You’re probably here today because the insurance company has denied your claim for long-term disability benefits, saying that they’re denying you due to a pre-existing condition.
What Does Pre-existing Mean?
The first thing is, the pre-existing condition is going to be specifically defined in your policy. A page from an Aetna long-term disability policy says:
“No benefit is payable for any disability that is caused by or substantially contributed to by a pre-existing condition or medical or surgical treatment of a pre-existing condition and starts before the end of the first 12 months following your effective date of coverage. A disease or injury is pre-existing if, during the three months right before your effective date of coverage, it was diagnosed. Or you received medical treatment, care, or services for the disease or injury. Or you took drugs or medicines prescribed or recommended by a physician for the disease or injury.”
The best way to come to understand how a pre-existing condition impacts a long-term disability case is to perhaps use an analogy to a different kind of case:
So let’s say that someone was just diagnosed with cancer, and they didn’t have any health insurance before. They now realize the importance of health insurance and that it would have been nice to have health insurance to get all the treatment that’s required for that type of serious condition. However, if someone has cancer, and they go out to try to buy a new health insurance policy, very few insurance companies are going to want to underwrite that. So they’re either going to deny coverage, saying that we’re not going to cover you for cancer, or they’re going write a policy saying that we’re going to cover you for every type of medical condition except for cancer. So they exclude it as a pre-existing condition.
The same type of concept applies to a long-term disability claim. The idea is they don’t want to cover you for something that you’ve been getting treatment for if you go out on disability within a year of starting your job. So that’s where it says if it starts before the end of the first 12 months following your effective date of coverage then it is a pre-existing condition.
So, let’s use an example within the long-term disability world. Let’s say that someone started working on January 1 of 2017. And they’re going along, working great for a few months. And then on April 1 of 2017, they have to stop work due to a back pain problem: They were in a car wreck, they herniated discs and they’re no longer able to go back to work because of their disc herniations and their pain, and the recovery goes along with that. Now, they were only at work for about three or four months before they went out of work, so they would be subject to the pre-existing condition exclusion because this condition arose within the first 12 months of their employment.
The insurance company is going to go back and look at what happened during the three months prior to the date the insurance took effect. So in this case, they’re going to look at October, November, and December of 2016 to see, “did that person get any kind of treatment for that condition in that three month time period?” So if they got treatment for a back pain condition in October, November, or December of 2016, then they would not cover it.
But, the thing was, using our example, the person was in a car wreck. So they probably weren’t getting treatment for a back condition. And, in fact, it can be shown that their condition is related to that accident, which did not occur during the pre-existing look back period. There probably would be coverage in that instance because it’s not a pre-existing condition. It’s a condition that arose after the coverage took effect.
But let’s change the circumstances a little bit. Let’s say they didn’t go out because of a back pain problem, but let’s say that they went out because of a breathing disorder. Like, they have really bad COPD, and it’s gotten to the point where they have extreme difficulty breathing, extreme difficulty doing activities of daily living, and difficulty doing work activity.
So again, it was only after three or four months on the job, and now the insurance company’s going to do the same evaluation. They’re going to look to see if the claimant was getting any kind of treatment during the three months prior to Jan 1 of 2017? Let’s say our person did get treatment on November 15 of 2016. They went to go see a pulmonologist because of the breathing problems they were having. It wasn’t as bad as it was when they ultimately went out of work, but they were still having problems, and so they were seeing a lung doctor.
Well, in that instance, the insurance company is very likely to deny the claim because they’re going to say you stopped working within one year and you did get treatment for that breathing problem in the three months before the coverage took effect. Therefore, because it’s the same condition, it’s a breathing problem, a lung problem, we’re not going to cover you for LTD benefits.
So some pre-existing conditions are relatively clear cut, such as those two examples that I just gave. But things can get a little bit more complicated when there does seem to be maybe some overlapping symptoms between what the patient got treatment for and what they ultimately stopped working for.
Let’s say that our hypothetical person went out of work, again in April of 2017, due to a heart attack. And let’s say that the insurance company gets all the medical records, and they go back to October, November, and December of 2016, to see if the person was getting any kind of treatment for a heart problem. And let’s say that the person was taking blood pressure medication for high blood pressure. Now, the insurance company is going to argue that this treatment was relating to a heart condition, or that the individual took drugs or medicines prescribed or recommended by a physician for treatment of that type of condition. And they may deny the claim because although you had the heart attack later, you were experiencing blood pressure problems during the lookback period. And therefore, they are going to deny you benefits.
So in that type of case, we’ve argued that there’s a distinction between high blood pressure and ultimately stopping work due to a heart attack, that you should pay benefits because they are not the same condition. It’s a new and materially different condition that they stopped working because of. So what you’re going to need to identify is either a condition that you did not get treatment for during the lookback period, or that your condition is so materially different than what you received treatment for back during the lookback period, that you should still be entitled to benefits. That’s where things can get a little bit tricky.
Ortiz Law Firm Provides Aggressive Representation to Long Term Disability Claimants
If you’ve been denied benefits under the pre-existing condition exclusion, then you’re going to want to talk to an experienced attorney about what your legal rights are. And we encourage you to contact our law firm because we do have experience in dealing with pre-existing condition exclusion denials by insurance companies. If you want a free consultation because you’ve been denied benefits, I encourage you to give us a call at (888) 321-8131. If you’d like a copy of a book that I wrote called the Top Ten Mistakes That Will Destroy Your Long-Term Disability Claim, you can download the book here. We look forward to hearing from you.