If you believe your disability insurance claim was wrongfully denied due to a pre-existing condition, you are not alone. Insurance companies often use pre-existing condition exclusions to unfairly deny legitimate claims. If a condition existed before coverage began, your insurer may deny your claim, even if the current disability is unrelated.

At Roy Law Group, we’ve seen disability insurance companies pull out all the stops to justify denying a claim. A denied disability claim can feel defeating, but it’s not the end of the road. With experienced legal representation, you can fight back against the insurance company to get the benefits you deserve.

In this article, we’ll discuss what you need to know about pre-existing conditions and how an exclusion clause can impact your claim. We’ll also cover what you can do to fight a denied claim and get the support you need.

What we’ll cover:

What is a pre-existing condition?

A pre-existing condition refers to a medical issue that was present before you obtained coverage from a disability insurance policy. It can encompass a wide range of medical issues, including physical and mental health conditions.

Most insurance companies include pre-existing condition clauses in their long-term disability policies. These clauses can limit coverage for any conditions that existed prior to the policy’s effective date.

Common pre-existing conditions include:

  • Anxiety
  • Arthritis
  • Asthma
  • Cancer
  • Depression
  • Diabetes
  • Hypertension
  • Heart Disease
  • Migraines

Having a medical issue before your insurance coverage began doesn’t automatically mean your disability benefits should be denied under the pre-existing exclusion. The insurance company can deny your claim only if the pre-existing condition directly causes your disability.

The importance of full disclosure

When you apply for long-term disability coverage, it may be tempting to withhold some details about your medical history. Your insurance company will use this information to set your premium based on how likely you are to need benefits. They may also exclude specific conditions from coverage entirely.

It’s essential to be honest and disclose all relevant medical information when applying for coverage. Failure to disclose a medical condition could lead to problems later. Insurers often have access to your medical records, and any discrepancies between your application and your medical history can raise red flags.

How do pre-existing condition exclusions affect long-term disability claims?

Pre-existing condition exclusions help insurance companies prevent adverse selection, where individuals with a higher risk of needing insurance are more likely to purchase it. Insurers rely on exclusions like this to help them protect their bottom line.

When you file a long-term disability claim, insurers typically review your medical history. If they find that your disability is related to a pre-existing condition, they may deny your claim.

Insurance companies often misapply pre-existing condition exclusions and deny valid claims by stretching definitions or connecting unrelated medical conditions. Many disability claims are denied for pre-existing conditions, but insurance companies do not have blanket authority to deny all claims on those grounds.

The lookback period matters

Disability insurance policies typically include a “lookback period” to determine whether a condition is pre-existing. This period typically ranges from 3 to 12 months before coverage begins.

Insurers will want to know whether you were diagnosed, treated, or had symptoms of your disability during the lookback period. If your medical history shows a pre-existing condition that occurred during this time, it can be used as a basis for denial.

What to do before you file a claim

Improving your chances of a successful long-term disability claim requires careful preparation, an understanding of what to avoid, and a solid grasp of your policy’s terms. Here are some recommendations to consider before filing your claim.

1. Review your disability insurance policy

Understanding your policy thoroughly is the first step toward avoiding surprises. Make sure you understand the exclusions and limitations of your policy. Look for any clauses related to pre-existing conditions and understand how they may affect your coverage.

In many policies, a pre-existing condition is only excluded if a claim is made within the first year of obtaining coverage. In those policies, if a claim is made after the first year passes then the preexisting condition clause does not apply.

You should also be aware of the elimination period in your policy. This is the length of time you must wait after becoming disabled before you can receive benefits. Typically, elimination periods are 6 months.

2. Document everything

It’s important that you maintain thorough medical records to document any condition that could affect your disability claim.

Keep records of your medical treatments, and any communications with your healthcare providers. This documentation can be invaluable in helping you physician fill out any requested Attending Physician Statements or drafting supportive correspondence if you need to appeal a denied claim.

3. Consult with a lawyer

If you know you have a pre-existing condition, consider consulting a disability insurance lawyer. They can help identify any potential pitfalls in the application process and help you avoid common mistakes. Having expert guidance from an experienced lawyer can make all the difference in the outcome of a claim.

4. Consider waiting

If you know you have a pre-existing condition, you might want to wait to apply for disability insurance until the pre-existing condition limitation no longer applies as defined by your policy. This can help reduce the risk of denial.

What to do if your disability claim is denied for a pre-existing condition

A denial of benefits based on a pre-existing condition can be stressful. But it’s important to remember you have options. If your claim has been denied, here are some important next steps.

1. Review your denial letter carefully

Review your denial letter to understand why your claim was denied and any important deadlines for filing an appeal. Insufficient medical proof, gaps in treatment, and failure to meet the strict definition of disability are common reasons for denial of disability claims.

2. Gather additional supporting evidence

Medical evidence is crucial in challenging denials based on pre-existing conditions, as it can demonstrate the distinction between past and current disabilities.

If you believe your insurance company has wrongfully denied your claim, you’ll need to provide additional medical records and evidence to support your case. This includes physician statements and any relevant test results or documentation that support the need for treatment.

3. File an appeal within the specified timeline

If your disability claim is denied due to a pre-existing condition, you may still have options to appeal the decision with additional medical evidence or legal support.

Under ERISA, claimants typically have 180 days to file an internal appeal after a denial.

Read also: How to Appeal a Long-Term Disability Denial

4. Contact an experienced disability insurance lawyer

Consulting a disability attorney can significantly improve your chances of winning an appeal against a denial based on a pre-existing condition.

Many people accept denials without question due to the complexity of insurance policies, but legal assistance can help challenge these decisions effectively. Attorneys experienced in disability claims can help interpret complex policy language and assess the validity of a pre-existing condition denial.

Fighting disability insurance denials is all we do

Roy Law Group is 100% dedicated to helping clients fight against insurance companies to secure the disability benefits they deserve. Our team of long-term disability attorneys has helped hundreds of claimants overturn claim denials.

If you’re considering filing a claim or an appeal or have questions about pre-existing conditions, we are here to help. Contact us for a free consultation today.

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