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.
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.
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.
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!
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?
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.
Jacquelyn,
I am unsure if we can assist you. Is your inquiry regarding a pre-existing provision under a disability insurance policy?
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.
Lea,
Please feel free to contact our office to review your policy and discuss any potential disability claim you may have.
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.
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.
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?
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.
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.
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.
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?
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.
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
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.
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?
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.
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!
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.
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
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.
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.
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.
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?
Susan,
You will need to discuss your concerns with an insurance agent to determine any potential eligibility for coverage.
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.
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.
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
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.
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.
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.
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…
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?
Amey,
Unfortunately, an insurance company is able to refuse to right disability and/or life insurance coverage based on health factors.
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.
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?
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.
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..?
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.
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.
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.
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!
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.
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?
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).
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
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.
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?
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.
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
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.
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.
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.
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?
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.
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?
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.
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?
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?
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.
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.
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?
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.
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.
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.
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?
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.
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?
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.
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.
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.
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
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.
I have been “disabled” with Muscular Dystrophy since birth, and treated for it since I was 5 years old.
I have worked at the same company for 20 years, occasionally taking sick leave for common ailments as well as occasional appointments with my neurologist (once a year). I have STD, LTD, Health, LTC, 401k through my employer, during the entire time I have worked for them. Over the years I have used the health plan for wheelchairs and other medical devices as my condition has progressed. There are no medications available for my condition. I still work full time and rarely miss a day of work, aside from using vacation time now and then.
My hands and arms are starting to lose the ability to move. Once they become immobile, I don’t see how I can continue working with computers since my job involves A LOT of typing. Aside from the typing, I will not be able to feed myself or use the bathroom without assistance.
Since I was disabled before starting work at my company, if I eventually need to use STD and then then LTD, will there be a good chance I will be approved or denied?
I started my job July 27 2015. I was diagnosed with lung cancer stage IV , non smoker, early April 2016. My LTD policy states:
My long term disability pre-existing condition (they are researching as these apply if employed less than 12 months, which is true for me):
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 had an ongoing cough prior to July 27, 2015 and this is in my records. They recommended allergy meds, saline rinses none of which worked. Can this become a pre existing condition ? I certainly hope not, it would be crazy. An Xray in June 2015 and another in Sept 2015 of my lungs were totally clear.
Hello, if a person made an appointment with their doctor for high blood pressure. The doctor then took notes and assumed it was from heavy alcohol use. This person has STD coverage with 12 month prior stipulation. The person never consulated or seeked treatment for alcohol. But since Doctor made note of it. They was denied STD when they entered rehab for alcohol. Can they deny for this reason.
Barry, without knowledge of the medical documentation, your doctor’s level of support and occupational duties we unfortunately would not be able to provide an idea of the chances of success. If you would like, please feel free to contact our office to discuss your situation further.
Lou, unfortunately, it could be potentially problematic if the stage/progress of the cancer would correlate back to the time you had the cough. Has your carrier indicated a potential pre-existing condition concern?
Bruce, it does seem like there could be a pre-existing condition concern if your doctor noted a potential issue with alcohol abuse in a medical note during the designated pre-existing condition period in the policy prior to your coverage.
Ive been with the same company since 2010. I first had a mental illness problem in 2012 and took 6 month STD. Inwent back to work. I intermittently took STD for mental illness until 2015. In feb 2016 my mental illness became very bad and I applied for Social Security and STD through my employer. At the end of this month it should roll to LTD. I have applied and all documentation is in.
Do I have to worry about pre existing?
Plan states: LTD benefits due to a Pre-Existing Condition will not be payable unless the period of disability begins
after you have been covered under the Managed Disability Plan for 12 months, beginning on the first day
of your coverage.
Pre-Existing Condition – A Pre-Existing Condition is any injury, sickness, mental illness, episode of
substance abuse or pregnancy for which you received medical treatment, care, consultation, or services, or
took prescription medications or had medications prescribed, in the three-month period prior to your
effective date of coverage for LTD benefits under Plan.
Because I wasnt treated for mental illness until 2012, do I have to worry I will be denied?
TJ, if you have bene covered under your employer’s plan since 2010 then you should not have anything to worry about as it relates to a pre-existing condition. If you do have any additional questions or concerns please do not hesitate to contact our office.
I had breast cancer stage 0 and was treated and cancer free after that, though I am on several medications and follow-up exams for 5 years. Shortly after this I went fulltime at work and eligible for short/long term disability. I filled out the paper work telling the complete truth and came back I was denied due to my pre-existing cancer. I argued and fought and even had my cancer doctor submit a report stating I am cancer free and they still denied me. The insurance co. is Gaurdian. I understand the rules, my question is, how long can they deny me, don’t they have to cover me sooner or later?
Lynn
Lynn, unfortunately, unlike health insurance, there is no affirmative duty for an insurance carrier to provide coverage in light of a pre-existing condition. Have you discussed with your HR department?
I had a baby earlier this year and applied for LTD through my employer a month after I returned back from taking FMLA. I was denied LTD because I had a baby. Is this a plausible reason to have been denied for LTD? Would I be able to dispute this decision?
Neidy, it would depend on the language contained in your policy. Without seeing the denial letter and/or policy we would not be able to tell whether the insurance carrier properly applied plan language.
My company switched insurance companies for short term and long term coverage. Can that company now use a preexisting condition against me? Also there was no paper work, just signed up on the computer. My company states there is a 1 year pre existing clause on this new insurance. If this is the case, what stops these companies from switching back and fourth. I have been with this company several years, and have always carried the STD and LTD.
Larry, typically there is continuity of coverage between the old and new policy. So if you were fully covered under the old policy then your coverage under the new would almost act as a continuation of the prior plan.
