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Can a Pre-Existing Condition Cause a Disability Claim Denial?

Tucker Law Group
April 22, 2020

When you suffer a disability, you expect to collect the disability insurance benefits you need when you need them. Unfortunately, disability insurance companies deny claims for many reasons. One of those reasons includes a denial due to pre-existing conditions.

When filing a claim for disability insurance, it is important to read your policy closely. Every policy is different and insurance companies tackle pre-existing conditions differently. For these reasons, it is important to have an experienced and skilled long term disability lawyer on your side. Retaining legal counsel before you file your disability insurance claim is important. It will give you the best chance of success when handling your disability insurance claim.

What Does Your Disability Insurance Consider a Pre-existing Condition?

When you file for disability, your insurance company will determine if your injury or illness is a pre-existing condition. Depending on the provisions of your policy, the insurance company will look at a certain time frame before your coverage began to see if you received medical care or had some reason to suspect that you had a medical problem.  The time period during which a condition would be considered pre-existing varies.

The purpose behind a pre-existing condition exclusion is that insurance companies do not want to write insurance for people who knew they had a medical condition without knowing about the condition before the coverage went into effect.  That is why a person has to answer questions about medical care when they buy individual policies.  However, group insurance is often written without medical underwriting in advance.  Insurance companies investigate whether there were pre-existing conditions after you apply.  For that reason, medical care, prescriptions, or other treatment you had during a specific period of time before your policy went into effect – the “look back” – matters.

Understanding the “Look Back” Period

Many policies state that if you become disabled within the first 12 months of coverage, the insurance company can review your records for the year before your coverage started to determine if there was a pre-existing condition. In other words, if you become disabled within the first year of coverage, the insurer will “look back” through your medical records for any pre-existing conditions. If they find that you were treated for the same disabling condition (or something that could have been that condition, but was not fully determined) during the look back period, your insurer can deny your claim. Depending on the state and the insurance company, some look back periods may be a matter or weeks and others may require months or a year look back.  It is legal for insurers to include look back periods within their policies. Therefore, you need to remain aware of your policy and its limitations.

Investigation of Pre-Existing Conditions

Nearly all long term disability insurance policies exclude pre-existing conditions. Thus, it is in the insurer’s best interest to investigate all the facts. The insurance company will review the following factors when processing your claim:

Yet, insurance companies routinely get pre-existing conditions wrong. They may claim that a condition was pre-existing when it was not and then wrongly deny your disability insurance claim. If you believe your long term disability claim was unfairly denied due to a pre-existing condition or other policy clauses, it is important that you speak to a disability attorney today.

Real World Examples of Disability Insurance and Pre-existing Conditions

Consider these examples when determining how your pre-existing condition might affect your disability insurance claim.

Example A:

  • Example Scenario: Suppose you begin working in January 2019. You become eligible for disability coverage in April 2019. In October 2019, you suffer serious injuries in a car accident that leaves you with severe and permanent disabilities. Your policy states that within the first year of coverage, your insurer can look back on medical records and treatments for the 12 months. Your disability occurred because of the car accident and not a pre-existing condition.
  • Example Claim Result: The insurer may do a pre-existing investigation, but then approves your disability claim.

 

Example B:

  • Example Scenario: In January 2018, you suffered a significant back injury in a car crash. In April 2018, you begin working at a new job and your disability insurance coverage became effective in July 2018. In October 2018, you stopped working because your low back pain has increased, causing you extreme pain. Your policy states that your insurer can look back on medical records and treatment received during the 12 months before your policy started. You suffered a back injury in a car accident within that year.
  • Example Claim Result: The insurer determines that your injury is a pre-existing condition and denies your disability claim.

 

Example C:

  • Example Scenario: Consider Example B above, but in that same situation change the date you stop working due to your back injury to August 2019. Because you did not stop working until you were past the initial 12 months of coverage, your insurance company cannot look back and a pre-existing condition investigation would not be proper.
  • Example Claim Result: The insurance company cannot claim that your disability was the result of a pre-existing condition.

As you can see, it is important to review your policy carefully to determine your benefits and your insurer’s look back period. If you suffer from any of the same symptoms during the look back period, your insurer may deny your claim.

Do you need help reviewing your policy? If you are not sure when you will be out of the disability insurance pre-existing condition period, consult with our disability insurance attorneys before stopping work.

Questions? Speak to a Long Term Disability Lawyer at Our Firm

At the Tucker Law Group, we can answer your questions about disability insurance claims and pre-existing conditions. We know the struggles you face when collecting long term disability benefits. We also know that disabled Americans need their benefits soon after they become disabled. That is why we fight aggressively through the disability appeals and litigation process for our clients.

If you have a pre-existing condition and need help reviewing your policy, contact our firm today. Contact our office by calling (866) 233-5044 or fill out our confidential contact form. Our law firm can provide counsel in all 50 states as our attorneys are licensed in Florida and many federal courts around the country. We are here to help, so call us today.