Disability insurance policies often ban coverage for disability that stems from pre-existing conditions. In other words, if someone had a medical problem within a specified time frame prior to their effective date of coverage and they became disabled within the first 12 months of being covered under the policy (although this timeframe could range between 6 months and 2 years), the insurance carrier may deny benefits on the basis that the disabling medical condition is a pre-existing medical condition.
An example of common pre-existing policy language is: You have a pre-existing condition if 1) You received medical treatment, consultation, care or services, including diagnostic measures, or took prescribed drugs or medicines in the 6 months just prior to your effective date of coverage (this is known as the “lookback period”); AND 2) The disability begins in the first 12 months after your effective date of coverage.
Thus, if a claimant files a disability claim due to cardiac failure within the first year of having the policy, the insurance company will review their medical records for the 6 to 12 month period prior to the effective date of coverage to determine if there is evidence of heart problems or heart related treatment.
Insurance companies may wrongly deny based on unfounded analyses
Too often, disability insurers try to use pre-existing condition clauses to deny valid claims by citing to information in prior medical records that is irrelevant or not related to the disabling medical condition. For example, the insurer may deny a claim by pointing to a single symptom not closely related to the disabling diagnosis, such as a single episode of shortness of breath in a cardiac claim, as evidence that the insured’s disabling condition is pre-existing.
In the recent case of Bayer v. Unum Life Insurance Company of America, which the U.S. District Court in the Eastern District of Louisiana released on May 20, Unum claimed that an eye problem during the lookback period was evidence of Multiple Sclerosis. The court conducted a de novo review (newly reweighing the evidence in the insurance claim file according to applicable law) and said that Unum wrongly denied the plaintiff’s long-term disability (LTD) claim based on the pre-existing condition clause.
Disability from multiple sclerosis
Kim Bayer was a senior property manager when she developed multiple sclerosis (MS), causing problems with standing, balancing, walking, memory and fatigue. She filed first for short-term disability (STD) benefits (also denied) and later for LTD benefits under a policy through her employer. Her experienced MS specialist, Dr. Bagert, “concluded that [p]laintiff’s job was a hindrance to her well-being” and that she should stop working.
Bayer’s employer had switched LTD insurance providers during her employment, from Prudential to Unum. The later policy had a “continuing coverage” clause providing that even if a claimant’s condition was pre-existing under Unum’s definition, if it was not pre-existing under the Prudential plan, Unum would not deny the claim.
Unum alleged that under the Prudential policy, Bayer’s claim failed due to the pre-existing exclusion. Specifically, it said that a diagnosis of an eye problem, pars planitis, and an appointment for “peripheral neuropathy” during the look-back period were both evidence of pre-existing MS.
The federal court disagreed, finding that the evidence did not support that conclusion. Specifically, the claimant’s treating doctor had clarified that the eye condition could – but might not have been – be related to MS and had assigned a later MS onset date than the date of the eye diagnosis.
Qualified medical analyses
The court emphasized that Unum never had an affiliated doctor – let alone an MS specialist – examine Bayer or even do a paper review of her records. Instead, Unum left the medical reviews to nurses and staff members without medical or MS experience. The court said that while the insurer does not have to give “special weight” to Bayer’s treating doctor, it may not “arbitrarily refuse to credit [her] reliable evidence, including the opinions of treating physicians.” The Court found that Unum arbitrarily ignored Dr. Bagert’s opinions and therefore its conclusion that the MS was a pre-existing condition was not correct.contact
An important takeaway is that while a claim denial may focus on symptoms and treatments cherry-picked from the lookback period, characterizing them as pre-existing evidence of the disabling condition, this conclusion is often not supported by the record in its entirety, giving appropriate weight to credible treating physicians and medical specialists.
If you believe that your claim was wrongly denied as a pre-existing condition, please contact Disability Insurance Law Group for a free consultation.