I have been an employee of my company for 8 years and have never taken time off for extended sick leave. This year I attempted to apply for long-term disability coverage for the first time. The company that holds the policy for my employer is Metlife. They denied my coverage because I indicated that I have been diagnosed with depression/anxiety and have taken medication for about 12 years. I was told by Metlife that I could appeal the decision by providing a letter from my physician stating whether or not I’ve had any incidents, missed scheduled appointments or anything else of concern to the physician. She provided that letter, I read it and have it, there was nothing concerning to report. No incidents, lowest clinical dosage of medication taken consistently, no missed time from work, no missed appointments, etc. My appeal was denied by Metlife solely because of the condition I indicated. I was told by the Metlife rep that the only reply my physician could have given was that I did not have that diagnosis. Do I have any case to obtain coverage for my family in the unfortunate event that I become ill and am unable to work?
David, unfortunately, an insurance company does not have a duty to provide disability coverage. In some situations they can exclude certain conditions from coverage. I suggest you speak with HR to see if applying for coverage during open enrollment may have an impact on your ability to get coverage.
My son has worked for this company for 5 years and when he went to work he applied for LTD and at that time he did not have to fill out anything about his health. So he wanted to increase the amount and had to fill out a health form to which he has colitus that was determined years ago. He has never had any problems with it. He takes medicine. He has never been out of work for that or any sick days or filed a claim. He is getting a letter from the doctor. Is there anything else he can do? He has 30 days to respond.
Sue, I do not necessarily follow as to the 30 days to respond. Is that relating to responding to an inquiry based on the application for increase in benefit amount/coverage?
I had LTD for two years which started after another company bought my company. When I turned 50 this year, the insurance company wanted me to reveal medical history over the past three years. My application was denied due to my shoulder tendonitis that I was treated for three years ago. At the time of my application is was under 3 years. Sometimes like 2.8. Meaning two years and 8 months. I haven’t had my shoulder treated since, and haven’t had difficulties. It has fully healed but to me, tendonitis is minor compared to other medical problems and the fact that I had the LTD insurance for two years (a lot closer to the injury)! Can they deny for any medical reason as long as it is under 3 years? Do I have to wait another year to apply since it will be longer than 3 years since I was treated?
Mike, an insurance carrier does have the right to deny coverage for disability benefits based on medical history. Did they give you the option to exclude any disabilities stemming from the shoulder tendonitis? Have you discussed the denial of coverage with your employer to see what they may suggest?
Hi !
I have psoriatic, rheumatoid and Osteo arthritis – everywhere. My left knee was bone on bone, deformed, huge spurs, painful and a fall risk. An Xray tech “mislabeled” my knee as a “normal” knee in January of 2015. Rheum did not catch it right away. I was sent to an Orthopedic in July 2016 , who described it as a meniscus tear, only wanted to perform shots and knee scope procedure. My Rheum strongly suggested a new Ortho. The new Ortho took his own Xrays, in Aug 2016, and shown the horrible condition of my knee. I had a total knee replacement Nov. 14th 2016.
My LTD Insurance company was reviewing my case, after being paid by them for 18 months. The review ended on Nov. 21st 2016. They concluded, without obtaining records from my new Ortho, that my knee was not bad. Only used the records from the former Ortho. I was denied a LTD continuation of pay as of Jan.19th 2017. I am appealing the denial. I am asking , is it in my best interest to submit the new Ortho`s records in my appeal?
In my mind, I think it shows how bad, damaging, and fast progressing my conditions are. I also was in recovery for 3 months from surgery, so I had been cut off during a recovery period. I wonder if the surgery shows me being better, as far as my knee? Will that hinder my appeal? I have the conditions in my hands, fingers, all joints, also neuropathy brought on by past aggressive Taxotere chemo for breast cancer, fibromyalgia, degenerative disc disease, thyroid issues… I am too young to run this gamut at 51. I believe my conditions were all brought on and grew worse in time from cancer treatments (that is when my symptoms started), cancer meds (Tamoxifen) and trauma of many surgeries, not to mention a breast reconstruction silicone implant leak. I also am a BRCA2 Mutation positive.
I know it`s hard to prove, though. I have reps from a consult firm through my employer (I was grandfathered into a contract) to handle my SSID case next month, but they cannot consult me on this matter. I had received some very helpful advice and direction in a consultation with a lawyer about the LTD appeal – he said his time and cost was so much more of value then the pay out of the appeal, and was before the subject of my knee replacement and the new Ortho records came up.
Thank you for any considerations and input :)
Manders, it is imperative to provide all updated medical information that supports disability to the insurance carrier for consideration. Please feel free to contact our office to discuss how we may be able to assist you in filing your appeal.
Hello,
I delivered my baby while covered under short term disability. I was diagnosed with severe postpartum depression, prescribed a cocktail of medications and my doctor wanted me out of work for an additional 3 months. I’ve submitted a long term claim. Prior to my becoming pregnant, I had been on antidepressants but has weaned off long before. Will this be considered a pre-existing condition? I feel it’s tricky because of the pregnancy. Also, the insurance company approved my FMLA for the same time I’d applied for long term. Does this factor in any decision?
Meg, if you have been working for your company or covered under the LTD plan for less than 12 months before your date of disability there could be an issue with a pre-existing condition review. The approval of FMLA does not guarantee a LTD claim will be approved as the requirements for each are very different. If the carrier does deny your claim please feel free to contact our office to discuss how we may be able to assist you.
