Did the insurance company deny your benefits because your condition was pre-existing? Are you worried you won’t be able to get on long-term disability because you suffered from a condition in the past? If so, you are in the right place.
Pre-existing conditions are one the most common reasons for a long-term disability denial. Most LTD policies have a pre-existing exclusionary clause that allows them to do this. However, just because your benefits were denied for this reason doesn’t necessarily mean your condition is pre-existing. These definitions are always subject to interpretation. So, you shouldn’t assume that the underwriter got it right.
In this article, we will discuss what a pre-existing condition is, how to interpret pre-existing limitation clauses, as well as what you can do after a denial.
This article is part of our Ultimate Guide to Long-Term Disability in Canada.
What is a Pre-existing Condition?
Every policy has a different definition for pre-existing conditions. So, you will need to read your policy to see exactly how it is worded in yours. However, most define it as a medical condition for which you’ve had treatment prior to your enrolment in your insurance policy. However, that doesn’t mean that any and every condition you’ve ever suffered from will be considered pre-existing.
A condition is usually only considered pre-existing if you received treatment for it within a certain time period. This time period is usually referred to as a pre-existing period. Each policy will have a different pre-existing period; however, most range from 6 months to two years. How it usually works is if you haven’t received treatment within that time period, then the insurance company wouldn’t be able to justify denying your benefits. For example, if your policy has a pre-existing period of one year following the effective date of your insurance coverage and you haven’t received treatment for your condition in five years, then the pre-existing limitation clause wouldn’t cover you. And the insurance wouldn’t be able to deny your claim on the basis of a pre-existing condition.
Keep in mind this is a general description of how pre-existing limitation clauses work. You will need to read your policy or group benefits booklet to find out how it is worded in yours.
What Conditions May be Considered Pre-Existing
Insurance companies won’t deny you benefits just because you suffered from a temporary illness or injury. So don’t be concerned if you caught a cold or had food poisoning prior to your enrolment. When it comes to pre-existing conditions, insurance companies are going to focus on chronic and long-term illnesses or injuries.
So, what conditions may raise a red flag with an underwriter?
Nearly any chronic condition could be considered pre-existing if you were treated for it during your policy’s pre-existing period. However, it will all depend on the wording of your policy.
The following are some common examples of pre-existing conditions:
- Arthritis
- Asthma
- Anxiety
- Back pain
- Depression
- Diabetes
- Cancer
- Epilepsy
- Heart disease
- HIV/AIDS
- Sleep apnea
- Mental disorders
- Multiple sclerosis
- Muscle and joint disorders
Note: This is not a comprehensive list of all conditions that could be pre-existing. However, these are some common examples of conditions that are often found to be pre-existing.
How to Interpret a Pre-Existing Limitation Clause
As discussed, every policy will have its own unique pre-existing limitation clause. However, in order to help you understand how to interpret these clauses, let’s overview the following example.
Example 1
“No benefits are payable for any period of Total Disability commencing during the first 12 months of coverage of a Participant if such Total Disability was directly or indirectly the result of an illness or injury that was treated by a Physcian or for which prescribed drugs were taken during the six month period immediately prior to the effective date of such coverage.
This provision does not apply for a Particpant who has been insured under this benefit for more than 12 months or for a Particpant who applies within the 60-day period immediately following the date he first meets the eligibility requirements for this benefit.“
Confusing, right? Insurance companies purposefully use complicated language in their policies. But let’s try and break this down in a simpler way.
This is an example of a 12 and six clause. These types of clauses are extremely common in group policies.
So how this works is if you make a claim before the first 12 months of coverage, then the insurance company will consider whether your condition is pre-existing. They will look to see if you had treatment or took prescription medication during the six-month period prior to your enrolment. And they will deny your claim if they find any evidence that you did.
However, if you have been enrolled in the plan for over 12 months and you make a claim, then you are in the clear. Meaning they won’t care what conditions you suffered from in the past.
Still confused?
Let’s break this down even further by considering the following dates:
- July 1, 2022: 6 months before you enrolled in the policy
- January 1, 2023: The date you enrolled in the plan
- January 2, 2024: You’ve been insured for more than 12 months
So, if you make a claim before the 12-month mark (i.e., between January 1, 2023, and December 31, 2023), then the insurance company would look to see if you had treatment in the six months prior to your enrolment. For example, suppose you did take prescription medication for depression from July 1 to November 1, 2022. In that case, the insurance could theoretically deny your claim under the pre-existing condition clause.
However, even if you did receive this treatment but made your claim for LTD more than 12 months after enrolling (January 2, 2024), then the insurance company wouldn’t be able to deny your claim. Simply put, under this policy, the insurance company won’t even consider pre-existing conditions as long as you make your claim after the 12-month mark.
Overall, pre-existing limitation clauses are extremely difficult to interpret. If you are having any difficulties understanding yours, call us at (888) 732-0470, and we can help break it down for you.
How to Tell if You Have a Pre-Existing Condition
Now that we’ve taught you how to interpret a pre-existing limitation clause, let’s talk about the steps you need to take in order to determine if your condition is pre-existing.
Read your group benefits booklet
The first way to decipher whether your condition is pre-existing is to read your policy or group benefits booklet. As discussed earlier, the definition of a pre-existing condition will differ from policy to policy. So, the only way to tell if your condition falls under the pre-existing limitation clause is to get your hands on your group benefits booklet or your individual policy if you are self-employed. Make sure you read the definition of a pre-existing condition as well as the pre-existing limitation clause — sometimes, they will differ. You will also need to make a note of how long the pre-existing period is. As soon as you do that, you can move on to the next step.
Pinpoint the onset of your condition
Once you know how your policy defines a pre-existing condition and what the pre-existing period is, you should see if your condition falls under those parameters. For example, let’s say you stopped all treatment for depression two years before you signed your signed policy. And your policy says the pre-existing period is 12 months before the effective date of your insurance certificate. In that case, your condition would not be considered pre-existing. If you are struggling with this step, then we recommend speaking to a disability lawyer.
Get legal advice
Oftentimes, pre-existing limitations clauses can be difficult to interpret. If you are struggling to understand it, contact an experienced disability lawyer. You should also contact a disability lawyer if your condition does not meet the pre-existing limitation clause, but you were still denied benefits.
What to Do After a Denial
Just because you were denied benefits on the basis of a pre-existing condition doesn’t necessarily mean that the insurance company got it right. Oftentimes underwriters will make mistakes. And even if they didn’t make a mistake, most pre-existing limitation clauses will have room for interpretation.
With that said, pre-existing condition cases are extremely technical. You should always contact a disability lawyer for advice. They can look at your denial letter and medical file and help you build a strong case against the insurance company.
Our lawyers at Resolute Legal have years of experience dealing with clients who have been wrongfully denied long-term disability benefits due to a pre-existing condition. We know how difficult a denial can be, and we want to help you win back the benefits you deserve. Call us at (888) 732-0470 for a free consultation.
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