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Pre-Existing Condition Limitation Archives

Court Ruling on Mutual of Omaha Pre-Existing Denial of Benefits

In the case of Horneland v. United of Omaha Insurance Company, the eleventh circuit reversed the United States District court for the Middle District of Florida's decision finding for the defendant. In the case, Horneland sued United of Omaha Life Insurance Company under ERISA, due to the fact that United of Omaha Life Insurance Company denied Horneland's long term disability. Horneland began to work as a real estate manager for Thornton's Inc. as part of the employment, Horneland received short term and long term disability coverage. However, per United of Omaha Insurance Company's insurance plan, long term disability coverage begins on the day following completion of 12 months of Active employment. The long term disability benefits also include a Pre-existing conditions exclusion. That exclusion states that the insurance company will not provide benefits for disability (a) caused by, contributed to by, or resulting from a Pre-existing Condition; and (b) which begins in the first 12 months after the individual is continuously insured under the policy. The eleventh circuit defines the term pre-existing as any injury or sickness for which the individual received medical treatment, advice or consultation, care or services including diagnostic measures, or had drugs or medicines prescribed or taken in the 3 months prior to the day they become insured under the policy.

The Pre-Existing Condition Provision in a Disability Insurance Policy

Most employer provided Long Term Disability policies and some individual disability insurance policies include an exclusion for disabilities caused by a pre-existing condition. Generally, a disability insurance pre-existing condition is defined as a mental or physical condition for which you become disabled within the first 12 months of coverage and that existed and for which you received treatment within the 3 to 12 month time period just prior to the date of coverage under the policy. The time periods, however, vary from policy to policy. The purpose of the pre-existing condition exclusion is to prevent individuals who have been insured for one year or less (in most cases) from receiving disability benefits for injuries they had prior to the start of the policy. As such, the disability insurance pre-existing condition may result in a denial of benefits. Most pre-existing condition provisions include two time periods: a "Look Back" period and a Pre-Existing Condition Waiting Period:

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