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ERISA LAW BLOG

Denial of a Long Term Disability Claim Due to Pre-Existing Condition

Denial of a Long Term Disability Claim Due to Pre-Existing Condition

One of the most difficult and complicated areas of ERISA law is a reversing a disability denial based upon a pre-existing condition exclusion. These types of exclusions are found in most every disability policy, and they contain language that states benefits will not be payable for pre-existing conditions that are the cause of a claimant’s disability during the first year of coverage or some designated time period.  Additionally, most of these policies have a “look back” provision that allows the insurance company to see if claimants have been treated for the alleged pre-existing condition during some set amount of time before insurance coverage took effect.

For example, let’s assume a claimant starts a new job on December 10, 2018. For the purposes of this example, let’s also assume that insurance coverage becomes effective on January 1, 2019 and that the policy has a 1 year pre-existing condition exclusion with a 3 month lookback period.  If that claimant goes to her doctor on January 15, 2019 and is diagnosed with a condition that causes her to apply for Long Term disability benefits, because she made a claim within the first year of coverage, the insurance company will be able to investigate whether she had received medical treatment or consultation for that condition from October 1, 2018 forward. Often, even if she was seen by a doctor for something unrelated, but similar, the insurance company may deny her claim based on the pre-existing condition exclusion.

The key to defending a pre-existing condition is analyzing the plan documents and relevant definitions.  Insurers will try to interpret the pre-existing exclusion as broadly as possible, but our experienced ERISA attorneys may be able to beat that interpretation and get you the benefits to which you’re entitled.  If you believe that your, or someone you know, was wrongfully denied Long Term Disability benefits based on a pre-existing condition exclusion, contact an attorney at the Foster Law Firm.

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