You’ve filed your software for long-term disability (LTD) benefits, rigorously offering all the required info and submitting all of your related medical data. If you get the insurance coverage firm’s response, you’re shocked to see a denial of advantages. The insurance coverage firm discovered that your disabling situations have been pre-existing (and due to this fact, not coated by your coverage).
At Bryant Authorized Group, we’re used to insurance coverage corporations broadly deciphering our purchasers’ medical data and incorrectly making use of pre-existing situation exclusions.
Whether or not you’re buying a brand new incapacity insurance coverage coverage, enthusiastic about submitting a declare, or are coping with an unfair declare denial, listed below are six issues it’s worthwhile to learn about how long-term incapacity insurance coverage offers with pre-existing situations.
1. Some Lengthy-Time period Incapacity Plans Exclude Pre-Current Circumstances
You probably have an employer-provided long-term incapacity plan, your pre-existing situation could also be coated after a ready interval. (For extra info on these lookback durations, see #3 beneath.)
The scenario is probably going completely different, nevertheless, when you’ve got a person LTD coverage that you simply bought by yourself.
As a cost-savings mechanism, most particular person long-term incapacity insurance policies exclude pre-existing situations. Which means that should you grow to be unable to work attributable to one in every of these situations, the insurer won’t pay advantages. (In the event you grow to be disabled attributable to a unique, new situation, you need to nonetheless be coated.)
So, what precisely is a pre-existing situation? The definition varies from coverage to coverage, however it normally consists of any bodily, psychological, or emotional situation that you’ve been handled for shortly earlier than you obtained protection. Generally excluded pre-existing situations embrace most cancers, bronchial asthma, coronary heart illness, a number of sclerosis, arthritis, despair, anxiousness, and lots of others.
2. In Order to Deny a Declare Primarily based on a Pre-Current Situation, the Situation Should Be Recognized or Suspected
After all, when you’ve got an already-diagnosed situation or damage, the insurance coverage firm will virtually at all times deem it pre-existing. Nevertheless, most long-term incapacity pre-existing situation clauses additionally cowl any situations that might be moderately suspected on the time you buy the coverage.
For instance, suppose you reported average again ache and a few numbness in your leg two months earlier than acquiring LTD protection. Later that yr, your physician referred you to a neurosurgeon who found a herniated disc in your decrease again. Despite the fact that you didn’t have a transparent analysis on the time you bought protection, the insurance coverage firm may deny your declare for incapacity insurance coverage advantages.
Alternatively, if there was no real looking purpose to suspect you had a disabling situation on the time you bought protection—for instance, you’ve a progressive genetic situation that was nonetheless asymptomatic on the time—the insurance coverage firm shouldn’t be capable of exclude it.
RELATED: Disability Insurance: A Look at Ambiguous Exclusion Clauses
3. For Employer-Sponsored Plans, You Would possibly Need to Wait a 12 months Earlier than Submitting an LTD Declare for a Pre-Current Situation
With group or employer-sponsored long-term incapacity insurance coverage insurance policies, the insurer received’t study every coated worker’s medical data. As an alternative, the insurance coverage firm locations limits on when it is going to cowl a pre-existing situation primarily based on a lookback interval.
Right here’s how this normally works:
- You file a incapacity declare inside a sure time interval after acquiring LTD protection. Often that is 12 months.
- Throughout this window, the insurance coverage firm will examine your medical data for any reported signs or medical remedy you obtained inside an outlined lookback interval. Most insurance policies outline the lookback interval as both 90 or 180 days earlier than your plan’s begin date, though in some instances it may be so long as 12 months.
With an employer-sponsored or group plan, should you’re in a position to deal with your pre-existing situation and work for not less than 12 months to your employer earlier than you file for incapacity, you may nonetheless be eligible for LTD advantages.
Nevertheless, each LTD plan is completely different, and your coverage may embrace a unique time interval or different exclusions. Be sure you learn your plan paperwork rigorously. In the event you need assistance deciphering your LTD coverage and calculating your exclusion durations, please contact Bryant Legal Group for assist.
