               Case: 16-11125      Date Filed: 08/31/2017      Page: 1 of 25


                                                                 [DO NOT PUBLISH]



                 IN THE UNITED STATES COURT OF APPEALS

                           FOR THE ELEVENTH CIRCUIT
                             ________________________

                                    No. 16-11125
                              ________________________

                      D.C. Docket No. 8:15-cv-00988-JSM-TGW



JULISSA BRADSHAW,

                                                        Plaintiff - Appellant,

versus

RELIANCE STANDARD LIFE INSURANCE COMPANY,

                                                        Defendant - Appellee.

                              ________________________

                     Appeal from the United States District Court
                         for the Middle District of Florida
                           ________________________

                                    (August 31, 2017)

Before ROSENBAUM and JILL PRYOR, Circuit Judges, and SCHLESINGER, *
District Judge.

ROSENBAUM, Circuit Judge:

         *
         Honorable Harvey E. Schlesinger, United States District Judge for the Middle District
of Florida, sitting by designation.
             Case: 16-11125     Date Filed: 08/31/2017   Page: 2 of 25


      Plaintiff-Appellant Julissa Bradshaw had a healthy pregnancy and no other

pre-existing medical conditions when she bought a disability-insurance policy from

Defendant-Appellee Reliance Standard Life Insurance Company.             About six

months later, nine days after Bradshaw gave birth to her daughter, tragically,

Bradshaw suffered a debilitating stroke. So Bradshaw filed a claim for long-term

disability benefits with Reliance, which Reliance denied. It denied the claim

because of Bradshaw’s healthy pregnancy at the time she purchased her policy;

Reliance asserted that qualified as a pre-existing condition that “contributed to”

Bradshaw’s stroke.

      Bradshaw brought suit alleging violations of the Employee Retirement

Income Security Act of 1974, as amended 29 U.S.C. §§ 1001, et seq. (“ERISA”).

Reliance moved for summary judgment, and the district court granted its motion,

concluding that Reliance’s decision denying benefits was reasonable.

      But our review of Reliance’s decision reveals that Reliance applied the

wrong standard in construing the language of its pre-existing-condition

exclusionary provision.    And when we apply the correct standard, we must

conclude that Reliance’s determination was unreasonable. So we reverse and

remand the case to the district court for an award of ERISA benefits.




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                                        I.

                                       A.

      Bradshaw worked for Pyramid Healthcare Solutions, Inc., as a medical

biller. As part of Bradshaw’s employment benefits, Pyramid offered her both

short-term and long-term disability coverage through a policy administered by

Reliance (the “Policy”). Under the terms of the Policy, Bradshaw’s disability

coverage became effective on May 1, 2013.

      At the time she was hired, Bradshaw was a few weeks pregnant. For the

next seven months, Bradshaw’s pregnancy proceeded without incident.

      On November 4, 2013, however, Bradshaw went to the hospital complaining

of a headache, elevated blood pressure, and swelling of her hands and feet.

Doctors diagnosed her with “mild preeclampsia” and placed her on bedrest.

      Two days later, when Bradshaw was 38 weeks and 2 days pregnant, she

returned to the hospital to undergo childbirth induction because of “mild

preeclampsia.” On November 8, 2013, Bradshaw gave birth to a healthy baby girl.

No complications were present during the birth, and Bradshaw was released from

the hospital on November 10, 2013, with stable blood pressure.

      A week after her discharge, on November 17, 2013, Bradshaw returned to

the hospital, complaining of a headache, dizziness, and nausea.         Bradshaw




                                        3
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underwent an MRI, and it revealed a “massive left cerebellar infarct,” more

commonly known as a stroke.

       Dr. Harold Colbassani, Jr., performed surgery to address the stroke.

Bradshaw had a craniectomy, 1 partial resection of her cerebellar hemisphere, and

the placement of ventriculostomy. 2 She remained at the hospital until December 1,

2013, at which time she was released. The hospital’s discharge summary reveals

that doctors diagnosed Bradshaw as having suffered a “[c]erebrovascular

accident,” “[l]eft vertebral artery dissection,” and “[h]ypertension.” The summary

identified “[h]ypertension” as “contributory to [Bradshaw’s] stroke,” and it noted

“[t]here was likely some residual deficit from her preeclamptic childbirth.”

