Intent Matters: The Eleventh Circuit Narrows ERISA “Preexisting Condition” Exclusions in Johnson v. Reliance Standard

I. Introduction

In Cheriese D. Johnson v. Reliance Standard Life Insurance Company, No. 23‑13443 (11th Cir. Nov. 21, 2025) (published), the Eleventh Circuit significantly reshapes how “preexisting condition” limitations in ERISA-governed long-term disability policies are interpreted within the Circuit.

The case concerns a claimant whose disabling disease—scleroderma—was not diagnosed, suspected, or treated as such until months after her long-term disability coverage became effective. Reliance Standard denied benefits on the ground that her disability was caused by a “preexisting condition” because she had received treatment, during the three‑month lookback period, for symptoms that were later understood to be consistent with scleroderma.

The majority opinion by Judge Grant, joined by Judge Kidd, rejects Reliance Standard’s expansive, purely symptom-based reading of the policy. It holds that, under the specific policy language at issue, a condition is “preexisting” only if the insured actually received treatment for that sickness or injury during the lookback period—meaning that there must be, at minimum, an intent to diagnose or treat the condition itself, not merely any general symptom that happens to be compatible with it in hindsight.

Chief Judge William Pryor files a forceful dissent. He argues that the exclusion should apply whenever the insured received treatment or diagnostic procedures because of symptoms caused by the later-diagnosed condition, whether or not the disease was known or suspected at the time.

The decision is important on three levels:

• It clarifies, in a precedential opinion, how Eleventh Circuit courts must construe “preexisting condition” clauses that use “for which the insured received treatment” language in ERISA disability plans.
• It demonstrates that, even under the deferential “arbitrary and capricious” standard, courts will invalidate insurer interpretations that effectively convert “preexisting condition” exclusions into “preexisting symptom” exclusions.
• It openly critiques, yet applies, the Eleventh Circuit’s uniquely complex six‑step Blankenship framework for reviewing ERISA benefit denials.

II. Factual and Procedural Background

A. Medical History and Onset of Disability

Beginning in late 2015, Cheriese Johnson experienced a wide array of symptoms, including:

• Fatigue and muscle weakness
• Joint swelling and generalized aching
• Chronic nausea and vomiting
• Cough and shortness of breath–type complaints
• Swelling of hands and feet
• Cognitive impairment, dizziness, and syncope (fainting)
• Gastroesophageal reflux disease (GERD) symptoms
• Raynaud-type symptoms (coldness/numbness in extremities)

She sought medical care repeatedly, seeing a variety of providers—nurse practitioners, neurologist, pulmonologist, thoracic surgeon, rheumatologist—over many months. During that time, she received numerous diagnoses, including:

• Fibromyalgia
• Borderline lupus erythematosus
• Probable somatoform disorder
• Helicobacter pylori infection
• Epistaxis (nosebleeds)
• Gastroesophageal reflux disease
• Edema
• Hypertension
• Sleep apnea
• Bronchitis

Conspicuously absent from this list is her true underlying condition: scleroderma, a rare autoimmune disease characterized by abnormal collagen deposition and fibrotic thickening of skin and internal organs, often producing joint pain, cough, shortness of breath, digestive problems, and fatigue.

Critically, the majority emphasizes that:

• No provider suspected scleroderma before her lung biopsy in February 2017, four months after the lookback period ended.
• No party alleges malpractice or bad faith in failing to diagnose scleroderma earlier.

By January 26, 2017—about four months after her long-term disability coverage took effect—Johnson became unable to work and was “totally disabled” within the meaning of the policy. A February 2017 lung biopsy finally produced the diagnosis of scleroderma.

B. The Policy and Its Preexisting Condition Limitation

Johnson began work at The William Carter Company in July 2016 and purchased long-term disability coverage from Reliance Standard. The policy became effective October 12, 2016.

Because Johnson became disabled within one year of the policy’s effective date, her claim was subject to the policy’s “Pre-existing Conditions Limitation.” The key language provides:

Benefits will not be paid for a disability that is:

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

a Pre-existing Condition.

“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.

With an effective date of October 12, 2016, the three-month lookback ran from July 12 to October 12, 2016. During that period, Johnson:

• Had multiple office visits for the wide array of symptoms listed above.
• Received various prescriptions (e.g., for GERD, pain, nausea).
• Underwent an upper GI endoscopy (a clear “diagnostic procedure”) for gastrointestinal symptoms.

