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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 76 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.

Ms. Kirk:

If my STD and LTD both state in my employee benefits guide ” pre-existing condition”…NONE. Then do they still gather detailed medical records for LTD? Also, stating they are gathering that information to make a decision on the claim!

Attorney Stephen Jessup:

Ms. Kirk,

An insurance company has to review the applicable medical records in order to determine eligibility for benefits under a policy. A diagnosis is not enough, there must be evidence that the condition causes functional restrictions and limitations.

David:

I am expecting my long term disability claim to be denied because of a “pre-eisxting condition” of high blood pressure. The doctor said my stroke was “likely” caused by high blood pressure, not “was caused by high blood pressure. If I am refused, what is the likelihood of winning an appeal?

David

Attorney Stephen Jessup:

David,

Chances of success will be very much dependent on the definition of pre-existing condition used in your policy and whether or not your policy contains a “discretionary clause.” Please feel free to contact our office in the event of a denial of benefits to discuss how we may be able to assist you.

Travis ( feeling hopeless:( ):

I signed up for my company’s short term and long term disability in May. I was hired at the beginning of February. I had to hemorrhoid surgically removed on July 27. I was out of work for 6 weeks. I contacted Principal my company’s disability provider. Their telling if I saw any doctor related to my surgery 3 months before the policy went into effect in May. That my disability would be denied because it is a pre existing condition. I just happened to have since a doctor on February 5 who recommended I have the surgery done. This all seems so unfair and not right. Do I have a chance in appeal their decision? Thank you so much.

Attorney Stephen Jessup:

Travis,

Unfortunately, the chances of winning an appeal on a pre-existing condition is very hard. Disability policies contain the provisions to prevent people from starting a job to then file for disability – it does seem unfair in a situation like yours – but that is the reality of the provision. You have nothing to lose in appealing the denial, so I would certainly encourage you to do so. The worst that can happen is Principal will say no.

Susan:

Hello,
I have arthritis in my knees and back, high blood pressure and I’m severely overweight. I’ve been working full time at the same company for 8 years. They don’t offer disability insurance. I’m thinking of purchasing disability insurance thru my auto insurannce company. Would I even be accepted for a plan given my health history or would it be a waste of time having a long meeting with the agent?

Attorney Stephen Jessup:

Susan,

You will need to discuss your concerns with an insurance agent to determine any potential eligibility for coverage.

Connie:

A friend of mine was in a psychiatric unit for 2 weeks and was terminated from his job. He received short term disability but once that reached its end, was denied long term disability benefits as he was told this was a pre-existing condition. How is this determined and what can be done to be approved for these benefits? Would an appeal need to be submitted and can this be done without an attorney?

Thank you.

Attorney Stephen Jessup:

Connie,

The LTD policy will clearly define what a pre-existing condition is. Unfortunately, if your friend’s situation falls within the confines of same there is little that can be done to get around the denial.

Chaim B.:

Hi, my name is Chaim and I have a situation regarding LTD benefits.

I was able to get a company policy via Mass Mutual without docs because my income is above a certain limit.

Problem: I have pre-existing depressive illness and now am sick and cannot work.

Caveat: I’m sick now because I need to WITHDRAW from my psych meds as per my physician.

Since this is not the same as original illness, Withdrawal effects causing disability vs psychiatric condition causing it, can this be a game changer due to worsening due to new situations?

Please assist.

Thank You

Attorney Stephen Jessup:

Chaim,

We would need to see a copy of your policy. That being said, the basis of disability would arguably be due to the overall mental health conditions so chances are that if you are still in the pre-existing period Mass Mutual would look to deny the claim on account of same. Please secure a copy of your policy if you do not already have one and feel free to contact our office to discuss further.

Darcy:

I have been seeing a Dr for muscle weakness in my body for about a year, I have only used sick time for specialist appointments but it has been getting worth so my Dr. put me off my long term condition started about the same time would this be a pretty existing condition. I had to to work a full year before I even had any insurance.

Attorney Stephen Jessup:

Darcy,

It would be dependent on the language in your disability policy. If you have been insured under the policy for less than a year when you go out on disability then it would trigger a pre-existing condition review. Most policies indicate that if you were treated for the disabling condition within 3-6 months prior to the effective date of coverage the condition would be pre-existing. However, every policy can vary in language. I would suggest obtaining a copy of your policy if you don’t already have one to see how it is defined.