4. Failure to Disclose Your Medical Circumstances in Your Software Can Imply Bother
If you apply for a personal LTD coverage, you usually should present details about your medical situations and remedy. Then, the insurance coverage firm calculates your premiums primarily based in your chance of needing advantages within the brief time period—and should even exclude particular situations (like most cancers) from protection.
As a result of pre-existing situations are normally not coated (and should improve your premiums), chances are you’ll be tempted to attempt to disguise an earlier remedy or analysis from the insurer. Nevertheless, that is by no means a good suggestion.
Failing to reveal your pre-existing situation received’t cease the insurance coverage firm from discovering out about it when you file a incapacity insurance coverage declare. Moreover, if the insurer believes that you simply intentionally lied to them in your software, they could void your complete coverage. This might be a catastrophe, particularly in case your incapacity was brought on by a brand new, fully unrelated situation or damage.
That mentioned, it’s additionally comprehensible that you simply won’t inform the corporate about each little twinge you’re feeling, significantly should you haven’t sought remedy for it (or that remedy didn’t result in a critical analysis). In these conditions, you need to seek the advice of with an skilled incapacity insurance coverage lawyer.
5. Pre-Current Situation Aren’t At all times Completely Excluded From Insurance policies—However Phrases Would possibly Be Modified
Not all insurance coverage insurance policies completely exclude pre-existing situations.
Suppose you’ve an already-diagnosed power situation that’s properly managed and is unlikely to intrude together with your work within the close to future—for instance, Crohn’s illness, sleep apnea, or most cancers that has been in remission for a few years. In these conditions, you may nonetheless be capable of get incapacity insurance coverage protection to your pre-existing situation if the insurer doesn’t consider there’s a excessive danger of incapacity.
Nevertheless (or alternatively), the insurer may place sure restrictions or limitations on protection associated to a pre-existing situation, akin to:
- Elevated ready time. For instance, you may want to attend 12 months as an alternative of 6 months after changing into disabled earlier than your long-term incapacity advantages can start.
- Time period limits. Your coverage might restrict the period of time advantages are payable attributable to a pre-existing situation—for instance, only one or two years, as an alternative of till retirement age.
Each insurance coverage firm has its personal set of requirements and tips when underwriting a customized coverage. So, when you’ve got any pre-existing situations and particular wants about potential protection, it’s necessary to buy round and browse the tremendous print rigorously.
6. Insurance coverage Adjusters Broadly Interpret Pre-Current Circumstances to Deny LTD Claims
Earlier than you apply for long-term incapacity advantages, you need to at all times evaluate your plan paperwork and determine potential obstacles. Your coverage will embrace a really particular definition of “pre-existing situation,” in addition to different exclusions. If these exclusions apply to your declare, you could be ineligible for LTD advantages.
Nevertheless, these definitions are at all times topic to interpretation, so you need to by no means assume that the insurance coverage adjuster was right of their evaluation. Many occasions, an skilled incapacity lawyer may help you make clear your situation and keep away from your plan’s pre-existing situation exclusion.
Refuting a pre-existing situation exclusion will not be a easy course of. You’ll have to rigorously evaluate the plan paperwork, determine all of your supporting medical data, and may even want to gather statements out of your physicians and different specialists.
Uncover Bryant Authorized Group’s Progressive Strategy to Incapacity Insurance coverage Appeals
Bryant Authorized Group is one in every of Chicago’s most revered incapacity insurance coverage regulation corporations. We pleasure ourselves on our sensible, client-centered method and complex authorized methods.
In the event you or a liked one have been not too long ago denied LTD advantages attributable to a pre-existing situation, it’s time to schedule a session with one in every of our expert and skilled incapacity legal professionals. We’ll make it easier to perceive all of your authorized choices and counsel significant subsequent steps relating to your declare.
You may contact Bryant Authorized Group by calling 312-561-3010 or completing this brief online form
