When you get coverage for long-term disabilities from an insurance company, you probably assume that you will be awarded benefits if you are unable to work due to a disability. After all, that is the whole point of this type of policy — to provide compensation to individuals who cannot work because of a medical or mental health condition. Unfortunately, insurance companies often work to deny coverage whenever possible by broadly interpreting limitations and exclusions.
This often includes denying applications for benefits whenever it can be argued that an individual has a pre-existing medical condition. This is often based on speculation or spurious arguments. If your claim for benefits has been denied on the basis of a pre-existing medical condition, a Cherry Hill disability benefits attorney can help you file an appeal.
Understanding Long-Term Disability Benefits
Long-term disability (LTD) insurance is a type of insurance plan that provides benefits to individuals who are unable to work due to a covered disability. Typically, these plans will pay 50 to 60% of your salary while you cannot work. LTD policies are often offered through your employer, although you may be able to purchase coverage for yourself.
Before applying for LTD benefits, you will have to wait for a period of time after the start of your disability. This is known as the elimination period; typically, elimination periods are 6 months. During this time, you may receive short-term disability benefits from your insurer.
To qualify for LTD benefits, you must have (1) a covered disability; and (2) an inability to work due to that covered disability. If you are approved for benefits, they may be paid for anywhere from 2 years or until retirement. However, if you return to work, then your benefits will cease.
Proving that you have a covered disability is critical to being approved for LTD benefits. Many insurance policies have specific limitations for certain types of disabilities. For example, some policies may not cover disabilities that arise from substance abuse or alcoholism, injuries caused by suicide attempts, and/or intentional acts that caused your disability.
These limitations and exclusions may come into play if you have what is considered a pre-existing condition. If you have a known and treated medical or mental health condition before you are covered by an LTD policy, it may limit your ability to receive benefits.
The Impact of a Pre-Existing Condition on a Long-Term Disability Claim
Many insurance companies specifically exclude or limit coverage for pre-existing conditions. This may occur if you did not disclose a condition when you applied for benefits, or if your condition started within a “lookback period.”
A look back period is used to define what conditions are pre-existing under an LTD insurance policy. They may range from 90 days to up to 1 year. The insurance company will “look back” through your medical history for that period of time to see if you were treated, evaluated, or had any indication that you had a medical or mental health condition.
The most common structure is a look back at the three months immediately prior to your eligibility, but only if your disability began within your first year of coverage. So, if you were hired on January 1, and were immediately eligible for coverage, and you become disabled prior to the following January, the insurance company would “look back” at the last three months of the prior year.
If your disability started within the “look back” period, it may be excluded from coverage under the policy terms. While these limitations have generally been upheld, some federal courts have found that simply being treated for symptoms, without being formally diagnosed with a condition, is not a basis for denying coverage for LTD benefits under a pre-existing condition limitation.
If your claim for LTD benefits is denied because of a pre-existing condition, you can appeal the denial with the help of a disability benefits attorney. Insurance companies often look for any reason — no matter how small — to deny benefits. This includes broadly interpreting your medical records in an attempt to find a pre-existing condition.
There are a number of ways that you can successfully challenge a denial of benefits based on a pre-existing condition limitation. The process starts with a careful examination of your policy terms, which will define “pre-existing condition.” For example, your policy may state: “You have a pre-existing condition when you apply for coverage when you first become eligible if — you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage.
Insurance companies will examine your medical history and look for any way that your current disability may be linked to a pre-existing condition. For example, if you received treatment for high cholesterol and hypertension, the insurance company may deny your claim for congestive heart failure that was diagnosed after you obtained coverage. A lawyer can argue that these treatments were merely preventative — and that you were not actually treated for or diagnosed with congestive heart failure in the lookback period.
The law regarding pre-existing conditions is complicated, and whether you are entitled to coverage depends both on the terms of your policy and your specific medical history. An experienced Cherry Hill disability benefits attorney will evaluate your policy and medical history in order to challenge a denial of benefits.
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Insurers are notorious for using policy limitations and exclusions to deny coverage whenever possible — even if the basis for such a denial is dubious. The insurance company may claim that unrelated symptoms are part of your condition, or that treatment for a similar condition means that you have a pre-existing condition. You don’t have to simply accept the insurance company’s conclusions; you can fight for your right to benefits with the help of a Cherry Hill disability benefits attorney.
At Bross & Frankel, our team of legal professionals are devoted to helping employees who are seeking LTD benefits — and those whose benefits have been denied. With nearly 100 years of combined experience, we understand how the law works — and we put our knowledge to work for you. To schedule a free disability claim review, contact us today at 856-795-8880 or reach out online.