       Bradshaw suffered deficits following the surgery. So she submitted a claim

for long-term disability benefits with Reliance. She asserted an inability to work

as a result of pain, confusion, anxiety, dizziness, forgetfulness, and coordination

problems caused by the stroke she suffered on November 17, 2013. Attached to

her claim form was paperwork that neurologist Ajay Arora completed on February

20, 2014. Dr. Arora confirmed that Bradshaw had suffered a cerebellar stroke with

       1
          In a craniectomy, part of the skull is removed to relieve pressure on the brain.
https://www.urmc.rochester.edu/neurosurgery/for-patients/treatments/craniectomy.aspx (last
visited Aug. 17, 2017).
       2
         In a ventriculostomy, a small catheter is placed into the brain, allowing medical
professionals to drain fluid from the brain in carefully controlled amounts. Steven Senne RN,
BSN, Head Drains: A Guide to Ventriculostomy Therapy for Patients and Families in the
Neurosurgery Intensive Care Unit (Dep’t of Neurosurgery, University of Michigan Health
System), at 5 (2012), http://www.med.umich.edu/1libr/neurosurgery/HeadDrains.pdf.
                                             4
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symptoms first appearing on November 17, 2013. 3 He further opined that, because

of problems with balance, coordination, and dizziness, Bradshaw was unable to

return to work.

                                              B.

       Since Bradshaw filed an application for disability benefits within the first

twelve months of her employment, Reliance conducted an investigation to

determine whether Bradshaw’s disability was subject to the terms of a pre-existing-

condition exclusion contained in the Policy. The exclusion in the Policy provides,

              PRE-EXISTING CONDITIONS: Benefits will not be
              paid for a Total Disability:

                  (1) caused by;
                  (2) contributed to by; or
                  (3) resulting from

              a Pre-existing Condition unless the Insured has been
              Actively at Work for one (1) full day following the end
              of twelve (12) consecutive months from the date he/she
              became an Insured.

According to the Policy,

              “Pre-Existing Condition” means any Sickness or Injury
              for which the Insured received medical Treatment,
              consultation, care or services, including diagnostic
              procedures, or took prescribed drugs or medicines, during
              the three (3) months immediately prior to the Insured’s
              effective date of insurance.


       3
         Dr. Arora’s notes list November 18 as the date of the first known symptoms, but this
appears to be a scrivener’s error.
                                              5
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The Policy, in turn, notes that the term “Sickness” “includes pregnancy . . . .”

      The three months before Bradshaw’s effective date of insurance ran from

February 1, 2013, through May 1, 2013. This period (and only this period)—better

known as the “look-back period”—is the timeframe Reliance was allowed to

consider when it evaluated whether Bradshaw suffered from a “pre-existing

condition.”

      On June 2, 2014, Reliance denied Bradshaw’s claim because it concluded

that Bradshaw’s disability from the stroke resulted from a “pre-existing condition”

for which she received treatment during the “look-back period”—namely,

pregnancy. The denial letter stated,

              Our investigation has revealed that you received medical
              treatment, consultation, care or services, or took
              prescribed drugs or medicines for pregnancy during the
              period from February 1, 2013 to May 1, 2013.
              Accordingly, your initial Sickness or Injury is considered
              to be Pre-existing and your claim for [long-term
              disability] benefits must be denied. We sincerely regret
              that our decision could not be more favorable.

Despite Reliance’s rejection of Bradshaw’s claim on the basis that her stroke-

related injuries were “caused by, contributed to by, or resulted from” her prior

pregnancy, the denial letter explicitly noted the progression of a “normal

pregnancy through November 4, 2013”—that is, more than six months after the

look-back period ended.



                                          6
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      On November 26, 2014, Bradshaw (who had by now retained counsel)

appealed Reliance’s denial of her claim, within Reliance’s appeal process. In the

appeal, Bradshaw emphasized that she had no problems with high blood pressure,

headaches, or stroke during the relevant “look-back period.” She contended that

Reliance’s decision to deny long-term disability benefits was wrong for many

reasons, including her belief that Reliance had improperly applied the pre-existing-

condition exclusion clause in her Policy. Bradshaw argued that Reliance failed to

evaluate whether Bradshaw had any symptoms or manifestations of high blood

pressure, headaches, preeclampsia, or stroke for which she received treatment

during the “look-back period.”

