Most every group long-term disability policy will include a complete exclusion for any disabilities caused by a pre-existing condition. Private long-term disability insurance policies purchased by individuals normally also exclude coverage for a pre-existing condition unless higher premiums are paid for special coverage that does not include the exclusion. Exclusions such as the pre-existing condition exclusion are often misused by companies to avoid paying disability insurance claims in effort to save a company billions of dollars, and is another common tactic used by companies to delay or deny payment of legitimate claims. Whether a condition is legitimately “pre-existing” (and thus excluded from coverage) or not depends upon the provisions in the policy applicable to disabilities caused by a pre-existing condition. The disability policy language related to pre-existing condition exclusions can vary greatly, and even the slightest distinction could mean the difference between your disability being covered or entirely excluded from coverage under the policy. Given that the disability income benefits at issue under these policies are customarily paid through age 65 or even lifetime, whether the disability is actually excluded under the policy according to the law governing these matters is hugely significant.
Generally speaking, a disability policy will define a pre-existing condition according to two time periods, which can be described as a “look back period” and a “pre-existing condition waiting period.” A look back provision defines which conditions are considered to be “pre-existing” under the policy. For example, a look back provision may involve something like the following: “a Pre-existing Condition means any Injury or Sickness for which the Employee incurred expenses, received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a Physician within 12 months before his or her most recent effective date of coverage.” While this particular look back period lasts 12 months, the look back period normally ranges anywhere from 3 months to 12 months. The pre-existing condition waiting period is the second time period at issue, which is the amount of time you must be covered under the policy before a pre-existing condition falling within the definition of the look back period will be covered under the policy. This period is normally 1 to 2 years, but it can vary according to the policy and according to the state where the policy is written or issued where varying statutory requirements regarding pre-existing condition exclusions likely exist. An example of a pre-existing condition waiting period is a provision following the look back provision which explains that “this limitation will not apply to a period of Disability that begins after an Employee has been in Active Service for a continuous 12 months during which the Employee has received no medical treatment, care or services in connection with the pre-existing conditions or is covered for at least 24 months after his or her most recent effective date of insurance, or the effective date of any added or increased benefits.” As one can readily see, the policy provisions involved in determining whether a medical condition causing a disability is truly pre-existing are both complicated and convoluted. Of course, if there is any chance that your medical condition involved in your disability claim filed can be argued under the pre-existing condition exclusion, then it will be and your company will deny coverage outright. Again, complete exclusions of disabilities from coverage under a policy saves companies billions of dollars and the insurance company representative reviewing your claim for benefits is an advocate for the insurance company and not you.
Denials of disability insurance benefits based upon a pre-existing condition exclusion in the policy is one of the most common reasons that we receive calls from individuals seeking legal counsel. Many times, disability claims are denied on the basis of a pre-existing condition exclusion when the individual and their doctors were entirely unaware that a certain medical condition even existing during the look back period. If you and your physicians were unaware of an existing medical condition at that time, how could you have received treatment, taken medications or consulted with a physician for a condition no one knew existed? In many cases, even if you had an undiagnosed medical condition that no one knew existed at the time, your disability caused by that condition will still be legally covered under the policy. However, these claims are most commonly denied outright by companies. A disability claim denied on this basis can become even more complicated when the provisions of the policy are not limited to treatment, consultation or medication actually received during the look back period but also encompass an injury, sickness or symptoms for which a “reasonable person would have consulted a physician.” Denials of disability claims on the basis of a pre-existing condition exclusion rarely involve a situation where an individual treats for a diagnosed medical condition during the look back period, which then disables them within the waiting period following the coverage effective date.
For example, if you are diagnosed with cancer and begin to undergo chemotherapy or radiation during the look back period, and then become disabled from your job due to the same cancer during the pre-existing condition waiting period, the condition (cancer) causing your disability is pretty clearly a pre-existing condition and excluded from coverage. However, this is rarely the situation at issue. Consider the example of a person who has a strong history of cancer in their family (such as breast cancer) but who has never had cancer him/herself, who undergoes preventative measures such as hormone or medication therapy, including during the look back period, and then is diagnosed with cancer during the 1 or 2 year pre-existing condition waiting period. The person was considered cancer free until the cancer was discovered, and did not experience symptoms that he/she (or his/her doctor) believed would be caused by cancer, but the company denies the disability claim on the basis of the pre-existing condition exclusion. Likewise, consider an individual who takes baby aspirin or another medication to prevent a heart attack for an extended period of time, and also during the look back period but does not treat with a cardiologist or other doctor regarding a heart attack or symptoms that would be caused by a heart attack – in fact, the person has no history of a heart attack and just has a family history. That same individual suffers a disabling heart attack during the pre-existing condition waiting period, and the company denies the claim on the basis that disability is due to a pre-existing condition. Do taking vitamins to ward off nutritional deficiency during a look back period then also create a pre-existing condition that will be excluded from coverage if you are disabled by the same condition during the pre-existing condition waiting period? Or, what if during the look back period you experienced cold like symptoms and consulted a doctor who diagnosed the symptoms as allergic rhinitis and noted a small lymph node (common with inflammation or infection) on examination, and then over a year later you were diagnosed with throat cancer by your physician which caused disability from work. The company argues that you treated for symptoms of throat cancer during the look back period and you became disabled during the pre-existing condition waiting period due to throat cancer and thus that your disability claim is excluded from coverage. These are very common scenarios that we are contacted by individuals about, and also involve scenarios where we have succeeded in securing disability benefits for our clients either directly with the insurance company or in court.
Many individuals faced with a denial of their disability claim assume that the company’s interpretation of the policy is correct and that their claim was accurately denied. However, the terms of the policy at issue are often written with ambiguous language and the companies deciding whether a claim should be paid or denied frequently apply an unreasonably restrictive interpretation of the policy language to deny a claim. Knowing your rights under your disability policy and the governing law can mean the difference between your benefits ultimately being paid or denied. As many times the disability income benefit at issue continues through your 65th birthday or even your lifetime, this is hugely significant. The pre-existing condition exclusion is another tactic utilized by companies to avoid being liable under a disability policy that it insures.
If you have experienced a delay or denial of payment of your disability benefits on the basis of a pre-existing condition investigation or denial, contact one of our experienced attorneys at www.dilawgroup.com.