Apples and Vitamin A In ERISA

As we have said many times before, ERISA is a technical piece of legislation, but sometimes just plain common sense saves the day. Such was the case with Marc Kutten who disputed with his insurer whether he was entitled to LTD benefits of $1000 per month or $6000 per month. Such a difference is no small potatoes to a man who can no longer work. Kutten v. Sun Life Assur. Co. of Canada, 2013 WL 2457182 (E. D. Mo.).

Mr. Kutten had been taking an over the counter Vitamin A supplement for many years, recommended for retinitis pigmentosa (not prescribed), by his doctor. Under the terms of his employer’s new policy, he would be entitled to $1000 monthly if he was found to have a pre-existing condition rather the $6000 monthly if there was no preexisting condition.

Sun Life reduced his LTD claim on the ground that taking the Vitamin A supplement constituted “medical treatment” received during the 3 months prior to the effective date of his employer’s new policy and therefore he was only entitled to receive the $1000 benefit under his employer’s old policy.

Even though the Court gave deference to Sun Life, see Firestone v. Bruch, 489 U.S. 101 (1989), it found the insurer’s “medical treatment” denial unreasonable. The policy defined “medical treatment” and “prescribed drugs” as separate and distinct bases upon which to find a pre-existing condition which would invalidate the new policy. The Court found that taking a vitamin supplement could not be considered a “medical treatment”.

At best, it could be a basis for a “prescribed drugs or medicines” denial of a claim as a preexisting condition as defined in the policy.

But, even if Sun Life had actually denied the claim on that basis the Court’s common sense analogy prevented a denial:

“…Prescribed drugs or medicines generally require that a person have interacted with a medical professional, at least when the initial prescription is given. Vitamin supplements, however, require no such medical intervention. A doctor recommending a person take Vitamin A for retinitis pigmentosa is more akin to a doctor suggesting to someone with digestive issues eat apples because they are high in fiber than it is like receiving a prescribed drug…”

The Court ordered judgment for Mr. Kutten so he will receive his $6000 month.

As an aside on this ruling we commend Judge Katherine Perry’s courage in following ERISA precedent by strictly adhering to policy language as called for in the recent case of U.S. Airways v. McCutchen, 133 S. Ct. 1537 (2013).

It is obvious from the facts of the case that Mr. Kutten did indeed have a preexisting condition, retinitis pigmentosa. But the facts in Kutten were clearly not covered by the definition of “preexisting condition” in the policy. So, enforcing the language of the policy as written, the Court found for claimant.

Bravo, Judge Perry.