Hi. I had surgery for an aortic aneurysm in March 2016 and at that time my company swicthed insurance companies starting January 2016. I returned to work in July of 2016 after being on std and sustained a work related injury shortly after my return in August. I have been out of work since late August and my workers comp ended in January 2017 after work comp drs ruled out any permanent damage to my back and cleared me to return to work. After then having my annual follow up with my cardiovascular doctor it was brought to my attention that they have found a sternal nonunion. I’m currently waiting for ltd review and yes they are looking at the previous 90 day period prior to me returning in July 2016 and my drs have compared and sent over ct scan images stating that the sternal nonunion was not present during the 90 period. Can they deny me for this as a pre existing condition because of my surgery for my aorta? To me this seems like an obvious total different disabilty which has nothing to do with my aorta. It was not visible on any of the scans prior to the 90 days of me returning to work and to my knowledge that time period would have been way too early to diagnos this type of disability. Can this be denied as a pre existing condition?
Jay, depending on the policy language contained in the new policy it could be possible that your claim could be denied due to a pre-existing condition. If you have a copy of your policy please feel free to contact our office to review the policy and discuss your claim further.
Hi. I had surgery for and aortic aneurysm in March 2016 and at that time my company swicthed insurance companies starting January 2016. I returned to work in July of 2016 after being on std and sustained a work related injury shortly after my return in August. I have been out of work since late August and my workers comp ended in January 2017 after work comp drs ruled out any permanent damage to my back and cleared me to return to work. After then having my annual follow up with my cardiovascular dr it was brought to my attention that they have found a sternal nonunion. I’m currently waiting for ltd review and yes they are looking at the previous 90 day period prior to me returning in July 2016 and my drs have compared and sent over ct scan images stating that the sternal nonunion was not present during the 90 period.
Can they deny me for this as a pre existing condition because of my surgery for my aorta? To me this seems like an obvious total different disabilty which has nothing to do with my aorta. It was not visible on any of the scans prior to the 90 days of me returning to work and to my knowledge that time period would have been way too early to diagnos this type of disability. Can this be denied as a pre existing condition?
Jay, the claim could be potentially denied for a pre-existing condition if you received medical treatment for any of the conditions that are resulting in disability during the defined pre-existing condition period. Although they may deny the claim, that does not mean you would not have rights to continue to pursue on appeal, or that the denial would hold.
I have been off work 10 weeks from back surgery. MD does not want me to return, however I am a nurse of 40 yrs and work in ER. I have been on STD, however am going to try and return to work. I really do not think I will be able to do it. I will need another knee replaced, ASAP. This is another thing that hinders activity. I have head neck fused and left knee done, bad Deg disc disease. Will returning to work and finding I can’t do it after few days affect applying for LTD if needed?
Pam, it could affect your claim depending on how long you return to work for. Many STD policies have a provision known as a re-current disability provision that states if you go back to work but have to go back out within 7 days they will not require you to file a new claim for STD. So if you go back to work for a month you may likely have to file a new STD claim before any LTD claim could begin. Please feel free to contact our office to discuss further.
My short term was denied for pre existing condition. I was of work from December 2016 toll Feb 2017 and I wasn’t diagnosed till January 2017….. I am understanding that I can’t be denied since I didn’t have a diagnosis till a month after I went off on medical. Is this factual?
Bill, often if you had treatment for a condition, or symptoms of a condition yet to be determined during the period prior to coverage under the policy then the disabling condition could be deemed pre-existing and excluded from coverage. Pre-existing condition provisions usually require that you be covered under a policy for a certain period of time before the limitation is lifted for a medical condition.
I am being denied by my company long term disability which I had for six months prior to an accident so they are claiming it was a preexisting condition. If I return to work and stay on the policy for the full year but am unable to keep working later will I still be denied a second time due to this original claim?
Crystal, if you return to work and meet the time requirements to get past the pre-existing limitation, and your condition continues to affect your ability to work you could look to file a claim at that point.
I have been denied my STD ins by my employer because they say its was pre existing. I had to have a hip replacement. They stated if i had any dr appts 3 mo prior to my surgery it was being denied. Of course my dr tried every option before surgery was the last option. Hip injections and anti inflammatory med. I had a dr appt 3 mo prior to see if i could get a hip injection for the pain and limping. It was then when my dr xrayed my hip and told me it was bone on bone and a injection likely would not help. It was time for surgery. I paid for this ins benifit and now my employer wont let me use it. I am going to appeal it.
My husband was denied disability insurance due to his anxiety and (cardiovascular disease) high blood pressure which we let them know is controlled with medication and has been for years. Is this legal? How can his anxiety be held against him and how many people have high blood pressure that is under control?
Sharon, for clarification – was an application to purchase a disability policy denied? Or, was a claim made to an insurance company for disability benefits denied? If it was the former, an insurance carrier has the right to refuse to write an insurance policy to an individual applying for same. If your husband had a claim for disability benefits denied he would have rights to appeal the decision.
I have exhausted my short Term Disability for a number of medical conditions. My long Term Disability claim is pending, but they are forcing me to gather information to submit from 2014 to present, attempting to use the pre existing condition clause. I have a non ERISA policy through my former local government employer. Our agent switched providers 1/1/16. I came out of work 3/10/16. I was assured I had continuity of coverage by my agent. I have carried std/ltd policies through him since 2013.
However, the latest form I received says my previous ltd company policy started 1/1/15, and my claim would be preexisting with them, as well. I haven’t lapsed my coverage, but my agent did tell me during open enrollment for 2015 that he was missing a form for my ltd coverage. I followed up, was told it was handled, my ltd policy was active. I even double checked with payroll, and it was coming out of my check still. I’m thinking my agent somehow let my policy end and restarted it 1/1/15 due to some error on his part. I can’t get any clear answers from him. He is notoriously hard to reach, and even harder to get a straight answer from. If he didn’t have my paperwork in order, resulting in my policy ending and restarting, can they deny me based on a pre existing condition?
