A pre-existing condition exclusion is a provision in a long-term disability insurance policy that limits or excludes coverage for a disability that is caused by a condition that existed before the policy became effective.
Under this provision, if an insured person has a pre-existing condition that causes them to become disabled within a certain period of time after the policy becomes effective, the insurer may deny or limit their claim for benefits. The specific terms of the pre-existing condition exclusion may vary by policy, but typically the exclusion applies to conditions for which the insured person received medical treatment, medication, or advice within a specified period of time prior to the effective date of the policy.
You’re probably here today because your long-term disability insurance company has denied your claim for long-term disability benefits, saying that they’re denying you due to a pre-existing condition. In this post, we’ll help you to understand what pre-existing means and how the term applies to long-term disability claims. Keep reading for three examples of how the pre-existing condition exclusion was applied in three different long-term disability claims.
What Does Pre-Existing Mean?
The pre-existing condition is going to be specifically defined in your policy. For example, a page from an Aetna long term disability policy says:
“No benefit is payable for any disability that is caused by or substantially contributed to by a pre-existing condition or medical or surgical treatment of a pre-existing condition and starts before the end of the first 12 months following your effective date of coverage. A disease or injury is pre-existing if, during the three months right before your effective date of coverage, it was diagnosed. Or you received medical treatment, care, or services for the disease or injury. Or you took drugs or medicines prescribed or recommended by a physician for the disease or injury.”
The best way to come to understand how a pre-existing condition impacts a long term disability case is to perhaps use an analogy to a different kind of case:
Let’s say that someone was just diagnosed with cancer, and they didn’t have any health insurance before. They now realize the importance of health insurance and that it would have been nice to have health insurance to get all the treatment that’s required for that type of serious condition. However, if someone has cancer, and they go out to try to buy a new health insurance policy, very few insurance companies are going to want to underwrite that.
So they’re either going to deny coverage, saying that we’re not going to cover you for cancer, or they’re going write a policy saying that we’re going to cover you for every type of medical condition except for cancer. So they exclude it as a pre-existing condition.
The same type of concept applies to a long term disability claim. The idea is they don’t want to cover you for something that you’ve been getting treatment for if you go out on disability within a year of starting your job. So that’s where it says if it starts before the end of the first 12 months following your effective date of coverage then it is a pre-existing condition.
Example One: Herniated Disc as a Result of a Car Accident
So, let’s use an example within the long-term disability world. Let’s say that someone started working on January 1 of 2017. And they’re going along, working great for a few months. And then on April 1 of 2017, they have to stop work due to a back pain problem:
They were in a car wreck, they suffered herniated discs in their back, and they’re no longer able to go back to work because of their disc herniations and their pain, and the recovery goes along with that. They were only at work for about three or four months before they went out of work, so they would be subject to the pre-existing condition exclusion because this condition arose within the first 12 months of their employment.
The insurance company is going to go back and look at what happened during the three months prior to the date the insurance took effect. So in this case, they’re going to look at October, November, and December of 2016 to see if that person received any kind of treatment for that condition in that three month time period. If they received treatment for a back pain condition in October, November, or December of 2016, then they would not cover it.
In our example, the person was in a car wreck, so they probably weren’t getting treatment for a back condition. It can be shown that their condition is related to that accident, which did not occur during the pre-existing look back period. There probably would be coverage for the condition in that instance because it’s not a pre-existing condition. It’s a condition that arose after the coverage took effect.
Example Two: Chronic Obstructive Pulmonary Disorder (COPD)
Let’s change the circumstances a little bit. This time the claimant didn’t go out because of a back pain problem, let’s say that they went out because of a breathing disorder. They have really bad COPD, and it’s gotten to the point where they have extreme difficulty breathing, extreme difficulty doing activities of daily living, and difficulty doing work activities.
Again, this occurred only after three or four months on the job, and now the insurance company is going to do the same pre-existing evaluation. In this example, the claimant did receive treatment on November 15, 2016. They went to go see a pulmonologist because of the breathing problems they were having. It wasn’t as bad as it was when they ultimately went out of work, but they were still having breathing problems, and as such, they were seeing a lung doctor.
In that instance, the insurance company is very likely to deny the claim because they’re going to say you stopped working within one year and you did get treatment for that breathing problem in the three months before the coverage took effect. Therefore, because it’s the same condition, it’s a breathing problem, a lung problem, we’re not going to cover you for LTD benefits.
Some pre-existing conditions are relatively clear cut, such as those two examples that I just gave, but things can get a little bit more complicated when there does seem to be maybe some overlapping symptoms between what the patient got treatment for and what they ultimately stopped working for:
Example Three: Heart Attack
Let’s say that our hypothetical person went out of work, again in April of 2017, due to a heart attack. The insurance company gets all the medical records, and they go back to October, November, and December 2016, to see if the person was getting any kind of treatment for a heart problem, and found that the person was taking blood pressure medication for high blood pressure.
The insurance company is going to argue that this treatment was relating to a heart condition, or that the individual took drugs or medicines prescribed or recommended by a physician for treatment of that type of condition, and they may deny the claim because you were experiencing blood pressure problems during the lookback period.
In that type of case, we’ve argued that there’s a distinction between high blood pressure and ultimately stopping work due to a heart attack, that you should pay benefits because they are not the same condition. It’s a new and materially different condition that they stopped working because of. You’ll need to identify either a condition that you did not get treatment for during the lookback period, or that your condition is so materially different than what you received treatment for back during the lookback period, that you should still be entitled to benefits. That’s where things can get a little bit tricky.
Ortiz Law Firm Represents Long Term Disability Claimants Denied Due to a Pre-existing Condition
If you’ve been denied benefits under the pre-existing condition exclusion, then you’re going to want to talk to an experienced attorney about what your legal rights are.
We have been successful in appealing numerous claims where the claimant had treatment for a “pre-existing condition”, but such treatment was remote and the claimant did not receive treatment or otherwise exhibit symptoms during the relevant “look back period”. In these circumstances, the insurance company was compelled to pay benefits.
We’ve handled other cases where the insurance company applied the pre-existing condition exclusion and we proved that the claimant qualified for benefits due to other, non-pre-existing conditions. We’ve handled still other cases where the insurance company applied the pre-existing condition exclusion and we proved that the condition was not in fact pre-existing.
I encourage you to call us today at (888) 321-8131 to schedule your free case evaluation. We look forward to hearing from you!