All agree that the relevant “Sickness” for purposes of the exclusion is scleroderma; the dispute concerns whether she received treatment “for” scleroderma during the lookback.

C. Claim, Denial, and District Court Proceedings

In October 2017, Johnson filed an ERISA claim with Reliance Standard for long-term disability benefits stemming from scleroderma. Reliance:

• Retained an endocrinologist who concluded that the record supported the scleroderma diagnosis.
• Determined that her disability was “caused by, contributed to by, or the result of” a preexisting condition—scleroderma—because she had been treated during the lookback period for symptoms consistent with that disease.
• Denied benefits on that basis.

Johnson sued under ERISA, seeking benefits and arguing that she could not have been treated “for” scleroderma during the lookback period because no one knew or suspected she had that disease then.

The district court:

• Denied Johnson’s motion for judgment on the administrative record.
• Granted summary judgment for Reliance Standard, holding that the preexisting condition limitation applied.

Johnson appealed. The Eleventh Circuit reversed.

III. Summary of the Eleventh Circuit’s Opinion

A. Standard of Review and the Blankenship Framework

Because this is an ERISA benefit-denial case, the court applies its six-step framework announced in Blankenship v. Metropolitan Life Insurance Co., 644 F.3d 1350 (11th Cir. 2011), which structures the interaction between:

• De novo review of the correctness of the administrator’s decision; and
• Deferential “arbitrary and capricious” review where the plan grants discretionary authority.

The panel candidly criticizes this framework as “likely unnecessarily complex” and possibly obscuring correct results, but applies it as binding precedent.

B. Key Holdings

1. Step One (De Novo Review): Reliance Standard’s determination that the preexisting condition limitation applied was wrong under the correct interpretation of the policy.
   • The court focuses on the phrase “for which” in the definition of “Pre-Existing Condition.”
   • “For” connotes purpose or intent; one cannot treat a person “for” a specific sickness without at least suspecting that sickness exists.
   • Because no provider suspected or intended to treat scleroderma during the lookback period, Johnson did not receive treatment “for” scleroderma, and the exclusion does not apply.
2. Step Two (Discretion): The policy expressly grants Reliance Standard discretionary authority “to interpret the Plan and the insurance policy and to determine eligibility for benefits,” so arbitrary-and-capricious review applies beyond step one.
3. Step Three (Reasonableness under Arbitrary and Capricious Standard): Even under this deferential standard, Reliance Standard’s interpretation is unreasonable (arbitrary and capricious) because:
   • It erases the distinction between treatment for mere symptoms and treatment for the underlying disease.
   • It converts the contract’s “preexisting condition” exclusion into a sweeping “preexisting symptom” exclusion not found in the text.
   • It would allow the insurer to deny coverage based on virtually any prior medical encounter so long as a symptom could be linked, in hindsight, to the eventual diagnosis.

Because the court finds the interpretation both de novo wrong and unreasonable, it does not reach steps four to six (conflict-of-interest analysis). It reverses summary judgment for Reliance Standard and remands for further proceedings.

C. The Dissent

Chief Judge Pryor dissents. He would affirm the denial of benefits, reasoning that:

• The word “for” in context is better read to mean “because of” (i.e., treatment or diagnosis occurred because of symptoms caused by the condition), not to impose an “intent” requirement.
• The policy’s inclusion of “diagnostic procedures” undermines the majority’s intent-based reading, because diagnostic procedures are performed precisely when the condition is unknown or unsuspected.
• Under the record, Johnson’s physicians treated and investigated the very symptoms that later were attributed to scleroderma; thus, she received treatment “for” scleroderma within the lookback period.
• It is neither arbitrary nor capricious for Reliance to interpret the exclusion as barring coverage for an undiagnosed but manifest and treated condition.

He also criticizes the majority for downplaying the Eleventh Circuit’s (unpublished) decision in Ferrizzi v. Reliance Standard Life Insurance Co., 792 F. App’x 678 (11th Cir. 2019), which interpreted the same policy language in a manner broadly supportive of Reliance Standard’s view.

