In November 2025, a United States appellate court found that a pre-existing condition exclusion in a disability insurance policy did not apply in circumstances where the insured had received treatment during the policy’s “look-back period” for generic symptoms which was only later diagnosed. The decision turned on the meaning, in the context, of the word “for”.

The court considered a disability policy that excluded claims if, in the three months before cover began, the insured received medical treatment “for” the sickness that later caused disability.  During that period the claimant saw clinicians for common complaints such as fatigue, nausea and pain.  Months later a rare autoimmune disease was diagnosed.  The insurer argued that because those symptoms were consistent with the disease, the exclusion barred the claim. 

The court read the clause by its ordinary meaning and focused on the word “for.” In plain language, treatment “for” a sickness is treatment aimed at that sickness.  Because neither the claimant nor her doctors suspected or intended to treat the specific disease during the look‑back period (rather, they treated the various symptoms individually), the clause was not triggered.  

The court rejected a broad, retrospective approach that would treat any symptom not inconsistent with the ultimate diagnosis as treatment for the disease, noting that this would turn a pre‑existing disease exclusion into a pre‑existing symptom exclusion.  The example proffered by the court was that an insurer, in this scenario, would not be entitled to exclude cover for a later-diagnosed brain tumour in circumstances where an insured had approached a doctor with headaches and had been advised to drink more water.

While the case turned on the specific wording of the policy and is in any event not binding in South Africa, the message is nevertheless relevant. While our principles of interpretation would invariably apply in a local context, one would expect the same result given the prevailing position that exception clauses which purport to limit the scope of an insurer’s obligation to indemnify are interpreted restrictively.

United States Court of Appeals for the Eleventh Circuit, 21 November 2025