The Eleventh Circuit Court of Appeals has sided with Cheriese Johnson in her battle with Reliance Standard Life Insurance Company, ruling that the insurance company wrongly denied her long-term disability benefits. The case centers on the interpretation of a “preexisting condition” clause in Johnson’s insurance policy and whether her symptoms, which eventually led to a diagnosis of scleroderma, were treated during a specific lookback period before her policy took effect.
The court’s decision, handed down on November 21, 2025, reverses a lower court’s grant of summary judgment in favor of Reliance Standard. The judges determined that Reliance Standard’s interpretation of its own policy was unreasonable, and therefore, its denial of benefits was deemed arbitrary and capricious.
The Backstory
Johnson began experiencing various symptoms, including coughing, pain in her hands and feet, nausea, and fatigue, in late 2015. Over the following months, she consulted with numerous doctors and underwent various tests. During this time, she received several diagnoses, including fibromyalgia and borderline lupus erythematosus. However, doctors did not diagnose her with scleroderma, a rare autoimmune disease that causes the hardening and thickening of skin and other tissues.
In July 2016, Johnson took a job with The William Carter Company and purchased a long-term disability insurance policy from Reliance Standard. The policy became effective on October 12, 2016.
By January 2017, Johnson was unable to work due to her health issues. She filed a claim with Reliance Standard for long-term disability benefits, citing her scleroderma diagnosis. However, Reliance Standard denied her claim, citing the policy’s “Pre-existing Conditions Limitation.” This clause allowed the company to deny benefits if the disability was caused by a pre-existing condition treated during the three months before the policy’s effective date. This three-month period is known as the “lookback period,” which in Johnson’s case, ran from July 12, 2016, to October 12, 2016.
The Policy’s Fine Print
The crux of the case hinged on the precise wording of the policy. The policy defined a “Pre-existing Condition” as “any Sickness or Injury for which the Insured received medical Treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines.” The key phrase here, according to the court, is “for which.”
Johnson argued that she couldn’t have received medical treatment “for” scleroderma during the lookback period because no one knew she had the condition until after the lookback period ended. Reliance Standard, however, took a broader view, stating that benefits could be denied if Johnson was treated for any symptoms during the lookback period that were not inconsistent with scleroderma, even if no one suspected she had the disease.
The Court’s Reasoning
The Eleventh Circuit sided with Johnson, finding Reliance Standard’s interpretation to be incorrect. The court’s opinion, authored by Judge Grant, focused heavily on the word “for.” The court explained that “for” implies intent, purpose, or the object of an action. The court reasoned that because Johnson’s doctors did not intend to treat her for scleroderma during the lookback period, and in fact, did not even suspect she had the condition, the denial of benefits was improper.
The court also noted that the symptoms Johnson experienced during the lookback period, such as nausea, fatigue, and swelling, were general and could be attributed to various ailments. The court emphasized that the doctors did not diagnose scleroderma during this period, and therefore, Johnson was not treated “for” the condition.
The court applied a six-step framework used in the Eleventh Circuit for reviewing ERISA (Employee Retirement Income Security Act) benefit decisions. The court found that Reliance Standard’s decision was “de novo wrong,” meaning the court disagreed with the company’s interpretation of the policy. The court also determined that Reliance Standard had discretion to interpret the policy. However, the court concluded that Reliance Standard’s interpretation was unreasonable, which meant the denial of benefits was arbitrary and capricious.
The Implications
This ruling clarifies the interpretation of “preexisting condition” clauses in disability insurance policies. It underscores the importance of the word “for” in determining whether treatment was provided for a specific condition. Insurance companies cannot deny benefits based on treatment for symptoms that might later be linked to a condition if the condition itself was not suspected or diagnosed during the relevant lookback period.
The court’s decision serves as a reminder that insurance companies must interpret their policies reasonably and cannot deny benefits based on a strained or overly broad interpretation of the policy language.
The court reversed the district court’s decision and sent the case back for further proceedings consistent with its opinion, meaning Johnson’s claim for benefits will now be reconsidered.