As Disability Insurance attorneys, we have seen more and more insurance companies aggressively use pre-existing condition exclusion clauses to deny Long Term Disability benefits. These clauses are often applied unfairly, and challenging them requires a careful review of the policy and medical records.

How Pre-Existing Condition Exclusions Work

These clauses generally apply if the disability occurs within one year of when the insurance coverage became effective. That raises an important question:

When did the coverage actually become effective?

We have a case right now where the insurance company went to great lengths to delay the effective date of coverage. This is a tactic insurers use to increase the chances that a claim will fall under the pre-existing condition exclusion.

The Look-Back Period

Most policies include a look-back period, usually covering the three months before the effective date of coverage. During this time, the insurance company will examine medical records, prescriptions, and diagnostic tests to argue that a disabling condition was present before coverage began.

Of course, the length of the look-back period varies from policy to policy, which is why it is so important to review the specific terms of the Long Term Disability plan.

Pre-existing condition exclusions typically state that a disability is pre-existing if the claimant received treatment or should have received treatment for the condition during the look-back period. Insurance companies often apply this language broadly, looking for anything in the medical records that can justify a denial.

Fighting a Pre-Existing Condition Denial

The first thing we do when reviewing these cases is determine whether there is more than one disabling condition. Insurance companies tend to focus on a single condition that they claim is pre-existing while ignoring other contributing factors.

For example, there is one reported case where a woman had a stroke four weeks after delivering a healthy baby, but the insurance company argued that her pregnancy was a pre-existing condition. Thankfully, the court ruled that the pre-existing condition exclusion had to be narrowly interpreted—otherwise, only people in perfect health would qualify for coverage.

In another case, a claimant had both coronary artery disease and a surgical wound infection. The insurance company attempted to deny benefits based on coronary artery disease, but the court ruled in favor of the claimant, finding that the surgical complications were separate from the pre-existing condition.

The Insurance Company Must Prove Its Case

Courts have consistently held that the burden of proof is on the insurance company to show that the exclusion applies. The law also requires that pre-existing condition clauses be interpreted in favor of the claimant.

This means that if your Long Term Disability claim was denied due to a pre-existing condition, the insurance company may not have properly applied the law.

If Your Long Term Disability Claim Was Denied, We Can Help

Every case is different, and every insurance policy has its own terms. If your Long Term Disability claim was denied based on a pre-existing condition, you may still have options.

At Herbert M. Hill, P.A., we handle these cases all the time. Contact us – we are happy to discuss your situation, and in most cases, we can set up a meeting at no charge and with no obligation to hire us. Let us help you fight for the benefits you deserve.