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Can my long term disability claim be denied for a pre-existing condition?


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Can My Long Term Disability Claim Be Denied for a Pre Existing Condition?

Disability attorney Stephen Jessup discusses if a claimant’s disability claim can be denied due to a pre-existing condition.

Your long-term disability claim can be denied for a pre-existing condition; however, it’s a very fact-specific analysis as to how it’s going to happen. For instance, on a private policy you purchased on your own, if you failed to disclose a medical condition on the application for benefits and then later on you file a claim for that same condition, the insurance company, in conducting their review of your entitlement to benefits, will get medical records. If they see that there is a condition that you didn’t disclose on the application, they will more than likely deny your claim for a pre-existing condition. On top of that, there’s a good chance that they’ll rescind the policy, no matter how old it is as for almost making a fraudulent misrepresentation on the policy.

Now on ERISA-governed group policies you get through your employer, for the most part, as soon as you become employed if there’s a waiting period to become eligible, you’re going to be covered under the plan. However, they do have pre-existing condition clauses contained therein. Usually a safe bet is if you haven’t filed a claim for disability within a year of being covered under your employer’s plan, more than likely you’re not going to fall into a pre-existing condition situation. However, all policies do differ, so if you do have questions, contact us and we can definitely review the policy for you.

There are 20 opinions so far. Add your comment now.

Tammie:

I failed to apply for short and long term disability with my employer’s insurance. I went back and requested to do so and was told to submit a FOI. I did so and it was denied. I am a paraplegic and am being denied. Is this legal and is there anything I can do. I do not need short/long term right now, but may in the future.

Attorney Stephen Jessup:

Tammie,

If you were not a covered employee under the policy at the time you applied there might be very little that can be done. Based on the information provided, I am uncertain as to what your legal rights may be. Please feel free to contact our office to discuss how we may be able to assist you.

Kelly Whittington:

Hi! My name is Kelly and I am trying to see if my husband insurance is trying to not pay what I think they should. My husband was just denied his long term disability as of yesterday. They gave him short term and discontinue in February, saying that they had to start the long term disability claim. They are saying that his medical condition is pre-existing but he has not had a lapse in insurance so I am not sure how they are claiming this. They owe us since Feb. 6 of this year so I am assuming they are not paying because of the amount of back pay they owe us. My husband has not worked since November and that is when he started receiving the short term. When he asked them why did he get short term and they said that it was over looked somehow that his condition was pre-exisiting. Just trying to see if we can fight this some kind of way? Help!

Jacquelyn:

I was denied an insurance claim through a financial company for a pre-existing condition. During May of 2013 I was having pain in my left heel I went to my primary Doctor and he only gave me pain medication the pain did not subside so I continued work in the meantime. I made a loan with this company around October of 2013. The pain increased so I decided to go to and othropedic in which he did an x-ray and found that I had and heel spur so he ordered me to wear a boot but the pain just worsened so he ordered an MRI then he found out that I had a torn tendon. Should I appeal this case?

Attorney Stephen Jessup:

Kelly,

Please feel free to contact our office. Many Short Term Disability policies do not contain pre-existing condition provisions, and for those that do, it requires a minimal amount of time with the company/coverage under the policy to overcome the provision. Long Term Disability pre-existing provisions are much more stringent.

Attorney Stephen Jessup:

Jacquelyn,

I am unsure if we can assist you. Is your inquiry regarding a pre-existing provision under a disability insurance policy?

Lea:

I am a nurse of 27 years have had arthritis for more than 10 years and took a pain pill and a muscle relaxer at night so I could sleep without pain. And rarely 1-2 times a yr I would have a bad week and go into the clinic for a steroid and an anti inflammatory injection. I have never missed a day from work because of the arthritis pain. Open enrollment in Dec of 2012 for the upcoming year 2013, I added the LTD to my benefits package. The pain became so much worse after a pretty bad fall at my house on an icy deck in Feb 2013, I ended up getting an epidural steroidal injection into my spine and it only got worse. Ended up in the hospital for 11 days, came home with surgeries to both right and left side joints, which has literally crippled me.

Attorney Stephen Jessup:

Lea,

Please feel free to contact our office to review your policy and discuss any potential disability claim you may have.

Melinda:

My insurance company is refusing to pay me long term disability benefits. I had 2 back surgeries done within the year and they are stating that I had a pre-existing condition, although my surgeries were for different reasons. I believe they were not correlated in any way. Can I still get benefits? Help me please.

Attorney Stephen Jessup:

Melinda,

Pre-existing condition provisions often contain language very favorable to the insurance company. Please feel free to contact our office to determine if we can assist you in appealing the denial on account of same.

Candice:

I have had insurance coverage with my job for a few years. I have had long term with a 90 day waiting period. During the enrollment period I switched to coverage with a 30 day waiting period. I delivered my son in October and filed for a claim a month later. I was told that I would not be because it’s considered a pre-existing condition. Should I still be eligible?

Attorney Stephen Jessup:

Candice,

Without seeing the policy or the denial letter we would not be able to determine. Please feel free to contact our office with the information so we can best determine how we may be able to assist you.