Amey:

Hi,
I applied for short term and long term disability through my company. I was denied based on my height/weight ratio. Is this legal? I’ve never heard of such a thing. I understand if it was for Life insurance but it wasn’t. Help, please…

Tiffany:

Hi my name is Tiffany. I had a work related back injury in January of 2015 I have had several treatments such as steroid shots physical therapy and different medications. My Dr felt that surgery was the next step.so on August 25 I had lower back surgery. workmans comp was denied so my employer did grant me std then it was to switched to Ltd.This took place in September. After a long drawn out battle they finally told me that they were conducting a “pre existing condition investigation” and that they needed medical records dating back to the first 3 months on the job. I did have a back injury back in 2011 but I was treated and released to go back to work full duty. Needless to say..they denied me stating that my current surgeon stated that this has been an on going occurrence and that he has treated me multiple times in the past. That is not true, I have only been treated by this Dr since 02/15. I don’t have any reason to believe he said anything different. Meanwhile I am completely destitute as I have been out of work for nearly 3 months. Is there anything I can do?

Attorney Stephen Jessup:

Amey,

Unfortunately, an insurance company is able to refuse to right disability and/or life insurance coverage based on health factors.

Attorney Stephen Jessup:

Tiffany,

You do have a right to appeal the denial of benefits. Pre-existing condition provisions can be very tricky and if your doctor indicates it is an ongoing condition with ongoing treatment it could be hard to dissuade the insurance company. That being said, please feel free to contact our office to discuss if there is a way we can assist you. We would need to see a copy of the denial letter as well as the policy.

Cl Stein:

I have had surgeries in the past for a odonotogenic keratocyst. This is a nonmalignant cyst however it can recur, sometimes right away, sometimes in ten Yeats or sometimes neve. Would this be considered preexisting condition?

Attorney Stephen Jessup:

Cl Stein,

Unfortunately your question is too broad to be able to give you any definitive answer. You will need to review the language for pre-existing conditions in the policy. Typically, if you have been covered under the policy for over 12 months then any condition would not be deemed pre-existing for purposes of disability benefits. However, if you have been covered for less than 12 months and file a claim there will be a look back period (usually 3-6 months before effective date of coverage) that if you received treatment during that time for the disabling condition then it would be pre-existing.

Mb:

I am currently receiving LTD from my current employer, I know that I will be having a heart transplant in the future I don’t know when , it could be a few months or a year. But I want to go back to work, if I go back to work at a different Co. Will I be denied LTD From the new company for pre existing conditions. Or are their policies available for people like me..?

Attorney Stephen Jessup:

Mb,

You would more than likely be deemed to have a pre-existing condition under a new company’s policy. Typically you would be required to be covered for 12 months before the new insurance company would waive the pre-existing clause. Ultimately, you would need to see the language used by the new insurance carrier, but you most certainly run the risk of being in a pre-existing situation.

CD:

Hi,
I’m 55 years old. I’ve been receiving treatment since approximately 2014 for osteoarthritis for my left knee by an orthopedic surgeon, physician’s assistant, and finally my current orthopedic surgeon (I wanted a 2nd opinion from another orthopedic surgeon).
Both surgeons agreed that I require a total knee replacement. My right knee also has osteoarthritis of approximately 50 percent. I’m not covered by my employer for st or lt disability, so I’m researching private companies in order to purchase my own disability policy. The surgeon wants me to have surgery asap. I’ve been working during this entire time period, getting cortisone injections in my knee. Should I get the st and lt disability asap and would I need to wait a year after having the policy to get the surgery and file a disability claim due to pre-existing clause?
Thank you.

Attorney Stephen Jessup:

CD,

A private disability insurance company may not be willing to write you coverage due to the knee problem and/or could reasonably exclude it from applicable coverage. Unfortunately, you may not be able to secure private coverage- the most you can do is contact insurance companies to discuss coverage options.

LG:

Job 1: I have been working with a company for 90 days. After I started working, I started to experience some symptoms that I wanted to have checked out by an MD but had no health insurance. Now after 90 days I will have health insurance and will able to go to a doctor. My LTD policy has a 30 day waiting period, but I don’t think I can make a claim unless I have been working there for 12 months?

Job 2: In the meantime, I secured a much better position at another company. They will pay my Cobra and during the first week of employment will be able to make selections for health insurance, STD, LTD etc.

Now if I go to the doctor and find out something is wrong with me and I have a chronic progressive illness will I be covered under LTD with Job 1 and/or Job 2. Should I stay at Job 1 and hope that I can make it there 1 year? Will my condition be considered preexsisting with Job 2?

Thanks for your help!

Attorney Stephen Jessup:

LG, a condition would be considered pre-existing if you sought medical treatment/advice for it prior to your effective date of coverage and then filed a claim within (typically) 12 months of coverage. You do stand a potential chance of being considered to have a pre-existing condition under the second employer’s policy and potentially the first based on when your coverage becomes effective. You would ultimately have to secure copies of both policies to determine how the term is being defined to know for sure.