IV. Detailed Analysis

A. The Eleventh Circuit’s Six-Step ERISA Review Framework

The court reaffirms and applies its distinctive six-step Blankenship framework:

1. Is the decision de novo wrong? If not, affirm.
2. If de novo wrong, does the administrator have discretion? If not, reverse.
3. If de novo wrong and discretion exists, is the decision reasonable (arbitrary/capricious review)? If no, reverse.
4. If reasonable, does a conflict of interest exist?
5. If no conflict, affirm.
6. If conflict exists, consider it as a factor in deciding whether the decision is arbitrary and capricious.

This framework is layered on top of the Supreme Court’s decisions in Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989), and Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105 (2008), which respectively:

• Establish that de novo review applies unless the plan gives the administrator discretionary authority.
• Hold that a conflict of interest is a factor in abuse-of-discretion review when the administrator both decides and pays claims.

The Johnson majority explicitly notes that the Eleventh Circuit “stands alone” in using this elaborate sequence, while most circuits simply ask whether, under Firestone/Glenn, arbitrary-and-capricious review applies and, if so, whether the decision survives that standard. The panel suggests its own framework is “likely unnecessarily complex” but treats it as binding.

Doctrinally, the key development in Johnson is at step three: even once deference applies, the court can (and here does) invalidate an interpretation as unreasonable when it is contrary to the clear text and common-sense structure of the plan.

B. Burden of Proof on Policy Exclusions

The court reiterates an important ERISA principle from Horton v. Reliance Standard Life Insurance Co., 141 F.3d 1038 (11th Cir. 1998):

When the insurer invokes a specific policy exclusion to deny coverage, the insurer bears the burden of proving the exclusion applies.

In this case, Reliance Standard had to prove that scleroderma was a “Pre-Existing Condition” as defined—that is, a sickness for which Johnson received treatment, consultation, care, services, diagnostic procedures, or prescription medications during the lookback period.

This burden interacts with the interpretation of “for which.” If there is no reasonable basis to say she was treated “for” scleroderma in that period, then Reliance fails its burden even under deferential review.

C. Interpreting “Preexisting Condition”: The Meaning of “For Which”

1. Majority: “For” Connotes Intent, Not Mere Compatibility of Symptoms

The definitional hinge of the case is the phrase “for which” in the definition of “Pre-Existing Condition.” The majority:

• Consults general dictionaries and Black’s Law Dictionary to conclude that “for” indicates “the object, aim, or purpose” of an action.
• Quotes Lawson ex rel. Lawson v. Fortis Insurance Co., 301 F.3d 159 (3d Cir. 2002) (then-Judge Alito), which characterized “for” in a similar clause as embodying an “implicit intent requirement.”
• Adopts Lawson’s core insight: it is “hard to see how a doctor can provide treatment ‘for’ a condition without knowing what that condition is or that it even exists.”

Applying that premise, the majority finds:

• None of Johnson’s providers suspected scleroderma during the lookback period.
• None of the tests performed at that time linked her symptoms to scleroderma.
• Her treatment was undeniably “for” other diagnoses (fibromyalgia, GERD, hypertension, etc.), not scleroderma.

Thus, as a matter of plain language, she never received treatment “for” scleroderma during the lookback period. The exclusion is not triggered.

The majority underscores its textual approach by declining to invoke contra proferentem (the rule that ambiguities are construed against the drafter). It holds that Reliance’s interpretation is so unreasonable that the policy is not even ambiguous in the relevant sense; the text, given its ordinary meaning, favors Johnson.

2. Distinguishing Symptoms from Disease

A key conceptual move is the majority’s insistence on distinguishing:

• Symptoms (e.g., fatigue, cough, joint pain), which may be associated with many conditions; and
• The underlying disease (scleroderma), which is a discrete “sickness or injury” covered by the policy definition.

The policy excludes only conditions “for which” treatment was received, not every condition that could retrofit itself through medical hindsight to any symptom present during the lookback period.

To illustrate the absurdity that flows from blurring this distinction, the majority uses pointed hypotheticals:

• A patient with headaches is told to drink more water for presumed dehydration; later she is discovered to have a brain tumor. Under Reliance’s interpretation, that headache visit was “treatment for” a brain tumor because headaches are consistent with tumors.
• A patient seen for cough and fatigue is treated for the flu; a later diagnosis reveals tuberculosis. Flu treatment would retroactively count as treatment “for” TB.