      In response to the appeal, Reliance asked Dr. Jason Pollock, a board-

certified doctor of obstetrics and gynecology, to perform an independent medical

review of Bradshaw’s records. After doing so, Dr. Pollock agreed that “no clinical

evidence suggest[ed] a neurovascular or hypertensive disorder” or preeclampsia

during the relevant “look-back period.” Nevertheless, Dr. Pollock concluded that

Bradshaw’s pregnancy and stroke were at least related because “[p]regnancy is

required for preeclampsia to develop, and certainly preeclampsia contributed to if

not caused her neurovascular accident. . . .” Significantly, however, Dr. Pollock

noted that “preeclampsia was in no way present nor could it have been effectively

predicted” during the “look-back period.”


                                          7
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       Reliance denied Bradshaw’s appeal, once again relying on the pre-existing-

condition exception in the Policy.          While the denial letter acknowledged that

Bradshaw did not have preeclampsia, high blood pressure, or any symptoms of

stroke during the “look-back period,” it noted that she received treatment for

pregnancy during this period. And because “preeclampsia is a condition related to

pregnancy,” and preeclampsia contributed to Bradshaw’s stroke, Reliance

concluded, Bradshaw’s stroke-related disability was not covered:

              The medical documentation supports that the conditions
              for which [Bradshaw] is alleging impairment were
              caused by or as a result of pregnancy. As the alleged
              impairing conditions were caused by or resulted from
              [Bradshaw’s] pregnancy, the claimed impairment is
              excluded from coverage and no benefits are payable.[4]

                                               C.

       On April 22, 2015, Bradshaw filed a two-count complaint in which she

alleged that Reliance violated § 1132(a)(1)(B) of ERISA when it denied her long-

term disability benefits. She based both claims on Reliance’s alleged improper

denial of benefits under the pre-existing-condition exclusion. Reliance filed a

motion for summary judgment.




       4
          Curiously, however, the denial letter noted that “[t]he condition for which your client
was indicating that she was unable to work was pregnancy and preeclampsia.” (Emphasis
added). This is incorrect since Bradshaw applied for long-term disability benefits based on only
the fact that she suffered a stroke.
                                               8
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      A magistrate issued a report and recommendation (“R&R”) recommending

that Reliance’s motion for summary judgment be granted. The magistrate judge

applied de novo review and concluded that Reliance’s denial of benefits under the

pre-existing-condition exclusion was not wrong and, even if it were, it was not

unreasonable. Significantly, however, the R&R did not include a warning that

failure to file written objections within fourteen days would waive objections.

When neither party filed written objections, the district court adopted the

magistrate judge’s R&R and entered judgment in favor of Reliance.

      Bradshaw filed a Motion for Reconsideration of the Judgment pursuant to

Rule 59(e), Fed. R. Civ. P., and simultaneously filed a Notice of Appeal of the

Final Judgment with this Court.       The district court denied the Motion for

Reconsideration.

                                        II.

      ERISA allows a person who is denied benefits under an employee benefit

plan to challenge that denial in federal court. Metro Life Ins. Co. v. Glenn, 554

U.S. 105, 108 (2008) (citing 29 U.S.C. § 1132(a)(1)(B)). The ERISA statute itself

does not provide a standard for courts reviewing the benefits decisions of plan

administrators. We have established and use a six-step test to evaluate a plan

administrator’s benefits decision:

         (1) Apply the de novo standard to determine whether the
         claim administrator's benefits-denial decision is “wrong”
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          (i.e., the court disagrees with the administrator’s decision); if
          it is not, then end the inquiry and affirm the decision.

          (2) If the administrator’s decision in fact is “de novo
          wrong,” then determine whether he was vested with
          discretion in reviewing claims; if not, end judicial inquiry
          and reverse the decision.

          (3) If the administrator's decision is “de novo wrong” and he
          was vested with discretion in reviewing claims, then
          determine whether “reasonable” grounds supported it
          (hence, review his decision under the more deferential
          arbitrary and capricious standard).

          (4) If no reasonable grounds exist, then end the inquiry and
          reverse the administrator’s decision; if reasonable grounds
          do exist, then determine if he operated under a conflict of
          interest.

          (5) If there is no conflict, then end the inquiry and affirm the
          decision.

