Most long-term disability insurance policies (and some short-term disability policies) contain a clause excluding pre‑existing conditions. This clause allows an insurance company to avoid paying benefits for conditions that existed before coverage began.
The most common clause provides that, if you become disabled within 12 months after the coverage began, no benefit will be paid if you received any type of medical treatment, care or service (including prescribed medications), related to the disabling condition during the 3 months before the coverage began (the “look-back” period). Some clauses extend the period to the first 24 months of coverage, with a 12-month look‑back period. Others provide that, if you were treated for a condition during the look-back period, no benefits will be paid unless you complete 12 months of coverage without further treatment for that condition. Ultimately, the clauses vary and the applicable terms can only be determined by reviewing the specific policy at issue.
As a general rule, insurance companies apply pre‑existing condition clauses very broadly. They look for any treatment received during the look-back period that could be used to justify denying benefits—regardless of how remote the relationship may be. For example, consider someone involved in a serious accident shortly after his or her disability coverage begins, who undergoes multiple low-back surgeries, and is left permanently disabled. In an effort to deny benefits, a company may look to a physician’s record documenting a nominal complaint of low-back pain during the look-back period.
If you are considering filing a disability claim, first determine whether you completed the policy’s pre‑existing condition period. If you have not, then consider whether, during the look‑back period, you received any type of medical service (including prescriptions) that even remotely-relates to your disabling condition. To the extent possible, you may want to delay your disability leave until you have cleared this landmine. Too often, individuals lose disability benefits they would have otherwise received, only because they took disability leave before completing the pre‑existing condition period.
If you are concerned that your insurer erroneously denied your claim based on a pre‑existing condition or if you need assistance applying for benefits, the attorneys at Guerrini & Thompson, P.C. stand ready to help you evaluate whether you could benefit from our services.