These examples highlight the danger of an ex post, diagnosis-driven reconstruction of earlier encounters: any symptom that is not inconsistent with a later diagnosis becomes a foothold to claim that the condition was “preexisting” and treated, even if, at the time, all participants reasonably believed something else was going on.

3. Other Circuits the Majority Embraces

The majority aligns itself with several influential decisions:

• Third Circuit – Lawson and McLeod:
  • Lawson v. Fortis Insurance Co., 301 F.3d 159 (3d Cir. 2002): Interpreted a similar “for which the insured received treatment” clause to require intent to diagnose or treat the specific condition. Warned against “backward-looking reinterpretation of symptoms” to support denial.
  • McLeod v. Hartford Life & Accident Insurance Co., 372 F.3d 618 (3d Cir. 2004): Rejected the proposition that any symptom experienced before diagnosis that is not inconsistent with the later-diagnosed condition suffices to trigger a preexisting condition exclusion. The majority lifts McLeod’s core warning almost verbatim.
• Seventh Circuit – Pitcher and Bullwinkel:
  • Pitcher v. Principal Mutual Life Insurance Co., 93 F.3d 407 (7th Cir. 1996): Held that a claimant was not treated “for cancer” where neither she nor her physician had reason to suspect cancer when symptoms appeared.
  • Bullwinkel v. New England Mutual Life Insurance Co., 18 F.3d 429 (7th Cir. 1994): Found a preexisting condition where the insured’s physician had been specifically concerned about cancer because of a breast lump detected during the lookback period. The majority distinguishes Bullwinkel as a case where the specific disease was suspected and evaluated, unlike Johnson’s.
• Second Circuit – McCauley:
  • McCauley v. First Unum Life Insurance Co., 551 F.3d 126 (2d Cir. 2008): Cited for the proposition that interpretations inconsistent with the “plain words” of the plan are arbitrary and capricious.
• State decisions:
  • Cases such as Estate of Ermenc v. American Family Mutual Insurance Co., 585 N.W.2d 679 (Wis. Ct. App. 1998), and Karagon v. Aetna Life Insurance Co., 228 N.W.2d 515 (Mich. Ct. App. 1975), similarly reject overly broad, hindsight-driven use of preexisting condition exclusions.

These authorities collectively reinforce the majority’s central point: when policy language focuses on “treatment for” a sickness during a defined period, courts should resist insurer interpretations that effectively treat any earlier general symptom as having been “treatment for” whatever disease is later diagnosed.

D. Arbitrary and Capricious Review: Why Reliance’s Reading Fails Even with Deference

Arbitrary and capricious review is highly deferential. As the court notes, if any reasonable basis supports the administrator’s interpretation, it must be upheld, even if the court might have reached a different conclusion de novo. See Jett v. Blue Cross & Blue Shield of Alabama, Inc., 890 F.2d 1137, 1140 (11th Cir. 1989).

Yet deference is not abdication. Citing Hess v. Hartford Life & Accident Insurance Co., 274 F.3d 456 (7th Cir. 2001), the majority stresses that:

Deferential review is not no review, and deference need not be abject. There are times when the plain language or structure of the plan or simple common sense will require the court to pronounce an administrator’s determination arbitrary and capricious.

Johnson is “one of those times.” Several factors drive the conclusion that Reliance’s interpretation is unreasonable:

• Textual distortion: The policy speaks of “any Sickness or Injury for which” treatment is received. Reliance’s reading effectively converts that to “any Sickness that existed or manifested in any symptom for which the insured received treatment,” a materially different clause the parties did not bargain for.
• Unlimited hindsight reasoning: Because almost any symptom is compatible with many diseases, Reliance’s approach allows it to post hoc reclassify any earlier visit as treatment “for” the later-diagnosed disease, even if those visits were, in fact, for genuinely different ailments.
• Illogical consequences: As the court’s dehydration/brain-tumor and flu/tuberculosis hypotheticals show, the insurer’s approach would treat clearly benign, correct advice (e.g., “drink more water”) as treatment for a serious, unknown disease, solely because some symptom overlapped.
• Misalignment with policy structure: The majority notes that if Reliance wanted a broader exclusion—e.g., one keyed to “manifestation” of symptoms or to conditions originating before coverage—it could have drafted the policy that way, as other insurers have. It did not.