Sabrina, without seeing the policies and knowing more of the facts as it relates to employment and coverage history the only answer we’d be able to give now is possibly. Please feel free to contact our office to discuss your claim in greater detail.
I am out for back surgery.
Blew out a disk.L5- working.
I have worked 11 years with my company.
I am on short term disability now.
I had a surgery L2-3 an 4 last year.
My company feels like I need to go out on LTD.
Do I have anything to worrie about for LTM
Working all these years?
Jo, as you are commenting on our section regarding pre-existing conditions I will answer within the context of the typical plan provisions for such. If you have worked with your company for 11 years and have been continuously covered under the company’s disability plan (regardless of carrier) there should not be a concern with pre-existing conditions. Furthermore, if you have been covered under the plan for more than a year before you filed your claim for STD there shouldn’t be a concern. Please feel free to contact our office if you would like to discuss your situation further.
MY EMPLOYER STARTED/ OR UPDATED THEIR LIFE AND LTD POLICY WITH Feb -1 – 2010. WE ALL HAD COVERAGE SINCE I STARTED WORK IN Jan 2007. I HAD RIGHT KNEE ISSUES SINCE 2009.
LTD – STATES EFFECTIVE DATE 2-1-10 WAITING PERIOD FOR EMPLOYEES IN ELIGIBLE GROUP BEFORE 2-1-2010 IS: NONE. CREDIT PRIOR SERVICE LTD WILL APPLY ANY PRIOR PERIOD OF WORK WITH YOUR EMPLOYER TOWARD THE WAITING PERIOD TO DETERMINE YOUR ELIGIBILITY DATE. What pre-existing conditions are excluded? You receive medical treatment, care or services for a diagnosed condition or took prescribed drugs or medicine for that condition in the 6 months just prior to your effective date or coverage and the disability begins in the first 24 months after your effective date of coverage unless you have been treatment free for 12 consecutive months after your effective date. No claim for disability commencing after 2 years of your effective date shall be reduced or denied on the grounds that a physical condition not excluded from coverage by name or description effective on the date of loss had existed prior to your effective date.
I am out on my 90-day waiting period before LTD which ends 10-20-17 for back surgery 7-5-17 and now have to have another surgery 10-9-17. My primary care MD wants to take me out of work not just for these surgery’s but overall condition: Which is 3 lower -back surgery’s my first was 8-16-16-plus, Right knee replacement 10-27-11 , Left knee scoped 2014 & issues on going. Plantar facial fibromatosis in both feet which require orthotics and cortisone shots when needed for pain.I have worked for this company 10-years 8 months. any worries on pre-existing ? Also is this OK for my doctor to do over all condition after having two more back surgery’s. I am 60-1/2 he states I need to stop do to all the surgery’s & conditions I Have at my age. Is that ok for him to do ? He is filing the one filing the paper taking me out of work. Anything I need to do? Pre-existing should be an issue? I have passed all the waiting periods and this is my only LTD claim ever?
A general question about pre-existing conditions when changing jobs. I Am looking at a new employer and their Long term Disability states a pre-existing clause of 3/3/12. Over two years ago I was diagnosed with Hodgin’s lymphoma I have since been treated and declared cancer free. I will continue to see my oncologist every 3 months and have ct scans every 3 to 6 months for the next year. So I am trying to understand my risk relative to the policy. I am guessing with the continuous follow up this will be defined as a pre-existing condition which means if I get diagnosed with Hodgin’s Lymphoma reoccurring within the 1st 12 months of coverage I will not be able to ever claim a long term disability related to the cancer even if it is 2 to three years down the road. Is this correct way to look at it and are all follow up appointments treated as treatment for a condition?
Hello – I started working for my employer on 6/13/16, and became eligible for STD/LTD as of 10/1/16. I was diagnosed with MBC in Jan ‘17, and went on STD leave in May ‘17. My benefits coordinator assured me that all pre-existing benefit clauses were removed from the disability policies 3 years ago…’it was the first thing she did when she started’.
LTD is due to start on 11/1/17, and I just received a letter that I may not qualify for LTD due to the pre-existing clause…they need all records for the 3 month’s prior to coverage. I had had breast cancer in the past that was treated with surgery, chemo, and radiation. I was considered ‘cancer-free’ at that time, but was on Adjuvant Therapy, taking a daily pill to prevent a reoccurrence.
1. Can they deny me due to taking this medication the 3 month’s prior?
2. Is MBC considered a new diagnosis or a pre-existing condition?
3. If they can deny me, and I choose to go back to work, when will I again qualify for STD and/or LTD?
4. The benefits coordinator that assured me that there were no pre-existing clauses is no longer with the company. Do I have any chance of fighting this based on what I was told by that employee? Unfortunately, I did not get it in writing.
Thank you!
Clyde, if you have had continual coverage under your employer’s disability plan since 2007 then there should not be any issues with pre-existing conditions. Under the vast majority of employer provided disability plans there is only an issue with a pre-existing condition if you have been covered under the employer plan for less than a year.
Mike, the overwhelming majority of employer provided policies (and yours seems to fit that description) are written to mean that if you file a claim for disability within the first 12 months of coverage it would trigger a pre-existing condition review. The carrier would then look at the three month period prior to the effective date of coverage and if you received treatment during that timeframe your claim would be denied on grounds of a pre-existing condition. However, if you do not file a claim for disability benefits within the first 12 months of coverage under the policy the pre-existing condition limitation would be lifted. So, if you do not file within the first 12 months of coverage you should not have to worry about a denial due to a pre-existing condition.
