In the world of ERISA law, the “pre-existing condition” exclusion is often a battleground of policy interpretation and semantics. However, a recent decision by the United States Court of Appeals for the Eleventh Circuit, Johnson v. Reliance Standard Life Insurance Company 159 F.4th 1304 (11th Cir. 2025), has provided a significant victory for policyholders by clarifying the limits of an insurer’s power to retroactively link vague symptoms to an undiagnosed disease. The court’s ruling emphasizes that for an exclusion to stick, there must be a genuine connection between the treatment received and the sickness causing disability itself—not just a backward-looking reinterpretation of symptoms.

The Long Road to a Diagnosis

Cheriese Johnson’s ordeal began in December 2015, months before she was hired by The William Carter Company and enrolled in a long-term disability (LTD) plan through Reliance Standard Life Insurance Company (Reliance Standard). Between July and October 2016—a crucial “lookback period” for her policy—she visited numerous doctors for a host of “garden-variety ailments,” including nausea, fatigue, and joint swelling. Despite receiving ten different diagnoses during this time, from helicobacter pylori to edema, none of her physicians suspected the rare autoimmune disease she had: scleroderma.

By January 2017, Johnson was “totally disabled” and unable to work. It was not until a lung biopsy in February 2017 that the scleroderma was finally discovered. Reliance Standard denied her claim for LTD benefits, arguing that because her symptoms during the lookback period were not inconsistent” with scleroderma, the disease was a pre-existing condition. After a district court sided with the insurer, Johnson appealed to the Eleventh Circuit.

The “For Which” Analysis

The heart of the case rested on the policy’s definition of a pre-existing condition: “any Sickness or Injury for which the Insured received medical Treatment, consultation, care or services” during the lookback period. The court focused heavily on the word “for,” noting that it “connotes intent” and indicates the “object, aim, or purpose of an action.” Applying this “ordinary and popular” meaning, the majority concluded that Johnson could not have received treatment for scleroderma because neither she nor her doctors knew or even suspected the condition existed at the time.

The court was biting in its rejection of Reliance Standard’s broader view. The majority noted that if an insurer could deny benefits for any symptom later deemed “not inconsistent” with a diagnosis, they could “deny coverage for a brain tumor if the doctor encouraged a patient with headaches to drink more water” during the lookback period. The court stressed that while Johnson was treated for symptoms like fatigue and nausea, those “symptoms are not the disease.” The Eleventh Circuit ultimately reversed the summary judgment in favor of Reliance Standard and remanded the case.

Arbitrary and Capricious Reasoning

Under the Eleventh Circuit’s unique “six-step dance” for ERISA reviews, the court found that Reliance Standard’s decision was not just wrong, but unreasonable. The court held that the insurer’s interpretation “completely elides the distinction between receiving medical care for symptoms not inconsistent with a preexisting condition and receiving medical care for a preexisting condition itself.” By attempting to “warp” the policy language into a pre-existing-symptom exclusion, Reliance Standard acted in an arbitrary and capricious manner.

The court further criticized the use of ex post facto analysis to bridge the gap between a patient’s symptoms and an eventual diagnosis.

Key Takeaways for ERISA Practitioners

The Johnson case provides several critical lessons for both insurers and plan participants:

• “For Which” Means Intent: The phrase “for which” implies that the doctor or patient had a specific condition in mind. You cannot provide treatment “for” a condition that is entirely unsuspected.
• Symptoms vs. Sickness: Vague, non-specific symptoms (like fatigue or coughing) that could point to many different ailments are generally insufficient to trigger a pre-existing condition exclusion for a specific, later-diagnosed disease.
• No Ex Post Facto Denials: Insurers cannot rely on “backward-looking reinterpretation of symptoms” to justify a denial if there was no evidence that the possibility of the disease “ever entered the minds” of the doctors during the lookback period.

Conclusion

This decision serves as a stern reminder that while LTD policies grant insurers significant discretion, that discretion is not absolute. As the court noted, deferential review is not no review, and insurers cannot rewrite their policies on the fly to exclude claims based on backward-looking logic. For Cheriese Johnson and others facing rare, difficult-to-diagnose diseases, the ruling ensures that the pre-existing condition shield cannot be used as a sword to cut off legitimate benefits.