The majority thus holds that an interpretation so broad that it “warps” the plan’s plain language and converts a preexisting-condition exclusion into a preexisting-symptom exclusion is arbitrary and capricious, even under deferential review.

E. Treatment of Ferrizzi and Other Precedents Relied on by the Insurer

1. Ferrizzi (11th Cir. 2019, Unpublished)

Reliance Standard pointed heavily to Ferrizzi v. Reliance Standard Life Insurance Co., 792 F. App’x 678 (11th Cir. 2019), an unpublished decision interpreting nearly identical policy language. There, the court:

• Rejected the claimant’s argument that a “formal diagnosis” was required during the lookback period for the exclusion to apply.
• Held that substance abuse was a preexisting condition because the insured had received treatment for that condition during the lookback period, even though the diagnosis label may have come later.

The Johnson majority distinguishes and limits Ferrizzi in two ways:

• It notes that unpublished opinions are not binding precedent in the Eleventh Circuit.
• Substantively, it emphasizes that Ferrizzi involved an insured whose doctors actually suspected and treated him for substance dependency during the lookback period. There, the condition itself, not merely generic symptoms, was in view.

Johnson, by contrast, involves a condition that:

• Was never suspected or investigated as such during the lookback period.
• Was only diagnosed via lung biopsy months later, despite multiple intervening tests.

Thus, Ferrizzi is consistent with the Johnson majority’s rule: a condition can be “preexisting” even without a formal diagnosis if, and only if, it was actually suspected and treated as such during the lookback period.

2. Bullwinkel and Other State Cases Cited Against Johnson

Reliance also relied on Bullwinkel v. New England Mutual Life Insurance Co., 18 F.3d 429 (7th Cir. 1994), in which coverage for breast cancer was excluded because:

• The insured had a palpable lump during the lookback period,
• Her doctor was specifically concerned about cancer, and
• She was referred to a surgeon on that basis.

The Johnson majority distinguishes Bullwinkel as:

• A case where the symptom (a breast lump) was a concrete manifestation of cancer,
• The physician actually suspected cancer during the lookback period, and
• Thus, the insured had in fact “sought advice for a sickness with a specific concern in mind,” bringing the treatment within the “for which” language.

Bullwinkel is used not as support for Reliance but as a boundary case: it illustrates when symptoms and medical attention cross the line into treatment “for” a specific condition (cancer), in contrast to Johnson’s diffuse, non-specific symptoms with no suspicion of scleroderma.

The majority also rejects reliance on non-analogous state cases where:

• The policy language explicitly focused on “manifestation” of symptoms or on conditions “first commenced or became evident,” not on treatment “for” a sickness.
• Definitions of “sickness” expressly swept in “complications” and “reoccurrences,” language absent from Johnson’s policy.

By emphasizing these textual differences, the court reaffirms a core contract-law and ERISA principle: courts interpret the policy actually written, not a more insurer-friendly variant that might have been drafted.

F. The Dissent’s Competing Interpretation and Policy Concerns

1. Reading “for” as “because of” in Context

The dissent argues that because “for” has many dictionary definitions, and because the clause covers “medical treatment, consultation, care or services, including diagnostic procedures,” the better reading in context is:

• “For” = “because of.”
• The preexisting condition is any sickness because of which the insured received treatment or diagnostic procedures during the lookback period.

Applying this, Chief Judge Pryor reasons:

• Diagnostic procedures by their nature are performed when the diagnosis is unknown. Requiring intent to target a specific disease is illogical.
• Doctors in fact performed a “diagnostic procedure” (the GI endoscopy) and other treatment because of gastrointestinal and systemic symptoms that her rheumatologist later attributed to scleroderma.
• Thus, in a factual/causal sense, Johnson did receive treatment “for” (because of) scleroderma before coverage, even if neither she nor her doctors knew that at the time.

He illustrates with his own hypothetical: a CT scan ordered for a suspected concussion reveals an unsuspected brain tumor. In his view, the scan was performed “because of” the tumor (its symptoms), even though the doctor did not intend to look for cancer. Under his reading, that would be treatment “for” the tumor.

