Navigating the complexities of long-term disability insurance can be daunting, especially when pre-existing conditions come into play. This blog aims to unravel the intricacies of how pre-existing conditions can influence the approval or denial of LTD claims.

What is a Pre-Existing Condition?

A pre-existing condition (often called a “pre-ex” or “pre-x” in the insurance industry) is any health issue that existed before you obtained your long-term disability insurance coverage. These conditions can range from chronic illnesses like diabetes and heart disease to mental health disorders and previous injuries.

The Look-Back Period

Different insurance policies deal with pre-existing health conditions in different ways. There is often a distinction between how private insurance policies deal with pre-existing health conditions versus group insurance policies. As with everything to do with insurance, it will almost always come down to the specific wording of your policy.

Generally speaking, long-term disability Insurance policies often include a “look-back period,” which is a specific timeframe during which the insurer examines your medical history to identify any pre-existing conditions. This period typically spans from 3 months to 1 year before the effective start date of your insurance coverage. If you received treatment, medication, or were diagnosed with a condition during this look-back period, it might be classified as pre-existing, sometimes even if you were not aware you had it depending on the wording of the policy.

How Pre-Existing Conditions Affect Long-Term Disability Claims

As stated above, it will depend on the specific wording of your long-term disability policy, however some of the common issues that arise when there is a pre-existing health condition that arises in the context of a long-term disability claim are:

• Waiting Periods – Some policies may include a waiting period during which coverage for pre-existing conditions is not available. These periods are policy dependent, but it is common to see waiting periods of 90 days, 180 days, or 356 days.  For example, if your policy has a 12-month (365 day) waiting period, you may have to wait a year from the start of your coverage before a claim related to a pre-existing condition can be considered
• Policy Exclusions and Limitations – Many long-term disability policies contain clauses that specifically exclude coverage for disabilities arising from pre-existing conditions. This means if your disability is linked to a condition you had during the look-back period, your claim could be denied
• Medical Evidence – Insurers often scrutinize medical records closely. If they determine that your current disability is related to or exacerbated by a pre-existing condition, they may deny your claim. It’s crucial to provide comprehensive medical evidence to support that your disability is new or that your pre-existing condition has significantly worsened independently of the look-back period and ensure that your doctor clarifies any discrepancies or unclear notations in your medical records.

What to do if Your Long-Term Disability Claim is Denied Due to a Pre-Existing Condition?

If your long-term disability claim is denied due to a pre-existing condition, there are several steps you can take:

1. Carefully Review Your Policy – Understanding the specific terms and conditions of your policy, including the look-back period, exclusions, and any waiting periods, is crucial to being able to successfully challenge your insurance company’s position.
2. Gather Medical Documentation – Collect thorough medical records that differentiate your current disability from any pre-existing conditions. This can include statements from your healthcare providers. Having your treating doctor on your side can go a long way in convincing your insurance company to pay your benefits.
3. Appeal the Denial – Most insurance companies offer an appeals process. Submit a well-documented appeal that includes additional medical evidence and a detailed explanation of why your disability should be covered and is not a pre-existing health condition.
4. Seek Legal Advice – Often times once an insurance company has made up their mind about a claim, it is extremely hard to persuade them to view the claim in a different light. Contacting an experienced lawyer who specializes in long-term disability claims can provide valuable guidance in making your insurance company think twice about denying you the benefits you are entitled to.

If Your Long-Term Disability Claim Has Been Denied

If your long-term disability claim has been denied due to a pre-existing health condition, the experienced insurance denial lawyers at Taylor & Blair LLP can help. Our lawyers can review and help you interpret your insurance policy, gather the necessary information and evidence required to convince the insurance company and their lawyers that you deserve to be paid the long-term disability benefits you contracted for.

Contact the long-term disability denial lawyers at Taylor & Blair LLP today for a free consultation.