Pre-existing Conditions Exclusion Clauses: How to Avoid Them

As Disability Insurance attorneys, one thing which has come to our attention more and more often is the aggressive use of “pre-existing condition” exclusion clauses to preclude payment of Long Term Disability benefits.

These clauses generally apply when the disability occurs within 1 year of the date the disability insurance became effective. This is usually one subject of debate.

When did the coverage become effective?

We have a case right now where the insurance company made every effort to delay the effective date.

The next issue is the “look back” period which is generally the 3 months before the effective date. Now, these periods of time, such as the 1 year period and the 3 month period vary from policy to policy, but these are the periods we routinely see. The Long Term Disability insurance policy has to be reviewed to be specific about this. Pre-existing conditions exclusion clauses generally provide that the disabling condition is one for which treatment was received (or should have been received) during the “look back” period. This includes diagnostic testing and/or medications.

The starting point of our review is to determine whether there is more than 1 disabling condition. The insurance company will pick the one they say is “pre-existing” and ignore the others. The next issue is whether the disabling condition is, in fact, pre-existing. There is one reported where an unfortunate mother had a stroke 4 weeks after delivery of a healthy baby, but the insurance company contended the pregnancy was a pre-existing condition. Thankfully, the court said to construe the pre-existing conditions exclusion clauses; otherwise, it would have meant that only perfectly healthy people could beat the clause.  Another case involved coronary artery disease and a surgical wound infection, with a similar favorable result for the claimant.

Courts have held that the burden is on the insurance company to prove the pre-existing condition. Courts have also held that pre-existing conditions exclusion clauses are to be narrowly construed in favor of the claimant. Now, please keep in mind that you cannot rely upon the foregoing as legal advice applicable to your claim for Long Term Disability insurance benefits. Each case is different because each set of plan documents or insurance policy governing your entitlement to benefits is different.

If you have questions about a pre-existing condition issue, please give us a call.  As disability insurance attorneys, we handle these issues all the time. If you would like, after discussing your case, we can set a meeting. In most circumstances, that meeting would be free of charge. You would not be under any obligation to hire me.

Herbert M. Hill, P.A. is a law firm located in Orlando, Florida with a practice extending throughout the state. While many of the cases that we handle are for disability insurance benefits, other areas of practice include employee benefit claims. We also handle any claims arising under the Employee Retirement Income Security Act for disability benefits, medical benefits, retirement benefits, including pension, 401k, termination agreements as well as claims arising under private disability policies.

By |2018-08-13T13:54:26-04:00August 3rd, 2018|Blog|0 Comments