2. Use of the Record and Admissions by Treating Physicians

The dissent stresses that Johnson’s own rheumatologist:

• Identified symptoms dating back to October 2015 as symptoms of scleroderma.
• Reported that he had treated her “every 1–3 months” for these same symptoms during the period spanning the lookback.

Given this, and under the more generous deference owed at step three, the dissent would hold it was well within the range of reasonableness for Reliance to find that scleroderma was a “sickness for which” treatment was received during the lookback period. The policy does not, in his view, require suspicion, diagnosis, or naming of the condition; existence, manifestation, and treatment of symptoms caused by the condition suffice.

3. Broader Policy and Market Considerations

The dissent situates preexisting condition clauses in their historical function:

• To prevent adverse selection and fraud—where applicants wait until they are sick (or symptomatic) to obtain coverage.
• To treat similarly situated insureds alike, regardless of whether a particular doctor happened yet to attach a diagnostic label.

Citing numerous cases from other jurisdictions, he notes that many courts have upheld exclusions for conditions that were undiagnosed or unsuspected during the lookback period when:

• The condition had already manifested in symptoms; and
• The insured had sought treatment for those symptoms.

From this perspective, allowing coverage simply because no doctor yet “named” the disease introduces an arbitrary distinction between a person with manifest but undiagnosed disease and a person with the same disease already labeled. It also potentially incentivizes individuals aware of serious, unexplained symptoms to obtain insurance before seeking thorough medical evaluation.

G. Doctrinal and Practical Impact

1. Narrowing Preexisting Condition Exclusions in the Eleventh Circuit

For ERISA disability plans using language like Reliance’s, Johnson establishes an important rule:

A condition is not “preexisting” merely because the insured had symptoms consistent with it and received treatment for those symptoms during the lookback period. The exclusion applies only if the insured received treatment, consultation, care, services, diagnostic procedures, or medications for the condition itself—that is, where the condition was at least suspected and intentionally investigated or treated.

The decision thus:

• Protects claimants from insurers’ ex post recharacterizations of generic prior complaints as treatment “for” a subsequently discovered disease.
• Requires a demonstrable connection in the contemporaneous clinical reasoning—however inchoate—between the condition and the treatment during the lookback period.

2. Guidance to Insurers on Policy Drafting

The opinion implicitly instructs insurers who wish to bar coverage more broadly to draft accordingly. Options include:

• Defining “preexisting condition” to include diseases that:
  • “first commenced,”
  • “became evident or manifest,” or
  • “produced signs or symptoms”
  during a pre-coverage period, regardless of diagnosis or treatment intent.
• Explicitly tying exclusions to “any signs or symptoms that are consistent with or attributable to the condition,” as some of the state cases cited by the dissent did.

Johnson underscores that courts will not re-write narrower contractual language into these broader formulations post hoc.

3. Practical Litigation Effects

In ERISA benefit litigation within the Eleventh Circuit, Johnson:

• Supplies claimants a powerful precedent to challenge denials based on preexisting conditions where:
  • The disabling disease is rare or complex (e.g., auto-immune conditions, certain cancers, neurological disorders) and
  • Was neither suspected nor targeted by physicians during the lookback period.
• Signals to district courts that even under arbitrary-and-capricious review, an insurer’s interpretation can be overturned if it:
  • Stretches plan language beyond its plain meaning, or
  • Yields absurd practical consequences.
• May prompt more rigorous record development around what conditions clinicians actually suspected and sought to diagnose during pre-coverage visits.

Insurers litigating in the Eleventh Circuit will likely:

• Lean heavily on contemporaneous medical records to show that the specific disabling condition was suspected or under investigation during the lookback.
• Revisit policy forms to incorporate more expansive “manifestation” or “symptom-based” language if they wish to avoid Johnson’s more claimant-friendly construction.

4. Potential for En Banc or Supreme Court Review

The 2–1 split, the presence of the Chief Judge in dissent, and the explicit divergence from some other circuits’ approaches (or at least some of their dicta) suggest:

• This area is doctrinally unsettled and could draw en banc attention, especially if later panels read Johnson broadly.
• At a minimum, within the Eleventh Circuit, district courts are now bound to apply Johnson’s interpretation to the same or materially identical policy language.