          (6) If there is a conflict, the conflict should merely be a
          factor for the court to take into account when determining
          whether an administrator’s decision was arbitrary and
          capricious.

Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir. 2011) (per

curiam (citing Capone v. Aetna Life Ins. Co., 592 F.3d 1189, 1195 (11th Cir.

2010)).

      We review de novo a district court’s grant of summary judgment affirming a

plan administrator’s ERISA benefits decision, applying the same legal standards as

the district court. Blankenship, 644 F.3d at 1354. Our review of an ERISA

benefits decision is “limited to consideration of the material available to the
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administrator at the time it made its decision.” Id. (citing Jett v. Blue Cross & Blue

Shield of Ala., Inc., 890 F.2d 1137, 1140 (11th Cir. 1989)).                      Whether an

administrator’s decision is either de novo correct or reasonable is a question of law.

Id.

                                                III.

                                                A.

       Before turning to the merits of the appeal, we first address Reliance’s

contention that Bradshaw waived the arguments she raises on appeal because she

failed to present them to the district court. In particular, Reliance complains that

Bradshaw cites to cases in her initial brief that she did not cite in responding to the

motion for summary judgment.

       Of course, it is well settled by now that we generally will not consider a

legal issue unless it was presented to the trial court. Ramirez v. Sec’y, U.S. Dep’t

of Transp., 686 F.3d 1239, 1249 (11th Cir. 2012) (citations omitted). But here,

Bradshaw did not waive her arguments on appeal because she fairly presented

them to the district court.5


       5
         Bradshaw did not file objections to the magistrate judge’s R&R. Eleventh Circuit Rule
3-1 provides, in relevant part, “A party failing to object to a magistrate judge’s findings or
recommendations contained in a report and recommendation in accordance with the provisions
of 28 U.S.C. § 636(b)(1) waives the right to challenge on appeal the district court’s order based
on unobjected-to factual and legal conclusions if the party was informed of the time period for
objecting and the consequences on appeal for failing to object.” 11th Cir. R. 3-1 (emphasis
added); see also Resolution Trust Corp. v. Hallmark Builders, Inc., 996 F.2d 1144, 1149 (11th
Cir. 1993) (per curiam). Here, however, the magistrate judge’s R&R did not include any
                                               11
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       Bradshaw’s overarching argument on appeal is that Reliance incorrectly and

unreasonably interpreted the Policy by applying the pre-existing-condition

exception to deny long-term disability benefits. In Bradshaw’s view, the exception

does not apply because she did not receive treatment for a stroke during the “look-

back period.” She also urges us to find Reliance’s interpretation of the Policy to be

unreasonable based on its attenuated definition of causation. Bradshaw fairly

presented both of these arguments in the district court.

       First, when Bradshaw opposed Reliance’s motion for summary judgment,

she asserted that Reliance’s decision was de novo wrong, clearly arguing that

Reliance had misapplied the pre-existing-condition exception. Bradshaw disputed

that her pregnancy was related to her stroke and argued in the alternative that

Reliance used a “leap of logic [and] stacked inferences in concluding that the

preeclampsia was the cause of the stroke, and failed to consider any other

intervening cause.”         She also contended that Reliance’s decision was not

reasonable because it ignored that Bradshaw had no symptoms of and received no

treatment for stroke during the “look-back period.” 6



provision warning the parties that they had fourteen days to file written objections to the findings
in the R&R or that failure to do so would waive objections. As a result, Bradshaw’s failure to
assert objections to the R&R does not deprive her of the ability to raise her arguments on appeal.
       6
         In her supplemental filing in opposition to the motion for summary judgment, Bradshaw
similarly argued that Reliance predicated its denial of long-term disability benefits on an
improper application of the pre-existing-condition exclusion clause in the policy. Again,
Bradshaw claimed Reliance improperly stacked, without support, inferences that Bradshaw’s
                                                12
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        While the manner in which Bradshaw presents her arguments on appeal is

not precisely the same as it was at the district court level, it need not be. A party

may take a “new approach” to an issue preserved for appeal; she may improve how

she articulated the same arguments when she was before the district court, and a

good attorney often does. “Once a federal claim is properly presented, a party can

make any argument in support of that claim; parties are not limited to the precise

arguments they made below.” Yee v. City of Escondido, Cal., 503 U.S. 519, 534

(1992) (citations omitted). While new claims or issues may not be raised for the

first time on appeal, new arguments relating to preserved claims may. Pugliese v.