Sheri:

Hello. I was diagnosed with Cancer and was out of work on LTD for 2 years. I am ready to return to work. I have to get CT-Scans every 3 months. Would it be considered a pre-existing condition with a new employer if after signing up for my employers LTD >12 months passed and at some point I again had to go out on short or LTD?

Attorney Stephen Jessup:

Sheri, if your new employer’s policy indicates that you have to be covered under the policy for 12 months to waive pre-existing condition language, then yes. Some policies have a 24 month requirement, so I would caution you to make sure you see a copy/speak to an attorney before filing any new claims (which hopefully you will not).

Chandra:

I have worked for almost 7 years with same company. I always get std and ltd.insurance. last feb. 2015, I was diagnosed with cancer which has metastased to multiple organs, I am receiving chemo. I have gone back to work parttime to maintain my insurance and pay my bills as I have no other income or help.
I do receive Ltd monthly income which helps, however last November 2015 I enrolled for Ltd insurance as I always do at enrollment and now I am denied due to my cancer.
Can I be denied? I thought under Obama care one cannot be denied insurance for a medical condition. My cancer was discovered in 2015. Before that I was healthy. When I enrolled in november 2015 for the 2016 year I disclosed my cancer. I did not think this was possible. I oftenget sick and cannot go into work especially the week of treatment. I don’t get paid unless I have pto which has been used up.
I am concerned as I did not think they would deny my coverage because of my medical diagnosis which I disclosed.

Thanks

Attorney Stephen Jessup:

Chandra, Obamacare does not apply to disability insurance policies. It is not common though that you have to reenroll and provide proof of health each year. If you received correspondence as to the denial of coverage please feel free to contact our office to discuss/review.

Carissa:

Hello, my name is Carissa Melton. I am sending this in regards to my daughter. She has applied for life insurance, and short and long term disability thru our employer. She has received a denial for all three, she appealed and appllied again, denied again. According to them the reason is her ‘body build and her diabetes”. Is this legal? I understand the life insurance being denied, but isn’t long and short term disability suppose to be a “paid benefit” to employees as long as the insurance premium is being paid?

Attorney Stephen Jessup:

Carissa, if a policy requires proof of health to be eligible, an insurance carrier can deny coverage for disability and life insurance. This is not typically the case with most employer provided plans, but it is not unheard of.

Mary:

I’m on STD. There has been a medical change different than what I’m out on. How do I approach that for LTD? Is it too late? Or when STD runs out can my doctors diagnosis/recommendations differ on the LTD application.
Thank you

Brandi:

Out on STD. It has exsaserbated my chronic back pain, anxiety and insomnia greatly. My meds, weight loss and lack of sleep have rendered me without the stamina and mental sharpness to continue in my career as a clinical health care professional. I truly need to be through with my work. There is a 90 day pre existing clause. How can an attorney help me with that language to obtain my benefits?

There are 2 issues I’m dealing with that I haven’t been diagnosed with but are very real. Depression and neck pain with numbness and loss of sensation in my working hand.

Do I look at getting a different diagnosis quickly that has not been documented for my LTD.

Attorney Stephen Jessup:

Mary, it would be wise to advise your carrier now that you have a new diagnosis. Most insurance companies will transition a STD claim to an LTD claim if the policies are administered by the same company. That being said, as your comment is on an article designated for pre-existing conditions your situation may be completely different. Please feel free to contact our office to discuss your claim in greater detail.

Attorney Stephen Jessup:

Brandi, dependent on your policy’s pre-existing condition provision language and the facts and circumstances (to include medical records) there may be little any attorney can do to assist you in getting around a pre-existing condition exclusion. That being said, as each case is unique, please feel free to contact our office to discuss your situation in greater detail.

Bev:

I had an mri done prior to my STD kicking in but had surgery done after insurance kicked in. Mri showed different than what my surgery was for but I’m being denied for pre existing condition. Is this allowed?

Attorney Stephen Jessup:

Bev, it will depend on the language used in the policy for pre-existing conditions. Please feel free to contact our office with a copy of the denial letter and policy so we can discuss your denial in detail.

Confused & Upset:

I had been having chest pains off and on throughout the course of 2015. By October, I began to notice I started having shortness of breath. Really didn’t think nothing of it. In November, I had decided to sign up for short term disability through my job; they were having a health fair. Well noone contacted me back regarding registration. By December, I had no choice but to leave work and go to the ER. Found out I had a mass in my chest. A fellow co-worker referred me to an agency where I could sign up for short term disability, middle of January. By the end of January 2016, the doctor contacted me saying I had to have surgery. Went out for surgery in February. By the end of February I filed a claim for my surgery. Just received notice that my claim was denied because condition was pre-existing. How is that if the claim is for my surgery?