For now, however, Johnson stands as controlling law in the Eleventh Circuit on the meaning of “for which the insured received treatment” in preexisting condition clauses.

V. Complex Concepts Simplified

1. ERISA and “Federal Common Law”

ERISA is a federal statute governing employer-sponsored benefit plans. But it leaves many interpretive questions unanswered. Federal courts therefore develop a body of “federal common law of ERISA” to:

• Set burdens of proof (e.g., insurer bears burden on exclusions).
• Define interpretive rules (e.g., plain meaning; contra proferentem where appropriate).
• Structure standards of review (e.g., de novo vs. arbitrary and capricious).

2. Lookback Period and Preexisting Condition Exclusions

A “lookback period” is the time before coverage starts during which an insurer examines medical history to determine whether a condition was “preexisting.” If:

• The insured becomes disabled within a specified period after coverage starts (here, one year),
• And the disability is attributable to a sickness or injury that meets the policy’s definition of “preexisting” during the lookback period,

the insurer can deny benefits under the exclusion.

3. “For Which Treatment Was Received” vs. “Manifested” Conditions

Policies differ sharply in how they define “preexisting condition.” Two common approaches are:

• Treatment-focused (like Johnson’s): Condition is preexisting if, during the lookback period, the insured “received treatment, consultation, care, services, diagnostic procedures, or prescription drugs” for that condition.
• Manifestation-focused: Condition is preexisting if it “manifested,” “first commenced,” “became evident,” or produced signs or symptoms during the lookback period, whether or not treatment was directed to it or it was formally diagnosed.

Johnson is about a treatment-focused clause; the majority warns courts not to import the broader manifestation-focused concept where the contract does not say so.

4. De Novo Review vs. Arbitrary and Capricious Review

• De novo review: The court decides from scratch whether the plan administrator’s decision is correct, without deference. Under Firestone, this applies when the plan does not give the administrator discretionary authority to interpret plan terms or determine eligibility.
• Arbitrary and capricious (or abuse of discretion) review: The court does not ask what decision it would have made. Instead, it asks whether the administrator’s decision falls within a range of reasonable interpretations. If so, the decision is upheld—even if the court would have read the plan differently.

In the Eleventh Circuit’s six-step framework, the court first asks whether the decision is de novo wrong; if so, but the administrator has discretion, the court shifts to arbitrary-and-capricious review to decide whether the wrong decision was nevertheless within the bounds of reasonableness.

5. Contra Proferentem

“Contra proferentem” is a rule of contract interpretation that says ambiguous terms are construed against the drafter—in insurance, usually against the insurer. In ERISA cases, some circuits apply this rule only at the de novo stage; others consider it even under deferential review. In Johnson:

• The majority does not resort to contra proferentem because it holds Reliance’s interpretation is not even reasonable, so no true ambiguity exists once ordinary meaning is applied.

VI. Conclusion: The Significance of Johnson in the ERISA Landscape

Johnson v. Reliance Standard marks a meaningful shift in how preexisting condition clauses will operate—at least for treatment-focused language—in the Eleventh Circuit.

The court:

• Anchors its analysis in the ordinary meaning of “for which the insured received treatment,” insisting that some degree of intent to diagnose or treat the specific condition is required.
• Rejects as unreasonable, even under deferential review, an insurer’s attempt to deny coverage based purely on the fact that earlier general symptoms can be retroactively linked to the disabling disease.
• Aligns the Circuit with decisions like Lawson, McLeod, and Pitcher, and distinguishes or limits contrary authorities that rested on different policy language or on clear suspicion of the disease during the lookback period.

For claimants, the decision offers robust protection against broad, hindsight-driven preexisting condition denials in ERISA disability cases where rare or complex diseases are involved. For insurers, it is a cautionary tale about both policy drafting and claim adjudication: if they wish to bar coverage based on undiagnosed but manifested conditions, they must say so clearly in the contract and avoid interpretive leaps that cannot be squared with the text actually adopted.

In the broader ERISA context, Johnson also showcases that the label “arbitrary and capricious” still has bite. Where plan language is clear and an administrator’s reading effectively rewrites it—expanding a narrow exclusion into a sweeping one—the Eleventh Circuit is prepared to intervene, notwithstanding deference to plan fiduciaries.