On This Page[Hide][Show]
If your long-term disability (LTD) insurance claim was denied due to a “pre-existing condition,” know that you’re not alone. Many claimants are in the same situation, often without a clear understanding of what the term means or how it applies to their case. This article will explain the concept of pre-existing condition exclusions in LTD policies using real-world examples to help you understand your rights and options.
What Is a Pre-Existing Condition Exclusion?
A pre-existing condition exclusion is a clause found in many LTD insurance policies. It allows the insurer to deny benefits if your disability is linked to a condition for which you received a diagnosis, treatment, or care during a defined period before your coverage began—usually the three months prior to your effective date.
Here’s a sample clause from an Aetna policy:
“No benefit is payable for any disability that is caused by or substantially contributed to by a pre-existing condition and starts before the end of the first 12 months following your effective date of coverage.”
In short, if you become disabled within the first 12 months of coverage and received treatment for the disabling condition during the three months before coverage began, the insurer may use this exclusion to deny your claim.
Watch: Understanding Pre-Existing Conditions in LTD Claims
Why Do Insurers Include This Exclusion?
Think of it like applying for new health insurance coverage after receiving a cancer diagnosis. Insurers are unlikely to cover the newly diagnosed condition, and they may issue a policy that excludes it. Disability insurance operates similarly. For example, if you begin receiving treatment for a condition and then file a claim for that condition soon after your coverage starts, the insurer may claim that it falls within the pre-existing exclusion period.
RELATED POST: Do Short-Term Disability Policies Have Pre-Existing Condition Exclusions?
Real-Life Examples of Pre-Existing Condition Evaluations
Example 1: Back Pain After a Car Accident
A claimant starts a new job on January 1, 2025, and long term disability coverage is effective immediately. A few months later, they are in a car accident that causes herniated discs. They stop working on April 1, 2025, due to debilitating back pain.
Will this be considered a pre-existing condition?
The insurer will review medical records for the three months before January 1st (October 1, 2024 to December 31, 2024). If the claimant did not receive treatment for back pain during that time, the back condition will likely not be excluded, especially if it was clearly caused by a recent accident.
Example 2: COPD and Prior Treatment
Now consider a different scenario. A claimant develops COPD and stops working three months into a new job. Records show that they saw a pulmonologist for milder breathing issues within the three-month look-back period.
Will this be considered a pre-existing condition?
Probably. Even if the condition worsened later, the insurance company could argue that the treatment during the lookback window was related and deny the claim.
Example 3: High Blood Pressure vs. Heart Attack
Suppose a claimant stops working due to a heart attack. During the lookback period, they were only being treated for high blood pressure.
Would this be a valid pre-existing condition denial?
Not necessarily. We have successfully argued that high blood pressure and heart attacks are medically distinct conditions. If the heart attack is new and materially different, the exclusion should not apply.
Navigating the Gray Areas
Sometimes, the connection between a prior condition and the disabling condition isn’t clear-cut. Insurers may try to link even loosely related conditions to justify a denial. In these cases, claimants must demonstrate that:
- They received no treatment for the disabling condition during the look-back period, or
- The current condition is materially different from anything treated previously
This is where professional advocacy can make all the difference.
Real LTD Lawsuits Involving Pre-Existing Condition Denials
Pre-existing condition exclusions are one of the most common reasons insurance companies deny LTD claims. In fact, many federal lawsuits we’ve reviewed and summarized involve disputes over whether a condition was truly pre-existing.
Here are a few examples of long-term disability cases where courts reviewed pre-existing condition exclusions:
- Krueger v. Reliance Standard – Exclusion Rejected: Ms. Krueger filed a claim for LTD benefits after developing disabling symptoms from postural orthostatic tachycardia syndrome (POTS). Reliance Standard denied her claim, asserting POTS was pre-existing due to earlier treatment for migraines and tachycardia. The court disagreed, finding the insurer failed to show her pre-coverage treatment was for the same disabling condition. The judge emphasized the importance of clear diagnostic distinctions when applying pre-existing condition clauses.
- Harrison v. LINA – Exclusion Applied: Ms. Harrison’s LTD claim was denied by Life Insurance Company of North America (LINA) after she became disabled due to Right Hemisphere Deficit Syndrome—a condition affecting her cognitive function. Although this specific diagnosis was new, LINA argued it was related to her long-standing depression and anxiety, which were treated prior to her coverage date. The court agreed, finding the insurer could apply the pre-existing condition exclusion since her earlier mental health conditions “substantially contributed” to her disability.
- Kaiser v. Mutual of Omaha – Exclusion Rejected: In this case, the Mutual of Omaha denied Mr. Kaiser’s LTD claim, citing a pre-existing condition exclusion. The claimant had visited doctors for shoulder pain during the lookback period but later developed cervical radiculopathy that forced him out of work. The court ruled in Kaiser’s favor, stating the condition that caused his disability was new and materially different from what he had previously treated.
Each of these cases highlights how insurers interpret “pre-existing condition” differently—and how courts may disagree, especially when symptoms overlap but diagnoses differ.
View more LTD lawsuit summaries on our blog.
How the Ortiz Law Firm Helps with Pre-Existing Condition Denials
We’ve successfully appealed numerous denials involving pre-existing condition exclusions. We’ve helped clients in situations where:
- Treatment occurred outside the lookback period
- The disabling condition was unrelated to anything treated during that time
- The insurer tried to apply the exclusion too broadly or unfairly
We prepare strong appeals with detailed medical evidence, provider statements, and legal arguments to show why your claim should be approved.
Get Help with a Long-Term Disability Appeal or Lawsuit
If your long-term disability claim was denied due to a pre-existing condition exclusion, don’t give up. Our team has extensive experience in challenging these types of denials, and we may be able to help you recover the benefits you deserve. Call us today at (888) 321-8131 or contact us online for a free case evaluation. We look forward to hearing from you and discussing how we can help you fight back against your insurer.