Pukka Dev., Inc., 550 F.3d 1299, 1304 n.3 (11th Cir. 2008) (citing Yee, 503 U.S. at

534).

        Nor do Hamilton v. Southland Christian School, Inc., 680 F.3d 1316, 1319

(11th Cir. 2012) and Singh v. U.S. Attorney General, 561 F.3d 1275, 1278 (11th

Cir. 2009) (per curiam), change the analysis, as Reliance suggests. Hamilton and

Singh relate to a party’s failure to cite case law in an opening brief on appeal, so

they are inapplicable here. See Hamilton, 680 F.3d at 1319; and Singh, 561 F. 3d




pregnancy caused or contributed to the disabling condition of preeclampsia and that
preeclampsia or Bradshaw’s pregnancy (or both) caused her stroke. Bradshaw also alleged that
Reliance failed to evaluate whether she had symptoms of high blood pressure, headaches, or
stroke for which she received treatment during the “look-back period.”
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at 1278. A party is entitled to rely on new cases as long as the issues on appeal

were preserved. Here, they were. 7

                                               B.

       We now turn our attention to the merits of this appeal—whether Reliance

reasonably interpreted the Policy when it denied Bradshaw long-term disability

benefits under the Policy’s pre-existing-condition exclusion.

       Both parties agree that the plan gives Reliance discretion to interpret the

Policy. Reliance also appears to be responsible for paying claims, and it had

authority to determine eligibility under the plan. This means that Reliance acted

under an apparent conflict of interest. Under these circumstances, we apply the

arbitrary-and-capricious standard, taking Reliance’s conflict of interest into

consideration. Under this standard of review, our role “is limited to determining

whether [the administrator's] interpretation was made rationally and in good

faith—not whether it was right.” Anderson v. Ciba–Geigy Corp., 759 F.2d 1518,

1522 (11th Cir.), cert. denied, 474 U.S. 995 (1985) (citations omitted).

       In the context of ERISA cases, the arbitrary-and-capricious standard is

interchangeable with the abuse-of-discretion standard. Blankenship, 644 F.3d at
       7
          Even if Bradshaw had failed to properly preserve the issues she raises on appeal, we
could still exercise our discretion to consider them because they involve a pure question of law.
Where an appeal involves a pure question of law, we may consider that question if we determine
that a refusal to do so could result in a miscarriage of justice, that “the proper resolution is
beyond any doubt,” or that the issue involves “significant questions of general impact or of great
public concern. Ramirez, 686 F.3d at 1250 (citation and quotation marks omitted). Here, at least
one of these circumstances applies.
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1355 n.5 (citation omitted). Nevertheless, a ruling based on an erroneous view of

the law necessarily is arbitrary and capricious. Cf. Highmark Inc. v. Allcare Health

Mgmt. Sys., Inc., 134 S. Ct. 1744, 1748 n.2 (2014) (quoting Cooter & Gell v.

Hartmarx Corp., 496 U.S. 384, 405 (1990)) (“A district court would necessarily

abuse its discretion if it based its ruling on an erroneous view of the law . . . .”).

      A plaintiff suing under ERISA to recover benefits bears the burden of

proving her entitlement to those benefits. Glazer v. Reliance Standard Life Ins.

Co., 524 F.3d 1241, 1247 (11th Cir. 2008) (citation omitted); Horton v. Reliance

Standard Life Ins. Co., 141 F.3d 1038, 1040 (11th Cir. 1998) (per curiam) (citation

omitted). Nevertheless, where an insurer contends that an exclusion contained in

the policy applies to deny benefits, the burden generally falls on the insurer to

prove the exclusion prevents coverage.           Horton, 141 F.3d at 1040 (citation

omitted).

      Here, it is undisputed that Bradshaw became “[t]otally [d]isabled,” as

defined in the Policy, as a result of her stroke.           So the sole issue for our

consideration concerns whether Reliance was reasonable in its interpretation and

application of the pre-existing-condition exclusion.

