What is a Pre-Existing Condition in Long-Term Disability

If you have a long-term disability policy, it probably has a few outlined clauses including pre-existing conditions. While it’s not uncommon for policies to have limitations, it’s important to understand how a pre-existing clause can affect a long-term disability claim later on when you need benefits. Here’s how pre-existing conditions work in long-term disability cases.

What Exactly is a Pre-Existing Condition?

Pre-existing conditions are one of the most common reasons for disability claim denials. When reviewing possible pre-existing conditions in long-term disability policies, insurance companies often take a very broad approach in their examination which can lead to a claim being falsely denied.

Even after examining all the facts, insurance companies will find a way to reject a claim and in many cases, it’s done so without merit. When faced with a long-term disability denial, it’s best not to go head to head with the insurance company alone. Most insurance company case managers are well-versed in ERISA laws so, having a long-term disability attorney on your side who knows all the tactics insurance companies use to deny claims can make all the difference.

The insurance company will review the following factors related to your illness or injury to make their determination of whether or not it’s a pre-existing condition:

  • Medical care, treatment, and other healthcare services.
  • Professional medical consultations.
  • Any prescription medication administered for your injury or illness.

What Types of Medical Conditions are Covered Under Long-Term Disability?

Both physical and mental conditions can be covered under long-term disability insurance. Although certain criteria need to be met, here are some qualifying conditions that may be covered under your long-term disability policy.

  • Physical Injuries
    For those who have a physically challenging job or dangerous occupation, injuries like broken bones and back problems can be covered under long-term disability.

  • Mental and Emotional Illness
    Long-term disability claims involving mental and emotional illnesses are often riddled with red tape and extremely complicated. While your policy may outline that emotional illnesses such as PTSD or anxiety are covered, these conditions can be tricky to prove. First and foremost, having proper medical documentation of your mental illness is paramount to the success of your claim as well as having an experienced disability attorney in your corner to assist you.

  • Other Diseases
    Cancer, HIV, diabetes and other diseases may be covered conditions under your long-term disability policy. Also, if you’ve developed an occupational illness, such as emphysema or lung cancer, through prolonged exposure to toxic materials, you may be eligible to receive disability benefits for these ailments.

Common Qualifying Mental Conditions For Long-Term Disability Benefits

There are many types of mental conditions that can be covered under long-term disability. The following conditions include but are not limited to:

  • Depression
  • Anxiety
  • Mental retardation
  • Personality disorders
  • Bipolar disorders
  • Alcohol/drug addiction disorders
  • General anxiety disorder
  • PTSD
  • Traumatic Brain Injury

Check your policy to determine the time limitation on benefits for a mental health disability claim. Benefits for mental health ailments typically only last up to 24 months. To ensure your disability benefits aren’t wrongfully terminated or denied based on the 24-month health limitation period, contact a disability attorney as soon as possible.

What is the “Look-Back” Period?

The “look-back” period is defined by the three months before your effective insurance date (in some cases longer) to determine pre-existing conditions. It’s no secret that insurance companies look for the slightest detail that can give them a reason to deny claims. Since most policies have pre-existing condition clauses, the “look-back” period can be one of the avenues in which they can determine that your illness or injury was pre-existing.

What is the Waiting Period?

The waiting period, also known as the elimination period, is the time between the onset of your disability and when you become eligible to receive long-term disability benefits. Your waiting period will begin on the day your disability began, not the day your claim was filed. Even if your application has bee approved, in most cases, you won’t be able to receive your long-term disability benefits until the full completion of the waiting period. While waiting periods usually last 90 days, some can last 180 to 365 days.

Exclusions in Long Term Disability Policies

Carefully reviewing your long-term disability policy’s exclusions can help you be better prepared when it comes time to file a claim for benefits. Besides pre-existing conditions, the following limitations could be noted in your policy:

  • Mental/nervous limitation
  • Alcohol and substance abuse limitation
  • Other exclusions
    • Aircraft injuries ( besides airline passengers)
    • War injuries or acts of war
    • Attempts of suicide
    • Normal pregnancies
    • Injuries on the job
    • Intentionally causing a disability

Again, insurance companies take a wide-approach when it comes to denying claims over exclusions. Consulting a disability for any of the above lmitations will be in your best interest when filing a long-term disability claim.

Ways Your Long-Term Disability Claim May Get Denied

There are many reasons why a long-term disability claim can be denied. The following are the most common:

  • Not submitting medical records on time.
  • Lack of proof/medical evidence.
  • Daily activities - Many insurance companies use surveillance tactics as a way to point out contradictions in your claim.
  • Social media - Social media posts can give insurance companies ammunition in claiming you are performing activities otherwise reported that you cannot do.
  • Filing a claim without a long-term disability attorney.

What to Do if Your Long-Term Disability Claim Has Been Denied

If your claim has been denied over a pre-existing condition or any other policy clauses and exclusions, its’ critical to contact a disability attorney as soon as possible.

Filing a long-term disability claim can be stressful, especially for those unfamiliar with ERISA laws. If you have been denied long-term disability benefits over a pre-existing condition or have a new claim, we can help. As an experienced ERISA law firm, we can handle all cases throughout the United States. Contact Dabdoub Law Firm today at (800) 969-0488 to schedule a consultation and learn more about your options.


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