The Plaintiff’s claim for long-term disability benefits under a group policy of insurance issued by the Defendant was dismissed. The court held that a pre-existing condition exclusion clause was operative where symptoms of a disorder were exhibited during the applicable waiting period even though the ultimate diagnosis of the condition was delayed until after the expiry of the waiting period.

29. March 2004 0

Van Maele v. Alberta Blue Cross Benefits Corp., [2004] A.J. No. 367, Alberta Court of Queen’s Bench

The Plaintiff was diagnosed and treated for a cluster of illnesses and symptoms both before and during the three-month waiting period for his group policy of disability insurance. The policy, issued by Alberta Blue Cross, contained an exclusion clause which provided that long-term disability benefits were not payable for any disability caused by or resulting from a pre-existing condition. A “pre-existing condition” was defined in the policy as follows:

A pre-existing condition means sickness or injury for which the employee, during the three months immediately prior to the effective date of long-term disability coverage has received medical treatment, consultation, care or services (including diagnostic measures) or has been prescribed medication.

The Plaintiff’s constellation of symptoms, including asthma, a back condition and depression, were eventually recognized as symptoms of Cushing’s Syndrome and the diagnosis of this condition was made after the expiry of the waiting period. However, it was clear that the Plaintiff had received treatment and undergone diagnostic testing with respect to the constellation of symptoms both prior to and during the waiting period.

The court held that the exclusion clause could not be avoided by the Plaintiff as the presence of symptoms of Cushing’s Syndrome during the waiting period was sufficient ground to defeat the claim notwithstanding the delay in making the ultimate diagnosis. The court stated that to find otherwise would:

  1. Defeat the underlying commercial purpose of insurance by making a defendant a surety rather than a calculated risk-taker;
  2. Diminish the importance of the reasonable expectations of the parties as the insured was aware of the symptoms he had during the waiting period; and
  3. Permit unequal treatment of claimants simply on the basis of the competency and skill of their diagnosticians.

In the result, the Plaintiff’s claim was dismissed with costs payable to the Defendant.

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