Most long term disability insurance policies have limits in what they cover. These limits are written into the policy, and are called exclusions. Their purpose is to eliminate coverage for certain risks the insurance company is not willing to take on.
One very common example is the pre-existing condition exclusion.
If you have a mental or physical condition that existed prior to the effective date of your disability insurance policy, that is a pre-existing condition.
The exclusion clause in your policy prevents you from being eligible for LTD benefits for an illness or injury that existed, and that you knew about, prior to the start of your disability policy.
As the video explains, pre-existing exclusions generally kick in if you have been eligible for benefits for less than a year. Some policies state the “exclusion” period is up to two years.
For example, if your policy has a 12-month pre-existing exclusion,
- the “condition” in question is one that you were aware of and treated for within 12 months of the effective date of coverage under the policy; and,
- These provisions also include a treatment period, usually 3 months or 6 months, called the “pre-existing period.” This basically means that you cannot have been treated for, or taken prescribed medications 3 months before the effective date of coverage.
How a Pre-existing Condition Exclusion Properly Limits Disability Benefits
The pre-existing exclusion provision exists in most group disability insurance plans. It is an obstacle that disabled employees should be prepared to deal with when applying for LTD benefits.
Individual disability insurance policies may also have the exclusion. However, these policies are often customized to include special coverage for higher premiums, such as a medical exclusion rider, for certain preexisting medical conditions.
According to the policy’s wording, the pre-existing condition exclusion gives the insurance company the right to deny a claim if it finds the illness or injury that you are claiming benefits for:
- is the result of a pre-existing condition you did not disclose when you applied for disability insurance coverage;
- started within the 2 years (or otherwise stated period) after the policy became effective.
The insurance company will want to review your medical records for the year prior to the date of your disability. They will look into any symptoms you’ve complained of, what conditions you are diagnosed with, and what prescriptions you are taking.
If any of these symptoms are even remotely connected to the condition you claim is causing your disability, the insurance company will likely turn down your claim based on the preexisting conditions exclusion.
How Insurance Companies Use the Pre-Existing Condition Exclusion to Wrongly Deny Benefits
Where things often go wrong is if your insurance company embellishes the policy’s meaning of “pre-existing condition” in order to meet their own objective of denying claims.
Example: Your current disability claim is for Alzheimer’s. You have never before been treated for this impairment. After poring over your past medical history, the claims administrator identifies mention of a brief period of anxiety – and uses it as “evidence” of a pre-existing occurrence of the mental condition you are now claiming.
Example: Another maneuver is for the insurance company to find a prior use of a medication that is the same medication you take now for your current disability. A claims examiner will allege your impairment was pre-existing and deny coverage merely because the medicine is the same, with no mention of the separate and different condition for which it was previously prescribed.
Contact Our Disability Insurance Attorneys for Immediate Help
If your claim has been denied due to a pre-existing condition exclusion or for any reason, please contact our law firm.
Marc Whitehead & Associates is a national practice representing disabled individuals across the country. We can help you at the initial disability claim application level, the administrative appeals level, and in lawsuits at state and federal courts.
Our attorneys’ work is sustained by talented and caring legal staff, many of whom develop dedicated relationships with our clients as we work our way through the applications and appeals systems.
If you were denied long term disability benefits, Social Security Disability or Veterans’ Disability Compensation, we are prepared to help you now.