993, this Court considered memoranda submitted on the papers by the parties pursuant to Local Rule 220-1 to determine the standard of judicial review in this ERISA case. Attorney for plaintiff KEVIN S. PETERS is Thomas Edward Wall, Esq. Attorney for defendant LIFE INSURANCE COMPANY OF NORTH AMERICA is John Lockley, Esq.
After considering the papers submitted and the record in the case, the Court rules that the standard of review in this case is a de novo trial in which new evidence may be admitted. The Court's ruling is based on the following:
Plaintiff was hired by Defendant San Francisco Federal Bank (SFFB) on October 3, 1988. Defendant's disability benefits program limits certain disability claims made during the first twelve months (the "limitation period") after the effective date of the program. The effective date for Plaintiff was February 1, 1989. The limitation is based on three questions:
1. Did the claimed disability begin during the limitation period?
2. Did the insured receive medical treatment, medication or advice during the ninety days prior to the beginning of the limitation period (in this case November 3, 1988 through January 31, 1989)?
3. Were any of the conditions for which the insured received medical attention during the ninety day period a condition that caused or resulted in the claimed disability?
If the answer to all three questions is "yes," the plan allows the insurer to deny the disability benefits claim.
Plaintiff filed a claim for disability benefits due to Hodgkin's Disease on March 1, 1990. Plaintiff admits this disability began during the limitation period, so the answer to question one is "yes." The parties also agree that Plaintiff received medical attention during the ninety day period in question, so the answer to question two is "yes."
However, the parties disagree on the answer to question three, specifically which conditions the Plaintiff was treated for during the ninety day period ending January 31, 1989 and whether those conditions caused or resulted in his Hodgkin's Disease.
Defendant denied Plaintiff's claim on September 7, 1990 and the appeal on January 28, 1991. The denials were based on the policy's pre-existing condition limitation, citing medical treatment Plaintiff received in the month of January, 1989.
The record before the plan administrator at the time Plaintiff's claim was denied does not include any physician reports that directly address whether Plaintiff's medical conditions for which he received treatment during the crucial ninety day period are related to his Hodgkin's ...