      We have instructed that “[w]hen ERISA governs, federal substantive law

developed in this area of contract law controls.” Hauser v. Life Gen. Sec. Ins. Co.,

56 F.3d 1330, 1333 (11th Cir. 1995). ERISA is silent on matters of contract


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interpretation or construction. Dixon v. Life Ins. Co. of N. Am., 389 F.3d 1179,

1183 (11th Cir. 2004). But we are not left without guidance since “[c]ourts have

the authority to develop a body of federal common law to govern issues in ERISA

actions not covered by the act itself.” Horton, 141 F.3d at 1041 (internal quotation

marks and citation omitted). When creating this “body of common law, federal

courts may look to state law as a model because of the states’ greater experience in

interpreting insurance contracts and resolving coverage disputes.” Id.

      In order to decide whether a particular rule should become part of ERISA’s

common law, courts must examine whether the rule, if adopted, would further

ERISA’s scheme and goals. Id. (citation omitted). ERISA’s two central goals

include (1) protection of the interests of employees and their beneficiaries in

employee benefit plans and (2) uniformity in the administration of employee

benefit plans. Id.(citation omitted); see also Dixon, 389 F.3d at 1184.

      With these guidelines in mind, we turn to Florida law. Under Florida law,

we must construe insurance contracts “in accordance with the plain language of the

policies as bargained for by the parties.” Auto-Owners Ins. Co. v. Anderson, 756

So. 2d 29, 34 (Fla. 2000). When interpreting insurance contracts, “the language of

the policy is the most important factor.” Taurus Holdings, Inc. v. U. S. Fid. and

Guar. Co., 913 So. 2d 528, 537 (Fla. 2005). The plain meaning of the provision

and how an ordinary person would read the provision govern. See Union Am. Ins.


                                         16
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Co. v. Maynard, 752 So. 2d 1266, 1268 (Fla. 4th Dist. Ct. App. 2000). The insurer

must make clear what is excluded from coverage. Id. (citation omitted). And

under ERISA, clauses that exclude coverage are interpreted narrowly. See Fought

v. UNUM Life Ins. Co. of Am., 379 F.3d 997, 1011 (10th Cir. 2004) (per curiam)

(citing 29 C.F.R. § 2590.701-3(a)(1)(i)(C)), abrogated in part on other grounds by

Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (2008); Critchlow v. First UNUM Life

Ins. Co. of Am., 378 F.3d 246, 256 (2d Cir. 2004).

          Here, the Policy permits Reliance to deny long-term disability benefits for a

total disability that was “caused by,” “contributed to by,” or “resulting from” 8 a

pre-existing condition unless the insured has been actively at work for a full year.

Reliance claims that it reasonably applied the exclusion because Bradshaw had not

been employed for a full year, was pregnant during the “look-back period,” and her

pregnancy “played a part in producing” the stroke. More specifically, Reliance

justifies its denial of Bradshaw’s claim since it views her pregnancy as having

“contributed to” her stroke.

          We disagree and find Reliance’s interpretation of the pre-existing-condition

clause and, in particular, the phrase “contributed to,” to be both unreasonable as a

matter of law and at odds with the goals of ERISA.



          8
              The terms “caused by,” “contributed to by,” or “resulting from” are not defined in the
Policy.
                                                  17
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      Our reasoning in Dixon leads naturally to this conclusion. In Dixon, Horace

Dixon had an accidental-death policy. Dixon, 389 F.3d at 1180. His policy

provided benefits for bodily injuries “caused by an accident which happens while

an insured is covered by the policy” and “which, directly and from no other

causes, resulted in a covered loss.” Id. (emphasis added).

      Unfortunately, Mr. Dixon died in a single-car accident, though the cause of

his death was heart failure—a fact the parties did not dispute. Id. at 1181. Annie

Dixon, the beneficiary of the policy, claimed that her husband’s heart attack, and

therefore his death, was caused by a car accident, entitling her to coverage under

an accidental-death provision of the insurance policy. Id. at 1180.

      We considered whether, and to what extent, language in an ERISA policy

requiring loss “directly and from no other causes” precluded recovery for

accidental injury where some pre-existing condition was a “contributing factor” to

the loss. Id. at 1183. After reviewing other circuits’ approaches to an inquiry of

this nature, we noted our agreement with the reasoning of the Fourth Circuit in

Adkins v. Reliance Standard Life Ins. Co., 917 F.2d 794 (4th Cir. 1990). The

Fourth Circuit explained—and we agreed—that “adopt[ing] a strict and

unambiguous interpretation of ‘directly and independent of all other causes’ would

yield untenable results.” Dixon, 389 F.3d at 1184. We approvingly noted the

Fourth Circuit’s reasoning: “[T]o recover under such policies as the one here


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involved, and with such a stringent construction, a claimant would have to be in

perfect health at the time of his most recent injury before the policy would benefit

him, and that, of course, is a condition hardly obtained, however devoutly to be

wished.” Id. (quoting Adkins, 917 F.2d at 796) (quotation marks omitted).