KBC, as you have multiple issues with your claim it would be best to contact our office directly to discuss with one of our attorneys. However, as it relates to the question regarding pre-existing condition provisions – I have never seen an ERISA group disability policy that didn’t contain one – your benefits coordinator may be confusing the issue with health insurance and not disability insurance.
Hello,
Thank you for taking my question. I was diagnosed with cystic fibrosis over 20 years ago. I will receive treatment for my cystic fibrosis indefinitely. I have been employed with my current company for 2 years and they provide long-term disability insurance for all full-time employees. If it is needed in the future, would I be eligible for long-term disability? Would my cystic fibrosis preclude me from being eligible for any long-term disability benefits if my disability is directly related to cystic fibrosis?
My plan states the following regarding pre-existing conditions:
“This plan will not cover any Disability or Partial Disability:
1. Which is caused or contributed to by, or results from a Pre-Existing Condition; and
2. Which begins in the first 12 months immediately after the Covered Person’s effective date of coverage.
“Pre-Existing Condition” means a condition resulting from an Injury or Sickness for which the Covered Person is diagnosed or received Treatment within three months prior to the Covered Person’s effective date of coverage.”
Thank you!
Kay, based on the information you provided – If you have been covered under your employer’s disability policy for at least 12 full calendar months then your condition should be deemed pre-existing for purposes of excluding coverage. Please feel free to contact our office to discuss your situation in greater detail.
Dear Mr. Jessup, my division was sold to a company that only supports a long term disability payout of five years. My prior employer paid until 65. My concern is since I am an amputee to a botched foot surgery that happened while I was working at the previous company, that I will eventually become disabled. I am in my 40’s and am worried I will eventually be filing for LTD. Is there anything I can do to maintain my LTD until I am 65? I am devastated by the sale of my group with lower benefits.
Linda, unfortunately, there is likely little you can do to maintain the former policy. Your only option may be to secure individual disability coverage through an agent, but there stands the chance your condition would be excluded. With respect to the 5 year maximum – have you seen the policy? Most through any major insurance company will go to 65 or your SSNRA. The five years may potentially relate to the “own occupation” period where a company determines disability based upon the inability to perform your own occupation. Five year own occupation periods are not common, but they do occur.
I have ulcerative colitis/Crohn’s disease. I have had several complications from the disease such as abscesses and my bowels were in such bad shape that I was told I needed surgery to remove the large bowel. I was on Short term disability already per recommendation of my GI doctor. During this time I had the surgery and inevitably had to miss a good amount of work for recovery (will be returning in a few days). During the process, short term disability was discontinued after 13 weeks I believe and I applied for long term. Several weeks had gone by, gave them a call only to learn I would not be eligible if I had a pre existing condition. My concern is that I had missed so much work and have not received any income of benefit for some time now due to a circumstance (surgery and recovery) that was beyond my control.
I was wondering what do do if I am ineligible for long term disability? What route do I take, or is there any way to be compensated or receive some sort of income for the time that I had missed because of this major surgery and recovery?
Tim, if the LTD is denied due to a pre-existing condition the only source of potential monetary benefit may be for SSDI, but that process also takes a long time.
I have a short term disability plan I pay for and a long term plan paid by company. I was out of work for a year so I could have two spinal fusion surgery’s. I returned to work hoping the best. I continued to seek treatment in pain management. After two years back at work the back and neck seems to be getting worse. Multiple MRI and CAT scans shows deterioration. Will this be considered pre existing if I go back out of work again and use the STD and LTD for treatment? I have never let the policies lapse.
Kevin, no, I don’t think this will be a pre-existing issue as long as you are working for the same employer, you would just need to file a new claim since you have been back at work for more than 6 months.
My employer of over 13 years was bought by another company July 2017. We had sign on with new benefits of which I opted for both long & short term disability, plus an upgrade of LTD to 60% coverage. I do have a preexisting conditions tho. One that began a few years after my employment which is a blown cervical disc. I’ve needed a discectomy & fusion for several years but continue to stay off the operating table with traction & other means to control pain. Another issue has developed within the last 1.5yr with my index finger joint in my dominant hand which now has arthritis, & I need a fusion there as well. Both are common work related injuries in my field as a Sonographer. The problem with my finger has progressed & is very painful. I must have surgery. It interferes with my job & the simple tasks of writing & typing. I don’t know the name of the employer disability insurance company. The paperwork I have doesn’t state anywhere their name or coverage information. I’d have to call HR to inquire & am fearful they’ll terminate me if I do. The new company has been swinging the ax since the buy out…Good grief. Now what?
CJ, in situations like yours, if you were already covered under the prior employer’s group LTD policy then the group policy of the acquiring company typically contains continuity of coverage language that allows acquired employees to maintain coverage under the new policy without having to satisfy a new pre-existing condition period so long as you had already satisfied the prior employer’s group policy pre-existing condition period. If you did not have prior coverage and only now selected for the first time you are likely subject to the pre-existing condition provision. Further, even under the first scenario you may be subject to the pre-ex provision for the amount of the buy-up to 60%. (i.e., if your prior coverage was for 50% then you may be subject to the pre-ex on the 10% buy-up). The HR department of your new employer has a duty to provide you with a copy of the group policy/certificate upon written request or if the employer offers employees access through an on-line HR portal you may be able to find and download it from there.
Hi,
I could be leaving my employer soon. I am currently covered under their group policy. If I purchase a private policy prior to leaving the employer, will having continual coverage, despite different policies, give me protection from being denied for any pre-exsisting conditions that might become problematic while on the new private policy?
Colin, if you are considering purchasing a private disability policy on your own, the chances are any medical conditions you currently have that could be deemed to be disabling would be excluded from coverage. If your employer’s policy is “portable” meaning you can convert it to maintain coverage after you leave you may want to consider that option.
