You’ve filed your application for long-term disability (LTD) benefits, carefully providing all the necessary information and submitting all your relevant medical records. When you get the insurance company’s response, you’re shocked to see a denial of benefits. The insurance company found that your disabling conditions were pre-existing (and therefore, not covered by your policy).
At Bryant Legal Group, we’re used to insurance companies broadly interpreting our clients’ medical records and incorrectly applying pre-existing condition exclusions.
Whether you’re purchasing a new disability insurance policy, thinking about filing a claim, or are dealing with an unfair claim denial, here are six things you need to know about how long-term disability insurance deals with pre-existing conditions.
1. Some Long-Term Disability Plans Exclude Pre-Existing Conditions
If you have an employer-provided long-term disability plan, your pre-existing condition may be covered after a waiting period. (For more information on these lookback periods, see #3 below.)
The situation is likely different, however, if you have an individual LTD policy that you purchased on your own.
As a cost-savings mechanism, most individual long-term disability policies exclude pre-existing conditions. This means that if you become unable to work due to one of these conditions, the insurer will not pay benefits. (If you become disabled due to a different, new condition, you should still be covered.)
So, what exactly is a pre-existing condition? The definition varies from policy to policy, but it usually includes any physical, mental, or emotional condition that you have been treated for shortly before you obtained coverage. Commonly excluded pre-existing conditions include cancer, asthma, heart disease, multiple sclerosis, arthritis, depression, anxiety, and many others.
2. In Order to Deny a Claim Based on a Pre-Existing Condition, the Condition Must Be Known or Suspected
Of course, if you have an already-diagnosed condition or injury, the insurance company will almost always deem it pre-existing. However, most long-term disability pre-existing condition clauses also cover any conditions that would be reasonably suspected at the time you purchase the policy.
For example, suppose you reported moderate back pain and some numbness in your leg two months before obtaining LTD coverage. Later that year, your doctor referred you to a neurosurgeon who discovered a herniated disc in your lower back. Even though you didn’t have a clear diagnosis at the time you got coverage, the insurance company might deny your claim for disability insurance benefits.
On the other hand, if there was no realistic reason to suspect you had a disabling condition at the time you purchased coverage—for example, you have a progressive genetic condition that was still asymptomatic at the time—the insurance company should not be able to exclude it.
RELATED: Disability Insurance: A Look at Ambiguous Exclusion Clauses
3. For Employer-Sponsored Plans, You Might Have to Wait a Year Before Filing an LTD Claim for a Pre-Existing Condition
With group or employer-sponsored long-term disability insurance policies, the insurer won’t examine each covered employee’s medical records. Instead, the insurance company places limits on when it will cover a pre-existing condition based on a lookback period.
Here’s how this usually works:
- You file a disability claim within a certain time period after obtaining LTD coverage. Usually this is 12 months.
- During this window, the insurance company will check your medical records for any reported symptoms or medical treatment you received within a defined lookback period. Most policies define the lookback period as either 90 or 180 days before your plan’s start date, although in some cases it can be as long as 12 months.
With an employer-sponsored or group plan, if you’re able to cope with your pre-existing condition and work for at least 12 months for your employer before you file for disability, you might still be eligible for LTD benefits.
However, every LTD plan is different, and your policy could include a different time period or other exclusions. Be sure to read your plan documents carefully. If you need help interpreting your LTD policy and calculating your exclusion periods, please contact Bryant Legal Group for help.
4. Failure to Disclose Your Medical Conditions in Your Application Can Mean Trouble
When you apply for a private LTD policy, you typically must provide information about your medical conditions and treatment. Then, the insurance company calculates your premiums based on your likelihood of needing benefits in the short term—and may even exclude specific conditions (like cancer) from coverage.
Because pre-existing conditions are usually not covered (and may increase your premiums), you may be tempted to try to hide an earlier treatment or diagnosis from the insurer. However, this is never a good idea.
Failing to disclose your pre-existing condition won’t stop the insurance company from finding out about it once you file a disability insurance claim. Furthermore, if the insurer believes that you deliberately lied to them on your application, they may void the entire policy. This could be a disaster, especially if your disability was caused by a new, completely unrelated condition or injury.
That said, it’s also understandable that you might not tell the company about every little twinge you feel, particularly if you haven’t sought treatment for it (or that treatment did not lead to a serious diagnosis). In these situations, you should consult with an experienced disability insurance lawyer.
5. Pre-Existing Condition Aren’t Always Permanently Excluded From Policies—But Terms Might Be Modified
Not all insurance policies totally exclude pre-existing conditions.
Suppose you have an already-diagnosed chronic condition that is well managed and is unlikely to interfere with your work in the near future—for example, Crohn’s disease, sleep apnea, or cancer that has been in remission for many years. In these situations, you might still be able to get disability insurance coverage for your pre-existing condition if the insurer does not believe there is a high risk of disability.
However (or alternatively), the insurer might place certain restrictions or limitations on coverage related to a pre-existing condition, such as:
- Increased waiting time. For example, you might need to wait 12 months instead of 6 months after becoming disabled before your long-term disability benefits can begin.
- Term limits. Your policy may limit the amount of time benefits are payable due to a pre-existing condition—for example, just one or two years, instead of until retirement age.
Every insurance company has its own set of standards and guidelines when underwriting a custom policy. So, if you have any pre-existing conditions and specific needs about potential coverage, it’s important to shop around and read the fine print carefully.
6. Insurance Adjusters Broadly Interpret Pre-Existing Conditions to Deny LTD Claims
Before you apply for long-term disability benefits, you should always review your plan documents and identify potential obstacles. Your policy will include a very specific definition of “pre-existing condition,” as well as other exclusions. If these exclusions apply to your claim, you might be ineligible for LTD benefits.
However, these definitions are always subject to interpretation, so you should never assume that the insurance adjuster was correct in their assessment. Many times, an experienced disability lawyer can help you clarify your condition and avoid your plan’s pre-existing condition exclusion.
Refuting a pre-existing condition exclusion is not a simple process. You’ll need to carefully review the plan documents, identify all your supporting medical records, and might even need to collect statements from your physicians and other experts.
Discover Bryant Legal Group’s Innovative Approach to Disability Insurance Appeals
Bryant Legal Group is one of Chicago’s most respected disability insurance law firms. We pride ourselves on our practical, client-centered approach and sophisticated legal strategies.
If you or a loved one were recently denied LTD benefits due to a pre-existing condition, it’s time to schedule a consultation with one of our skilled and experienced disability lawyers. We’ll help you understand all your legal options and suggest meaningful next steps regarding your claim.
You can contact Bryant Legal Group by calling 312-561-3010 or completing this brief online form