Attorney Stephen Jessup:

Confused, if the surgery is based on the pre-existing condition, which unfortunately it appears that it does, there may be little that can be done in light of your policy’s pre-existing condition limitation. Please feel free to contact our office to discuss further to see if there some way to get around it.

Deegriff01:

I enrolled in STD/LTD insurance plan in May 2014. I went out on worker’s comp due to a injury sustained at work. In March 2015 after my doctor released me back to work I had to go to the company doctor and the company doctor refused to release me back to work because I am a diabetic and was using insulin. I went to my endocrinologist and asked if we could treat my diabetes with a different medication other than insulin so that I could return to work. He agreed and changed my medication to oral meds. I returned to work and in July 201 my sugar levels were extremely high I was off work for a couple of weeks. When trying to return I again had to go the company doctor for release and he asked for a list of medications to be faxed over from my doctor’s office, I had to go back to insulin.

Since I am unable to return to work due to insulin dependency I applied for Short Term Disability through the company insurance and received payments for 26 weeks. When it was time to switch to Long Term Disability my claim was denied. The said my effective date on the policy changed from May 2014 to March 2015 because I was off work. Then I was told that the policy had a 6 month pre-existing clause. They contacted my endocrinologist and solicited my medical records. I was informed that during the months of October 2014 to March 2015 if I received medication from a pharmacy, consultation or visited a doctor regarding my diabetes this would fall into the pre-existing condition clause – which means that I would not qualify for benefits. How is it that I qualified for STD for the same condition but not LTD. Can they legally do this?

Attorney Stephen Jessup:

Deegriff, if the carrier is properly applying the policy language as it relates to pre-existing conditions and eligibility provisions, then unfortunately, yes they can deny your claim due to a pre-existing condition. Did you ever appeal the denial?

Charlotte:

Hello,

I have been employed with the same employer with continuous benefits (health, STD, LTD & Life) for 10+ years.

Three years ago I was diagnosed with cancer and have been cancer free since the end of treatment or 2.5 years. I worked through most of my treatment with the exception of 6 weeks with STD.

I have an opportunity for a new position at a new company. I still receive standard check ups with my oncologist every 90 days- office visits but no other treatments, procedures, tests…

I’m wondering (1) are standard post cancer treatment follow up appointments consider in preexisting exclusion rules? (2) do you think I would be eligible for STD/LTD/Life given the continuous coverage I have to date and time out from diagnosis/treatment?

Any assistance on the the above would be greatly appreciated.

Attorney Stephen Jessup:

Charlotte, if you have been continuously covered under your employer’s STD/LTD plan for over 10 years I do not see where there would be an issue as it relates to a pre-existing condition. Most policies apply a pre-existing provision if you have file a claim for benefits within the first 12 months of coverage (which you are already well beyond) and you received treatment for the condition within the 3-6 months prior to the effective date of coverage. Even if your employer switched carriers there are typically provisions in the new policy that will state if you were covered under the employer’s prior plan that pre-existing provisions would not apply. From your fact pattern it don’t think you would have any problems under your employer provided plan.

Amy A.:

I was wondering if you could tell me if I am approved for long term disability through my employer do they still have to pay for my insurance coverage and my benefits or does that office and just the disability coverage?

Attorney Stephen Jessup:

Amy, you would need to speak with your HR department as it is up to the employer as to whether or not they will continue ancillary benefits while on disability.

GARY:

I AM A DIABETIC, BEEN ON PILLS FOR YEARS, HAD STD AND COMPANY CHANGED CARRIERS IN JANUARY. AT THIS TIME WE WERE GIVN LONG TERM ALSO FEB 29TH MY DOCTOR WANT ME TO GO ON INSULIN. STARTED GETTING STD. NOW THEY WANT TO SWITCH TO LTD AND THINK I WILL BE DENIED FOR PREEXISTING CONDITION.

Attorney Stephen Jessup:

Gary, if you were covered under your employers prior policy (no issue with pre-existing) then chances are there is a provision in the new policy that will indicate you would not be subject to the pre-existing language. However, without seeing the policies there is no way to say for sure.

