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Examining Pre-Existing Conditions Limitations

Disability Wiki.

All insurance policies have limitations in what they cover. One such limitation in long term disability (LTD) coverage is for pre-existing medical conditions. It is preferable that an individual who is seeking LTD policy coverage has had no prior medical concerns, but not everyone’s health is ideal. As our NY long term disability lawyers know, having a pre-existing condition is a variable, and how it exactly will impact the individual claimant is a matter involving the nature of the condition, the type of coverage being sought and the underwriters of the insurance company involved.

pre-existing conditions

The Nature of the Condition

Some medical conditions may not impact LTD coverage in any way. Initially, the condition may not be debilitating in any way. Another important factor the insurer will look at with a pre-existing condition is the anticipated chance of recurrence; a high risk may preclude coverage entirely. Another factor to consider is that certain conditions, while having a high chance of recurrence, may only be likely to result in a short term disability rather than a long term problem. Each condition will be evaluated individually.  Specific conditions that our NY long term disability lawyers regularly see include:

The Type of Coverage

An exclusion of a specific pre-existing condition does not necessarily result in the complete denial of LTD coverage.  One option is to consider a medical exclusion rider. In some cases, a condition is deemed so likely to recur that the insurer will offer coverage if the person specifically signs a rider to the policy excluding a disability resulting from the specified condition.  A disability resulting from some other condition will be covered under the regular terms of the policy.  Medical exclusion riders are not necessarily permanent; if enough time passed without a recurrence of the pre-existing problem, the coverage options may be revisited.

The Underwriting

Every insurance company has various ways to limit LTD coverage.  Every policy has a waiting period before a claim can be filed. This is designed so that a person cannot get LTD coverage and receive immediate coverage when they know they have some illness or disease even though there may be no medical evidence. The waiting period time varies from insurer to insurer and insurer as well as on the type of policy, but typical waiting periods are six months or one year but may be as long as two years.

Many LTD policies have a provision known as a “look back period.” This is a time specified in the policy for which the insurer will closely examine the individual’s medical record for any evidence of medical attention sought, medications taken and any medical expenses incurred. The look back period can be anywhere from 90 days to one year.

Additionally, if at any time, the insured wants to change the policy by, for example, increasing coverage, the new coverage is subject to the limitations of the waiting period and look back period.

Non-disclosure

Many people may suffer from some illness or affliction for some time without realizing it or without seeking treatment. Others, however, purposefully do not inform the insurer of a pre-existing condition with the hope it will not be discovered and benefits will be available when needed.  Our NY long term disability attorneys will advise that it is important to realize that most LTD policies have clauses that relieve the insurer from paying any claims based on an intentional failure to disclose and allow the insurer to terminate the policy.

Denials Based on Pre-existing Conditions

Unfortunately, many LTD insurance companies routinely deny claimants. In fact, many of the larger carriers have been reprimanded and fined repeatedly by the government for unfair tactics when it comes to evaluating LTD claims. One of the primary reason claims are denied is because of a pre-existing condition. However, any denial based on those grounds must be carefully looked at; the insurer often stretches the meaning of pre-existing beyond credibility.

One tactic insurers employ is to take a minor reference in a claimant’s past medical record to the condition they now claim as the basis for disability and allege that as proof that the disabling condition existed before the LTD policy took effect.  An example may be where the individual is now claiming disability based on a mental condition and the insurer alleges a prior reference to anxiety indicates a pre-existing condition. Or how a fleeting reference to a headache in the past is proof a current claim of debilitating migraines should be denied.  Our NY long term disability lawyers will be able to help make sure that these issues are not involved when the insurance company is evaluating your claim.

An especially egregious tactic not uncommonly seen is for the insurer to note the claimant’s prior use of medication.  If that medication is currently prescribed to the claimant for the condition upon which their disability claim is based, the insurer will deny coverage simply because the medication is the same, not even considering why it was previously prescribed.

Contact Our NY Long Term Disability Lawyers for Legal Advice

Insurance companies have a vested interest in denying claims; it quite clearly improves their bottom line. The harder they make it for a claimant, the longer they delay a claim evaluation and the more they deny, the more likely it is that claimant will just walk away. Don’t you walk away. Fight for your rights and discuss your case with our NY long term disability lawyers.  Begin with a call to Riemer Law Firm at 212-297-0700.

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