      Based on Adkins’s analysis, we then adopted a “substantially contributed”

test. Under this test, the language “directly and from no other causes” precludes

recovery for otherwise covered events only where another condition “substantially

contributed” to the loss. Id. So the mere fact that another factor contributed to the

loss in some way is not enough to trigger the exclusionary clause.           As we

explained, “The ‘substantially contributed’ test gives this exclusionary language

reasonable content without unreasonably limiting coverage.        And, it advances

ERISA’s purpose to promote the interests of employees and their beneficiaries.”

Id.

      The exclusion in the Policy at issue here suffers from the same problem as

that at issue in Dixon. Just as the language of the Dixon policy—“directly and

from no other causes”—strictly construed, required the ruling out entirely of any

health conditions that in some way might have contributed to the loss, the language

of the Policy here—excluding coverage if the loss is “(1) caused by; (2)

contributed to by; or (3) resulting from a Pre-existing Condition”—strictly

construed purports to preclude coverage if any pre-existing health conditions in


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some way—no matter how remote—might have contributed to the loss. So like

the Fourth Circuit noted about the policy language at issue there, and as we agreed

in Dixon, the Policy language at issue here would essentially require a claimant “to

be in perfect health at the time of [obtaining the policy] before the policy would

benefit him [during the succeeding twelve months], and that, of course, is a

condition hardly obtained, however devoutly to be wished.” Dixon, 389 F.3d at

1184 (quoting Adkins, 917 F.2d at 796).

      To avoid a construction of the Policy that renders it essentially meaningless

for the first twelve months of its existence, consistent with our reasoning in Dixon,

we must construe the language “caused by; contributed to by; or resulting from a

Pre-existing Condition” to exclude coverage for only those losses substantially

caused by, substantially contributed to by, or substantially resulting from a pre-

existing condition. This interpretation of the Policy language not only comports

with our precedent but it also advances ERISA’s clear purpose to provide greater

coverage to beneficiaries.

      The Tenth Circuit’s decision in Fought, likewise supports our conclusion. In

Fought, the Tenth Circuit analyzed a pre-existing-condition-exclusion clause

similar to the one at issue here: it stated that benefits would not be paid to the

insured for a disability that was “caused by, contributed to by, or resulting from

your . . . pre-existing condition.” Fought, 379 F.3d at 999.


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      Fought had coronary artery disease. She was admitted to the hospital for

unstable angina syndrome, which caused her to undergo an elective coronary artery

revascularization surgery requiring a special procedure (based on Fought’s

anatomy) to close the surgical wound. The wound became infected, requiring

additional surgery and ultimately resulting in disability. The insurer asserted that

but-for Fought’s coronary artery disease, none of the rest of the chain of events

resulting in total disability would have happened. Id. at 1009-1012.

      The Tenth Circuit rejected the insurance carrier’s but-for theory of causation

because accepting the insurer’s reasoning would “effectively render meaningless

the notion of the pre-existing condition clause by distending the breadth of the

exclusion.”    Id. at 1010.    As the court observed, “there were at least five

intervening stages between the pre-existing coronary artery disease and the

disability.” Id. This caused the Tenth Circuit to note that “[t]he exclusion cannot

merely require that the pre-existing condition be one in a series of factors that

contributes to the disabling condition; the disabling condition must be substantially

or directly attributable to the pre-existing condition.”     Id. (emphasis added)

(citation omitted).

      Here, Reliance attempts to make a similar “but-for” argument: it asserts that

but for Bradshaw’s pregnancy, she would not have developed high blood pressure;

and but for her high blood pressure, she would not have developed preeclampsia;


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and but for her preeclampsia, she would not have suffered a stroke; and finally, but

for her stroke, Bradshaw would not have become totally disabled. Like in Fought,

multiple stages intervened between Bradshaw’s healthy pregnancy and her total

disability. We reject Reliance’s position for the same reasons the Tenth Circuit

found Fought’s insurer’s argument unconvincing and because such a broad

construction of the exclusion runs directly counter to ERISA’s central goal of

protecting the interests of employees and their beneficiaries in employee benefit

plans. See Dixon, 389 F.3d at 1184–85.