Cheryl:

I had 3 back surgeries in 2008, the last one was a spinal fusion. I had no issues since with my back until July of 2014, when I was sitting at work, and had shooting pain from my lower back to my foot. I couldn’t move after that and was in excruciating pain. I was admitted to the hospital for 1 week, and was on STD for 7 weeks. I opted to go back to work after 7 weeks, because my employer allowed me to work from home. A week later I was back in the office, and returned to full-time. I received cortisone/steroid epidural injections 4 times since that episode, and felt good until late October when the pain in my back and leg started again, along with the numbness in my foot. I have since received more injections, but they are doing nothing to alleviate the pain. My neurologist and neurosurgeon have diagnosed me with Failed Back Syndrome. I signed up for LTD and STD with my company in January of 2014. When I signed up for LTD and STD with my company, there was nothing in the paperwork about pre-existing conditions preventing me from LTD.

My question is this, can I get LTD for my recent diagnosis of FBS? I am a software engineer, and sit all day long. I am in pain 90% of the time, and am certain that the sitting is only exacerbating my already severe back issue. I can’t see going on like this indefinitely. Thank you. I appreciate any assistance you can offer.

Attorney Stephen Jessup:

Cheryl,

We would need to see a copy of your policy in order to best advise you as to the applicability of any pre-existing condition language. Typically, most LTD policies require you to be covered continuously for 12 months before a pre-existing condition exception is waived. Please feel free to secure a copy of your employer’s policy and contact our office to discuss same.

Pat:

July of 2014, I bent over to pick up a golf ball, when I raised up I had severe back pain. Thinking this would go away, I returned to work the next day as a Nurse. Five days passed and the pain became so debilitating that I sought medical advise. X-ray revealed a collapse vertebrae of T7 and I went out of work immediately. Approx 4 weeks later I underwent Kyphoplasty Surgery. After having surgery I continued to have several limitations that impacted my ability to return to work. I was later advised to have a bone density test which revealed that I had osteoporosis.

Covered by STD, I was paid for 11 weeks, then LTD took over. The coverage continued for 4 months, then I received a letter stating they were denying further benefits based on the fact that I was treated with Vit D 3 months prior to effective date of LTD coverage. The insurance company stated this since I was diagnosed with osteoporosis and had been treated for Vit D deficiency 3 months prior to effective date of coverage they were considering this to be a pre-existing condition.

While researching and reviewing different case scenarios I found a site where an attorney argued that the treatment prior to the actual diagnosis was considered a treatment but without a known causative factor and therefore this person was not considered to have a pre-existing condition. He won the case.

Do you feel I have the same or similar circumstance and could possibly win my case?

Attorney Stephen Jessup:

Pat,

Pre-existing condition clauses are unique to the policy and some are certainly more broad than others. Please feel free to contact our office with a copy of the denial letter to determine how we might be able to assist you in appealing the denial.

BendyZebra:

I am trying to figure out if my condition would be considered pre-existing under my LTD plan. This is what my plan states.

My long term disability pre-existing condition:

You have a pre-existing condition if both 1. and 2. are true:

1. (a) You received medical treatment, consultation, care of services, including diagnostic measures, or took prescribed drugs or medicines, of followed treatment recommendations in the 3 months just prior to your effective date of coverage or the date an increase in benefits would otherwise be available; or
(b) you had symptoms for which an ordinarily prudent person would have consulted a health care provider in the 3 months just prior to your effective date of coverage or the date an increase in benefits would otherwise be available.

2. your disability begins within 12 months of the date your coverage under the plan becomes effective.

I began my employment in July of 2008 becoming eligible for benefits after 90 days. I was diagnosed with a hereditary connective tissue disorder Ehlers-Danlos in October of 2011. I had been treated in the past for issues related to Ehlers-Danlos but was never properly diagnosed till 2011. Furthermore, in the 3 months before I was employed and 3 months after I was employed I was currently not seeking treatment for anything nor was I in need of treatment. My concern is that because I was born with Ehlers-Danlos and had been treated in the past for arthritis and hypermobility that they would consider it pre-existing. The way Im understanding it, is that as long as I wasn’t being treated or having a problem that needed to be treated in the 3 months prior and my disability began well after the 12 month mark, my condition should not be considered pre-existing?

Hope I explained that well. Thank you

Attorney Stephen Jessup:

BendyZebra,

Under the overwhelming majority of ERISA disability policies if you have been covered under the policy for over 12 months then all pre-existing conditions would be waived. Based on the information you provided you do not appear to be at risk of having the claim denied for a pre-existing condition. Please feel free to contact our office should you have any other questions or would like to discuss applying for benefits.

Jana:

I found out 5 months ago I have Lupus/RA.

Because of all the doctor visits, pain, fatigue that is causing me to call in sick; headaches, flu like symptoms, stomach problems, thinking clearly and working towards the correct medications to fix this (plus I have a fatty liver that could turn worse, we are checking this now) I went out on FMLA to cover my job.

I have LTD thru my employer however from what I read it would not be available to me for 1-2 years and that is “IF” I must leave my job due to this pre-existing condition.

I am single, age 56, so naturally there isn’t anyway that I can afford to lose my income and not have Insurance for a month let alone 1-2 years!

My question is: Should I stop paying for the LTD and start saving this money because I must continue to try to work but I am afraid my employer could fire me for unavailability reasons then I wouldn’t be able to apply for LTD anyway. Thoughts?

Attorney Stephen Jessup:

Jana,

Without knowledge of the actual policy language we would not be able to opine one way or another as to any applicable pre-existing provision. Please feel free to contact our office to discuss your situation further.

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