Katherine H.:

Hi,

I was in a car accident after I passed out at the wheel on my way to work one morning. I had a head injury and some facial lacerations, I was out for 6 days and went back to work thinking I was fine but a couple weeks later I didn’t feel right, the sun was blinding me so bad that I had to pull over (driving was a required part of my job)
I ended up going back off on STD and it was for Post Concussion Syndrome and I believe they said Post Traumatic Stress later. I ended up needing surgery on my face, but also the reason for the episode itself was the biggest issue, I needed a sleep study the surgeon who fixed my nose believed that the accident was attributed to a sleep apnea. I was out of work, having sleep studies, dealing with my reaction to what happened. I was terrified and afraid, well I was out about three months longer than the six months that STD allows, I did go back but I had to take a lower paying job. My LTD claim rep acted like he was going to help me because since February I had not received any money and will be evicted soon, well today I received the official denial letter. The reason they are saying that I had a pre-existing mental health issue, being that I didn’t work at the agency for a whole year just yet they are saying that is why I am being denied. I don’t believe this is fair because I was in an accident, sustained a head injury, over a illness (sleep apnea) that I was never diagnosed with, yes I was out awhile, yes I was traumatized and depressed but who wouldn’t be in a situation where they just came close to losing their life? I kind of didn’t know how to react. I feel that this is more of a discrimination against my mental health disorders that I was being treated for than it is anything. If this was about pre-existing conditions, why would they only be talking about my pre-existing mental illnesses and not my hashimoto’s disease as well?

Attorney Stephen Jessup:

Katherine, please contact our office to discuss the denial in further detail. It is crucial that your claim is clearly documenting the physical restrictions and limitations stemming from the accident.

Patrick:

I started working for my company in October 12th 2015. I had been diagnosed with a herniated and degenerative disc in September was told by my doctors it would heal on its own. It didn’t and things got bad. I had surgery on January 7th 2016 and went on STD. Had second surgery May 5th now running into LTD. Their evaluating now. The disability company is called UNUM. Their saying they may deny me because I had a pre existing condition. Can they do that?

Attorney Stephen Jessup:

Patrick, unfortunately, yes. Unlike health insurance, disability insurance policies do contain pre-existing condition limitations. From the dates you have provided it would appear that you fall within the typical pre-existing timelines contained in long term disability insurance policies.

Kathy:

My LTD has been denied for a precasting condition. According to the LTD carrier if I had gone to the Dr for my back pain at all, then it was a préccondition. My employer fired me after I asked for STD, telling me I had from Sept 18 when I filed for STD until Dec 9, then I would be fired. Long story short, the carrier for my LTD approved me enrolling in the plan and took my payments from,y paycheck each week. I understand Erisa comes into play, however I am not sure how that works. I am 58 years old, female, and was a corporate flight attendant for this well known wealthy company for 9 years. I have a 55 percent curved scoliosis, which I have never tried to hide, and have never had any problems with until now. No doctor anywhere says the pain is or isn’t from my scoliosis. The pain does not have a clear reason of why it hurts to even try to stand more than 5 minutes and or walk. Can you help? I am a single women, without income, have flown my entire life. Thank you, and I apologize for going into such long detail.

Attorney Stephen Jessup:

Kathy, please feel free to contact us with a copy of the denial letter to determine if there is anything we could do to get around the pre-existing condition denial.

Dom:

Hello, i had asthma,copd since 2007 i am 36 and never smoked in my life, my doctor said that it is rare for non smokers to get copd but it does happen some times.i take medication for this and occasionally require medical assistance. My questions is this I’ve been employed at my job for a year now and was offered UNUM LTD they state on there web page this : Pre-Existing Condition limitation

Benefits for pre-existing condition (defined as a sickness or physical condition for which within 12 months before the coverage effective date symptoms existed that would cause a person to seek treatment or; the insured individual was treated, received medical advice from a physician, or had taken medicine) will not be paid during the first 12 months the policy is inforce. this part is very clear to me but what i don’t understand is this part here:Pre-Existing Condition limitation

Unum will not pay benefits for a claim that is caused by, contributed to or occurs as a result of a pre-existing condition. Please refer to information provided in your certificate or consult with your benefit counselor to determine what would be considered pre-existing condition. A pre-existing condition is a condition for which symptoms existed within 12 months before your coverage effective date that would cause a person to seek treatment from a physician or for which a person was treated or received medical advice from a physician, or took prescribed medicine. The determination on whether your condition qualifies as pre-existing will be based on the date of disability and not the date you notify Unum. If i understood this correctly if in the future my asthma copd & sleep apnea prevent me from working they willl not pay any benefits to me because these conditions would be determined as pre existing. Please Help

Attorney Stephen Jessup:

Dom, correct. If you were receiving treatment for it in the 12 months before you became entitled to coverage then it is pre-existing and from what you indicate you would have to wait until you have been covered for 12 months under the policy before that limitation would be waived.

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