      The record makes clear that the only condition Bradshaw had during the

“look-back period” was a healthy pregnancy.              On this record, Bradshaw’s

pregnancy cannot be said to have substantially contributed to her total disability.

      Bradshaw’s pregnancy was progressing well, with no sign of difficulty or

complication at all during the “look-back period.” She had no symptoms of stroke,

did not suffer from high blood pressure, and did not have preeclampsia. During

the relevant period, even Bradshaw’s doctors did not suspect that she would

develop high blood pressure, then experience preeclampsia, and then suffer a

stroke. Indeed, during the look-back period, the chances of stroke were so remote,

they were not even a consideration based on Bradshaw’s healthy pregnancy.

Pregnancy is neither a necessary precursor to stroke nor does pregnancy normally

develop or progress into stroke. To be sure, preeclampsia is a complication that


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can occur during pregnancy, but stroke is not a condition typically associated with

a healthy pregnancy, like Bradshaw had at the time of the look-back period. 9

       Connecting Bradshaw’s healthy pregnancy during the look-back period to

her ultimate disabling condition requires four links. On this record, that’s too

many. To view Bradshaw’s healthy pregnancy as a substantially contributing

factor to her disability simply requires too much attenuation. See, e.g., Fought,

379 F.3d at 1010 (finding five intervening stages between disease and disability to

be too attenuated). And because it cannot fairly be said that Bradshaw’s healthy

pregnancy substantially contributed to her disability, Reliance’s use of the pre-

existing condition exclusion to deny Bradshaw benefits was unreasonable.

       Nor does Reliance’s reliance on Dr. Pollock’s report affect the analysis.

First, Dr. Pollock never opined that pregnancy qualified as a pre-existing condition

or that it contributed to Bradshaw’s total disability. To the contrary, Dr. Pollock’s

remarks, when read as a whole, appear to reveal his belief that Bradshaw’s healthy

pregnancy was not a pre-existing condition that substantially contributed to

Bradshaw’s disability and that the exclusion should not apply.




       9
         Well   fewer    than    1%      of    pregnant    women   suffer    from    stroke.
See http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3137888/ (last visited August 17, 2017)
According to the American Stroke Association, approximately three-hundredths of a percent of
pregnant women in the United States suffered strokes in 2016.
See www.strokeassociation.org/idc/groups/stroke-public/@wcm/@hcm (last visited August 17,
2017).
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       Significantly, in response to a question asking whether Bradshaw received

consultation, care, or services “for a condition that caused, contributed to, or

resulted in the alleged impairment,” Dr. Pollock stated,

              The consultation for pregnancy was underway during this
              time frame but at this point there was no clinical
              evidence suggesting a neurovascular or hypertensive
              disorder.      Although pregnancy is required for
              preeclampsia to develop, and certainly preeclampsia
              contributed to if not caused [Bradshaw’s] neurovascular
              accident that resulted in long-term impairment,
              preeclampsia was in no way present nor could it have
              been effectively predicted during the [look-back period].

(Emphasis added).        At best, Dr. Pollock’s report opines that preeclampsia

contributed to Bradshaw’s total disability. But it concedes that preeclampsia was

not present during the “look-back period,” and preeclampsia does not typically

occur during pregnancy. 10 For these reasons, Dr. Pollock’s remarks do not support

a finding that Bradshaw had a pre-existing condition during the “look-back period”

that substantially contributed to her total disability.

                                            IV.

       We conclude that the district court erred when it granted summary judgment

in favor of Reliance. Reliance’s decision to deny Bradshaw’s claim was

unreasonable, based on a correct construction of the Policy’s pre-existing-

       10
          Between 96% and 97% of pregnant women in the United States proceed to delivery
without developing preeclampsia.
See https://www.uptodate.com/contents/preeclampsia-beyond-the-basics (last visited August 31,
2017).
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condition exclusion. We therefore reverse and remand the case to the district court

for an award of ERISA benefits.

      REVERSED AND REMANDED.




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