Understanding the Pre-Existing Condition Limitation / Exclusion
Almost every long-term disability insurance policy has a limitation or exclusion clause for “pre-existing conditions.” But what makes a condition, “pre-existing?” Your Policy will define what a pre-existing condition is and how it applies.
Most definitions of pre-existing conditions fall along the lines of:
Receiving Medical Treatment or Advice for an Injury, Sickness, or Disease during a specified time period prior to the coverage becoming effective.
The time period is called the “look-back period.” Typically, it means that if you file a claim within the first twelve months of coverage, a pre-existing condition review will be triggered. The insurance company will review your medical history for three or sometimes 6 months prior to your effective date of coverage.
Depending on the definition of pre-existing, if you were treated for, took medication for, or had symptoms of, the condition for which you are claiming disability, the insurance company will allege it is pre-existing and deny the claim.
For example:
- Your effective date of coverage for the LTD policy is June 30, 2021.
- Your policy has a pre-existing condition exclusion with a look-back period of 3 months.
- You began treating for “muscle weakness” and “vision problems” in the three months prior to your effective date of coverage.
- You are then diagnosed with multiple sclerosis in September 2021.
An insurance company will likely deny your benefits under this scenario. They will state that because you were treated for muscle weakness and vision problems (common early symptoms of multiple sclerosis) during the look back period, your claim is excluded under the pre-existing condition limitation in the policy.
You cannot treat a condition that is not yet known
However, courts have ruled against this reasoning. In McLeod v. Hartford, the Third Circuit held, “Hartford wrongfully determined that McLeod who had been receiving medical care for various ailments since 1997, but who was neither diagnosed with not treated specifically for multiple sclerosis until after her benefits became effective in 1999, should have been excluded from coverage due to the existence of ‘pre-existing condition.’” 372 F.3d 618, 620 (3d Cir. 2004).
The Court concludes that Hartford could not deny the insured for a pre-existing condition when neither the insured nor the doctor knew what was being treated. In other words, you cannot treat a condition that is not yet known or diagnosed.
As a disability insurance law firm, we see pre-existing condition denials frequently. Sometimes they are warranted, but many times they are not. Understanding the law and the disability insurance policy terms is crucial when determining whether the pre-existing limitation is properly or improperly applied. We have successfully represented clients in their fight against the insurance company based on a pre-existing condition denial.
Our Lawyers Specialize in Disability Insurance Claims
Because our law firm has always focused only on disability insurance, our lawyers are experts in legal representation for disability insurance benefits.
That means our disability lawyers have:
- Won several major disability lawsuits that help make better laws for disability claimants;
- Experience fighting every major insurance company, such as UNUM, Hartford, MetLife, CIGNA, Prudential, and more.
- Successfully represented hundreds of clients and won millions of dollars in disability benefits.
Federal law applies to most disability insurance claims, so our lawyers can help clients across the country.
Disability insurance companies have lawyers. You should, too. Call Dabdoub Law Firm to get experienced disability lawyers on your side.
We can help with:
- Submitting a disability insurance claim,
- Appealing a long-term disability denial,
- Negotiating a lump-sum settlement, or
- Filing a lawsuit against your disability insurance company.
Call us at (800) 969-0488 or send us your information for a free consultation with a disability attorney. No fees or costs until you get paid.