I was informed by LTD insurance co coordinator over the phone that my claim will be denied due to pre-existing conditions. The denial is based on current medical records that contain errors. I will be submitting amended and or corrected medical records to support my claim. Can the insurance company still deny my claim after submitting these corrected records? I plan on submitting these corrected medical records prior to the deadline to file the original claim. Should I notify the insurance company that I will be sending these amended / corrected medical records to buy some time?
Robert, depending on what those records say regarding the conditions which the insurance carrier claims are pre-existing, the disability insurer may still have the legal basis to deny your claim. Please feel free to contact our office to discuss your disability claim with one of our disability insurance attorneys.
Hi, I have suffered from depression for a number of years. Last year I had an episode of Conversion Disorder and at the time was on STD. I returned to work only to go on STD again on Oct 11 2017. Whilst in therapy I had a psychological evaluation done and got a diagnosis of Agoraphobia and PTSD with delayed expression. My employer has denied LTD as they say these are both pre-existing conditions and related to the depression and anxiety. Apparently I became eligible for loans LTD after the year waiting period which was Nov 1st 2017, but because I went on STD 20days earlier I dont qualify. Why would the LTD be from the beginning of the STD? I’m so confused.
Angela, usually the your date of disability is the same for your STD and LTD claims. However, the LTD initial elimination period/waiting period overlaps with the period of time that STD benefits are payable. For example, if STD benefits are payable for 90 days typically the LTD waiting period is 90 days after which, LTD benefits become payable. Also, pre-existing condition limitations are very common in LTD policies and less common in STD policies.
Hi. I am currently off work receiving STD have new onset medical problems cardiac, stomach disorders Dx:with Menerie disease/ back condition/Acalasia/fibromyalgia/was out of work from 12/14 thru 7/15 had surgery for the Acalasia. I have gotten worst with these conditions and constant vertigo, now headaches in non stop pain. I have worked for my employer 22 years now I can’t go on now recently in hospital again new onset of cardiac issues. I applied for LTD with Reliance Insurance and was denied in 2015. I didn’t no what to do. I went back to work sick continue to struggle, now I came to the reality. I can’t continue, I’m now 60 yrs old be 61 this year I been off work 3 months now and looks like I be off indefinite. I’m on STD which I can get for 12 months then it ends. I have to be off 6 months to apply for LTD if I had not been denied in 2015 I would have applied for my SSA. I got worst continuing to work now I’m in the same boat. Do you think I need to hire a lawyer to get my LTD covered by Erisa law? Now this time around I’m to sick to return, my doctors are suggesting total disability at this point but for me to survive financially I need the LTD. Can you help me with this puzzle? I didn’t know I could have appeal this, they have contributed to my health getting worse from previous denial for unjust reason can you help me with logical advice to prevent this from happening again.
I’ve worked over 40 yrs, my body is totally broken down. The denial in 2015 was not for preexisting only because my PCP referred me out to MD specialist and continue to cover my disability time off work as I was treating with them and him this time I have 5-6 doctors treating me for different illnesses and continue under my PCP as well do I need all MD’s to cover the disability as well you only need PCP for STD paperwork how do I prevent what happen in 2015 from happening again now with time off work I will speak with each MD in regard to this matter. They were called by my PCP when I was hospitalized in March for consults, still treating with all MD’s now I just need to get approval from LTD now in order to get on my SSA now it’s to be unable to work and sick with no income. I will have to voluntarily terminate my employment if unable to return after 7 months off Fmla/ 4 month disability leave. I don’t know what to do. Thanks, your advise matters.
Cynthia, you have a complex situation. I suggest you contact our office and speak with one of the attorneys to address your specific questions regarding your claim situation.
Hello,
I have worked for my company for about seven years. In May of 2015, I had a double fusion of my lumbar spine. I was on STD until Sept. of 2015. I worked continuously until Dec. 2017 when I was laid off by my company. I returned in April of 2017 and started having more back issues which required me to have two more fusions in Nov. of 2017.
I have now run out of STD as of May and just received notice that I was rejected for LTD because I was considered a “New Employee” by the LTD provider and had not worked 12 months before the surgery. My company also dropped this provider in Jan. 2018 and went to a new insurance company, further complicating the issue. My company has credited me for the time I was laid off and explained that to the LTD carrier without success… Is there any hope here of a successful appeal?
Aaron, you have a complicated situation involving the Pre-existing condition provision contained in most Group LTD Policies. There are a number of issues and policy provisions involved. Based on your description I assume your reference to the “Dec. 2017” date should actually be December 2016. I suggest you contact our office and speak with one of the attorneys to address your specific questions regarding your claim situation.
I was denyined LTD benefits due to a pre – exsisting condition. I have depression and aniexty which was part of the reason I was off work. The other part was for short term stairing blackouts and tremors on my right side.
I have neurologist supporting medical records for these conditions. The insurance company faught me on STD but did end up paying out the full 26 weeks for the STD.
My employer stated it’s their policy to terminate an employee that exhausted STD, so I lost my job and now was forced to apply for SSD.
I was only with my company for a little under 6 months before these episodes started occurring. The blackouts and tremors were never diagnosed until after I was on STD, so they can’t say that was pre- existing. They also did not address that portion of my medical records in Evaluation in the denial letter.
Is there anything further that can be done to try and gain my LTD?
Lisa, did you ever apply for long term disability? If you were covered under the employer’s long term disability plan as of the date of your disability then the termination of employment should not effect your coverage status under the LTD plan. Please feel free to contact our office to discuss your situation further.
