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28 01, 2019

Pre-Existing Conditions—Don’t let these landmines blow-up your LTD claim!

By | 2019-01-28T21:16:45+00:00 January 28th, 2019|Uncategorized|0 Comments

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.

16 03, 2018

An Improved Standard of Review for ERISA Disability Benefit Claims in Texas

By | 2019-02-05T23:24:14+00:00 March 16th, 2018|Uncategorized|0 Comments

An Improved Standard of Review for ERISA Disability Benefit Claims in Texas

On March 1, 2018, the U.S. Fifth Circuit Court of Appeals (which decides how federal law applies in Texas), issued its decision in Ariana M v. Humana. The decision was a significant win for Texas citizens—providing us with protections that have been available to the rest of the country for years. With this development, an employee whose long term disability insurance claim or health insurance claim was wrongfully denied, can file a lawsuit and ask a federal judge to independently evaluate whether the claim should be paid.

Previously, when a Texas claimant challenged an insurance company’s wrongful denial of disability benefits, a federal judge would review the company’s “factual determinations” using the deferential “abuse of discretion” standard. The review might very in intensity, but usually resulted in the judge rubber-stamping the company’s decision—even though the judge actually disagreed with the decision and thought the benefits were otherwise owed. The Fifth Circuit, since its 1991 decision in Pierre v. Connecticut General Life, has been the only court in the country to mandate deference to insurance companies’ self-serving factual determinations, which provided shelter for denying eligible claims.

Now, the review standard used by trial judges will be de novo review. This means the judge will independently review and evaluate the medical evidence and proof of disability submitted by the claimant. The judge is no longer constrained to accepting the insurance company’s factual determination and is no longer required to accept the insurance company’s medical record reviewer’s opinions over those of the claimant’s treating physicians. Finally, after many years of unfair treatment, claimants in Texas have an improved standard of review by which to challenge wrongfully denied health and disability insurance benefits.