Are Pre-Existing Conditions Considered in Disability Applications?

If you can no longer work due to an illness or injury, you need long-term disability benefits to support yourself and your family. When you file a claim for disability benefits from your long term disability insurance carrier, the insurance company will consider a variety of factors when making their decision about whether you’re eligible for benefits. One thing they will want to determine is whether your illness or injury is from a pre-existing condition. Moreover, many insurance companies will place certain clauses and exclusions in their policies to avoid paying out benefits for any injuries related to your pre-existing conditions when the time comes that you make a claim for benefits.

Your rights and options for obtaining disability benefits with a pre-existing condition will depend on numerous factors, and the following are ways the insurance company may consider pre-existing conditions when they’re evaluating your claim:

Pre-Existing Condition Clauses

Most insurance companies will attach pre-existing condition clauses to their policies that will contain specific wording that defines those conditions and how they affect your benefits. Some insurers will not issue policies to applicants with pre-existing conditions, and other insurance companies will limit how much they will pay and what they will cover based on any pre-existing condition.

The following are common pre-existing conditions that may cause your insurer to deny your disability claim or limit your benefits, but your insurance company may include many more:

• Cancer
• Arthritis
• Hepatitis
• HIV/AIDS
• Heart disease
• Parkinson’s
• Multiple sclerosis

Exclusion Clauses

Along with a pre-existing condition clause, the insurance company may also place limitations on your policy that will affect your claim for benefits. These could include:

• Mental and emotional disorders
• Alcohol and drug abuse
• Intentional self-harm or attempted suicide
• On-the-job injuries
• Acts of war
• Aircraft injuries
• Pregnancy

In order to determine whether you have a pre-existing condition, the insurance company will review your medical history for a specified period of time, which is known as a “look-back period.”

Look-Back Period

Insurance companies are allowed to look at your medical history before your date of coverage, and the time period they’re allowed to see can range from two or three months all the way up to one year. During that time, they will review the following:

• Any medical care, therapy, or services you received
• Any medical consultations you received
• Any prescribed medications or treatments you received

The insurance company will scrutinize your medical records and try to obtain other evidence that the disability you are claiming was something you were already suffering from, and they could use that determination to deny your claim.

However, even though the insurance company may try to avoid paying you benefits by using a pre-existing condition to limit your eligibility, you may qualify for benefits if the condition has left you unable to work. You will have to carefully review your policy with the assistance of an experienced disability attorney to understand your rights and options.

Falsely Denied Claims and Bad Faith

Many insurance companies will look for every avenue to avoid paying on a policy, and some will falsely deny a claim by making broad, and sometimes questionable, interpretations of your pre-existing condition as it relates to your LTD benefits claim. You should have an attorney review your policy with you and offer a more objective and accurate interpretation of what your policy covers.

Additionally, some insurers will refuse to pay out on a legitimate claim, even when you provide all the necessary evidence and information. If they do this, they are acting in bad faith, and you can sue them if they fail to uphold their contractual obligations.

Appealing a Denied Claim

If the insurance company denies your claim because of a pre-existing condition, you have the right to appeal the denial. Under the Employee Retirement Income Security Act (ERISA), if your LTD policy is employer-sponsored, you have 180 days to file an appeal from the date you receive your denial letter.

Contact Us

Whether you’re filing for LTD benefits for the first time or appealing a denied claim, you need the skills and knowledge of an experienced attorney to help you with the process. The long term disability lawyers of Capitan Law have decades of combined experience dealing with all aspects of disability claims. You can contact us at (267) 419-7888 to request a free consultation.