I have been working for one company for eight years. In year six, a freak accident happened (not at work) that caused me to lose my left leg. I was able to return to work after six months of treatment. Now my division in this company has been sold to another company. They state all of our years of employment with company 1 will transfer to company 2 and allow us to maintain our status. Therefore, I have eight years of employment with company 2. Nine months into company 2, my back and hip joints begin to fail to the point I am unable to work. I am on STD which they will honor for 26 weeks at 100% pay because of my eight years of employment. But when I applied for LTD with company 2’s carrier, they say I have a pre-existing condition as this is related to the amputation. I have had continual coverage both medically and with disability policies. I have read the entire LTD policy with no said mention of this counting as a pre-existing condition as it speaks of those having more than five years of employment receive XYZ LTD benefits. Can they do this? I am not privy to the legal buyout contract between the two companies other than what the 1300 of us have been told.
Linda, typically, the disability policy with the new insurance company would have a “Continuation of Coverage” or “Takeover Provision” which would effectively state something along the lines of: If you were covered under your employer’s previous policy your coverage would continue under the new policy as if there was no lapse. This would eliminate the pre-existing problem. However, there are some situations were coverage could still be limited – but this would relate to your coverage status with the employer’s policy, or in your case- the fact that this is not the same employer, but a new employer with a new insurance company the takeover provisions could be interpreted differently. Nevertheless, one thing is clear – you need to appeal – so please feel free to contact our office to discuss your situation in greater detail and to review your policy documents and the denial letter you received so we can determine how we may be able to assist you.
My husband was diagnosed with Quada Equina Syndrome on December 28, 2016 and had to have emergency back surgery. He has permanent damage and is unable to return to work. He was originally approved for his LTD through his employer. We get a phone call today from the LTD company stating they did a review of his claim and determined that due to pre-existing conditions they are terminating his claim.
The pre-existing conditions they are referring to are:
Back surgery in 2011 which he recovered from and return to work as normal
Occasional visits to his GP for minor back pain due to DDD
A RX written for a back brace that was utilized as a preventative device during working hours
None of which prevented him from working and fulling performing his work-related duties. None of which every caused him to miss any days from work. In fact he had just gotten to work the day that he had the immediate onset conditions of Quada Equina Syndrome that resulted in emergency back surgery.
We have the option of appealing but the representative stated it would be very difficult to prove his current condition is not related to pre-existing conditions.
Any advise?
Cindy,
Pre-existing condition denials can be difficult to fight. Please contact one of our attorneys to discuss your options.
What options do I have? When I was 17 at my first job employment, I suffered a moderate head injury which required 8 stitches on the top of my head resulting in me experiencing odd equilibrium problems and short-term memory loss; at nearly all my other employers I accumulated some form of muscle strains and sprains in my arms, legs and back but never knew I could file a disability claim by purchasing disability insurance; so I have been working with all of these injuries ever since then; and now I have a lower back problem in the Si joints and a couple time each month I experience an odd pinching feeling in that part of my body which is very uncomfortable; and I’m contemplating an MRI or some type of medical scan to determine if I have a slipped disk. I completed manual labor for 16-years during part-time employment. I am unemployed now and have no disability insurance, can I purchase disability insurance today and file a claim and will it be paid? I thought the Obamacare rules said they cannot dismiss a claim because of pre-existing conditions? What are my options, if any remain?
Jack, unfortunately I don’t know of many options to offer you. I believe the Obamacare rules apply to Health Insurance. Going by the fact pattern you gave, you may have a hard time finding an insurance company who will give you an individual policy. If an insurance company agreed to cover you under an individual policy, they would likely not cover you for your current medical conditions.
You may be able to get coverage under a Group Policy if you worked full time for an employer that offers such, but please keep in mind that most group disability policies do contain pre-existing condition clauses and you would have to be covered under most policies for at least a year (or longer) before the pre-ex clauses wouldn’t be in effect. So your best bet to get coverage would be to return to work full time with an employer who offers disability insurance. If you are covered for a certain period (whatever the policy states) without making a claim and continuing to be covered, the pre-ex clause will no longer be in effect. Now I cannot say for certain when a pre-existing clause will no longer be in effect under a group policy without reviewing it first.
Your other possible option is filing for Social Security Disability if you still have enough credits for such.
When trying to obtain long-term disability insurance coverage from a private insurance company for being self-employed, can one be denied coverage for pre-existing conditions or have exclusions? How do we get around that?
Wondering, yes, to my knowledge, insurance companies are not required to provide individual disability insurance policies to everyone and they can chose who they wish to insure. If they chose to insure you, they can certainly prevent coverage for pre-existing conditions and their policies can include exclusions.
Group policies through an employer are entirely different. Most Group LTD Policies do contain pre-existing condition language, however, such language usually provides that if a person is covered for longer than a year, then a claim for a pre-existing condition will not be denied on that basis. Keep in mind every policy is different, so not every policy will contain this language or the exact language if it does contain such.
Hi. My employer has provided a LTD as of January 1, 2018 eligible after 180 days. My injury was on may 24,2018. I have seen a total of 3 doctors, including being on leave and put on modified duty. My employer decided not to accommodate my doctors orders, at my doctor visit dec 27, 2017 he put me on leave as of january 1,2018. We had surgery on January 24 2018.
Insurance is now telling me they are denying my claim since it’s a pre existing condition with in the 3 months them starting my coverage. It doesn’t make sense to me. If my initial injury was in may. It just took the third doctor to finally see that there was actually something wrong and take it to surgery. Please help as this is very confusing. This new coverage is new to my employer as well. They are not a good resource to contact.
Mk, your dates don’t quite line up. It say you were injured in May 2018 but had a doctor’s visit in December 2017. Pre-Existing condition provisions can be tricky and manipulated by the carrier. I suggest you contact our office and speak with one of the attorneys to address your specific questions regarding your situation.
Hi. I’m currently off work with anxiety and depression, and have applied for ltd. I had my phone interview today and will get an answer next week. I first started taking medication for anxiety around 2009 and was doing great. In 2013 I started a new job which after 1 year we were approved for ltd no forms required. In 2016 I got really ill with anxiety and depression which I took some time off changed meds and back to work, then off again. Now I have been off work for a year 2019 jan so can they deny me for pre existing even tho I was working with out illness for 3 years or so?
Hi. JJ, as long as you have been insured under the LTD policy for over a year prior to making a claim you should not have an issue with the pre-existing clause in the plan. When you haven’t been insured for at least a year they will do a look back to the 3 months before you became insured to see if you have treated for that condition.
Hi. I had stage I renal cancer in Oct. 2015, and then had a surgery. The doctor told me the survival rate was about 95% at that time, and no chemo and radiation therapy was needed. He even reduced my CT scan to once per year. I started a new job in Jan. 2018. The cancer came back as stage IV. I filed a short term disability leave in Dec. 2018 and would like to extend it to a long term disability leave in March 2019. It seems the insurance company used the Dec. 2018 as my file date, then it triggered pre-existing condition review. I didn’t have any treatment within a year prior to the coverage, so I am wondering if I will be excluded from the coverage?
Denise, based on the information you have provided it would appear the pre-existing condition does not apply however, the exact language of the provision is important and varies from one Policy to the next and from one Insurer to the next. I suggest you get a copy of the LTD Certificate/Policy from your employer and contact our office and speak with one of the attorneys to address your specific situation.
Hi, so my situation is a bit confusing to me. I was with my company since 2016 of July. I left voluntarily 10/2017 and came back 4/2018. I found out I was pregnant in June and was put on strict hospital bed rest due to complications of pregnancy incompetent cervix for 2 months. I was approved and put on STD that was exhausted and they opened up LTD now they are trying to use the 3 month thing saying pre-exising because I saw a ER DR in June 2018 for bleeding. This caused me to have severe muscle atrophy and lower back pain, along with postpartum depression.
I required months of physical therapy to regain my strength. When my short term disability claim was exhausted and I went 2 months into LTD. Since I pay into LTD with MetLife I was able to file a claim. My claim with MetLife was denied saying pre-existing condition. What should I do?
Demianna, if your claim was denied then you should appeal if you disagree with the decision. In an ERISA governed claim, the carrier should give you 180 – days to submit your appeal. Since you left your company voluntarily in 10/2017 then you likely lost your disability coverage and other employer sponsored benefits until you went back in 4/2018. Given that you were covered by your policy for only 2 months – assuming your coverage started again in 4/2018 – then a pre-existing condition investigation is usually part of the process of reviewing the claim. Pre-existing condition limitations are more common in LTD policies than in STD policies which may be why you received STD benefits without any problem.
Hello. I received treatment for anxiety and depression in August 2015 till April 2016. I was cleared back to work, stopped taking meds around same time, never had treatment again. I started a new job august 1 2018 on dec 2018 went on short term for anxiety depression, alcohol abuse. Applied for long term April 1. My short term done and will be doing inpatient treatment later in the month. Since I was not employed for a year they have a 90 day pre existing condition clause.
Is it your opinion I will be denied long term even though during the 90 days I was not seeing or needing any treatment or medications.
Kevin, the pre-existing condition in LTD policies can vary significantly from one policy to the next. Some are quite broad while others are much more restrictive. And each situation is fact specific. I suggest you contact our office and speak with one of the attorneys to address any questions you have regarding your specific situation.
During my employer’s Open Enrollment period which ended on Oct 19, 2018, I elected LTD. Since I had not elected LTD in the prior year, I had to fill out an EOI form which was not made available to any of the employees until after January 1, 2019. That’s the first issue.
On January 4, 2019, I filled out the EOI and faxed it back to Unum. Today is April 23rd, 2019 and I received a letter denying my application in its entirety based on a fall I had over a year ago and bursa of the hip. I understand that these could be considered pre-existing conditions but am wondering if Unum has the right to deny coverage in its entirety.
I worked under a collective bargaining agreement and have filed a grievance.
My question is, I am 71 years old and am wondering if they are refusing to cover me at all due to my age.
Stacey, I don’t know if age played a role in their decision, you would have to ask Met Life. You can probably appeal the determination.
I was wondering about STD. I have been signed up since the beginning of the year. I am 4 months pregnant now but my company is switching insurance companies. When I sign up for my STD from the new company will I be denied because of a preexisting condition. I was planning on using it after I give birth. My HR rep is unsure of what is going to happen.
Congratulations on your pregnancy. So long as you had coverage at the time you became pregnant and there was no time where you were uninsured, there should not be an issue with benefits. It is likely that the new policy will be paying, but I would love to review both of the policies to give you a true answer on this. Please get copies of the new and old contracts from your employer and please contact us.
Hello,
I have Prudential short term disability. The policy was effective 9/1/18. They have a 90 day look back period. I was approved for disability insurance for my bunion surgery in December 2018. My bone never healed and I just had my second surgery last week. This time they denied the claim stating pre-existing condition. This is based on office visit notes from 9/26/18 stating I have had pain in my left foot for the past 2 weeks. They said based on the information, while I had no office visits in the look back period and ordinarily prudent person would have sought medical consultation when the symptoms commenced. They also are requesting repayment of the initial disability claim. Not sure if they are being legit with me, it does not feel like it. Thank you.
Miles, this is an interesting and unusual situation. I suggest you request and send in your employer provided group policy and the denial letter to our office and contact us to speak with one of the attorneys to address your situation.