Yes, an insurance company can deny long-term disability benefits because of a pre-existing condition—but having a medical condition before your LTD coverage started doesn’t automatically disqualify you.
The insurer must rely on the pre-existing condition exclusion in your LTD policy. These clauses normally look at specific dates and ask whether you received treatment, took medication, consulted a health professional or experienced relevant symptoms during a set period before your coverage began.
The insurer must also connect that earlier condition to the medical condition that is now preventing you from working.
If the policy wording or dates don’t fit your situation, the insurer’s denial can be challenged.
On This Page:
- What Is a Pre-Existing Condition Clause?
- How Lookback Periods Work
- Stable or Older Conditions
- Does Medication Count?
- New Symptoms vs. an Older Condition
- Active-at-Work Requirements
- If Your LTD Claim Is Denied
What Is a Pre-Existing Condition Clause?
A pre-existing condition clause is a section of an LTD policy that can limit coverage for certain medical conditions that existed before your insurance took effect.
The clause should explain:
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What the insurer considers a pre-existing condition
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What medical treatment, consultation or medication counts
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How far back the insurer can look at your medical history
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How soon after coverage begins the exclusion can apply
Different policies use different wording. Some refer to treatment or medication, while others also refer to consultations, medical investigations, advice or symptoms.
If you don’t have the full insurance policy, read our guide on how to obtain your LTD policy.
How Does a Pre-Existing Condition Lookback Period Work?
The lookback period is the period before your LTD coverage started that the insurer can examine for relevant medical history.
For example, a policy might ask whether you received medical care or took medication for the condition during a certain number of months before becoming insured.
The policy can also limit how long after your coverage starts the pre-existing condition exclusion remains relevant.
This means the insurer often has to answer two separate timing questions:
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What happened before your coverage started? Did you receive the type of medical care described in the policy during the lookback period?
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When did you become disabled? Did your disability begin during the period when the pre-existing condition exclusion could still apply?
There is no single lookback period that applies to every LTD policy in Canada. Check your own policy rather than assuming the period is three, six or 12 months.
What if the Condition Existed Before Coverage but Was Stable?
A condition that existed in the past isn’t automatically excluded just because it appears in your medical history.
Suppose you had a health condition for years before joining your LTD plan, but it was stable and you didn’t receive the type of treatment described in the policy during the relevant lookback period.
The insurer still has to show that the pre-existing condition clause actually applies.
The same is true when an old condition had resolved long before your LTD coverage began. The fact that it appears somewhere in your medical records doesn’t necessarily make your current disability pre-existing.
Does Taking Medication Count as Treatment for a Pre-Existing Condition?
It can. The answer depends on how your LTD policy defines medical care or treatment.
Some policies specifically include taking prescription medication when deciding whether a condition was treated during the lookback period. Others use different wording. Canadian insurance policy examples expressly include medication as part of their pre-existing condition tests. :contentReference[oaicite:2]{index=2}
For example, an insurer could review whether you:
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Started a new medication
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Refilled an existing prescription
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Changed the dosage
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Discussed the medication with a doctor
But the insurer still has to apply the wording of your policy and connect the treatment to the disability for which you are claiming benefits.
What if Your Current Symptoms Are Different From the Older Condition?
An insurer can’t simply find an old diagnosis in your medical records and assume it caused your current disability.
The connection between the earlier condition and your current inability to work can become an important issue.
For example:
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Your current symptoms could be substantially different from the symptoms you had before coverage
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Your current disability could have a different medical cause
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An earlier condition could have resolved before a new problem developed
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Several medical conditions could now be preventing you from working
If the insurer says your current disability arose from an older condition, ask it to explain the medical and policy basis for that conclusion.
What if More Than One Condition Prevents You From Working?
You can be disabled by more than one medical condition.
If the insurer says one condition is excluded as pre-existing, that doesn’t necessarily resolve the claim if another condition also prevents you from working and isn’t caught by the exclusion.
Your medical evidence should clearly explain how your conditions affect your ability to work.
What Is an Active-at-Work Requirement?
Some group disability plans require you to be actively at work when your insurance coverage is supposed to begin.
This is different from a pre-existing condition exclusion.
An active-at-work requirement deals with whether your LTD coverage actually took effect on the expected date. A pre-existing condition clause deals with whether an exclusion applies after you became insured.
If you were already away from work because of illness or injury when new coverage was supposed to begin, the insurer can examine whether the policy delayed the effective date until you returned to active work. “Actively at work” is a recognized group-insurance eligibility concept, but the exact requirement depends on the plan. :contentReference[oaicite:3]{index=3}
If an insurer denies your claim because it says you weren’t actively at work when coverage began, ask for the full policy and the exact coverage dates it relied on.
Why Is the Insurer Asking for Older Medical Records?
If the insurer is investigating a possible pre-existing condition, it can ask for medical records covering the relevant period before your LTD insurance began.
Those records can show:
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When symptoms first appeared
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Whether you saw a doctor or specialist
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Whether medication was prescribed or changed
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What diagnosis was being considered
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Whether the older condition is actually connected to your current disability
Don’t ignore a reasonable request for medical information. But if the insurer is asking for a very broad medical history that doesn’t appear connected to the policy’s lookback period, get advice about what it is entitled to receive.
What Should You Do if LTD Is Denied Because of a Pre-Existing Condition?
A pre-existing condition denial can be challenged.
Start by getting:
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The denial letter. Identify exactly which condition the insurer says was pre-existing.
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The full LTD policy. Read the actual pre-existing condition clause, not just the insurer’s summary of it.
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The important dates. Confirm when your coverage began, the lookback period and when your disability started.
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Your medical records. Look at what treatment, medication or consultations actually occurred during the relevant period.
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Your doctor’s evidence. If the insurer has wrongly connected an old condition to your current disability, your treating doctor can help explain the difference.
Then compare the insurer’s reason for denial with the actual wording of the policy.
Common issues include the insurer using the wrong dates, treating unrelated medical care as evidence of a pre-existing condition, or claiming that an older condition caused a disability that developed for different reasons.
If your claim has been refused, read our guide on what to do when your long-term disability claim is denied.
Frequently Asked Questions About Pre-Existing Conditions and LTD
Can You Get LTD With a Pre-Existing Condition?
Yes. Having a condition before your coverage started doesn’t automatically prevent you from receiving LTD. The insurer must show that the pre-existing condition exclusion in your policy applies to your claim.
How Far Back Can an LTD Insurer Look at Your Medical History?
Your policy determines the relevant lookback period. There is no single period that applies to every LTD plan in Canada.
Does Taking Medication Make a Condition Pre-Existing?
It can if your policy includes medication within its definition and you took it during the relevant lookback period. The exact wording and reason for the medication matter.
What if I Had the Condition Years Before Getting LTD Coverage?
An older medical history alone doesn’t necessarily trigger the exclusion. The insurer must apply the specific timing and treatment rules in your policy.
Can the Insurer Deny Me for Symptoms That Weren’t Diagnosed Yet?
Possibly. Some policies include symptoms, medical consultations or investigations even if no formal diagnosis had been made. Check the exact definition in your policy.
Can I Challenge an LTD Denial Based on a Pre-Existing Condition?
Yes. A denial can be challenged when the policy exclusion doesn’t apply, the insurer used the wrong dates, the earlier condition is unrelated to your current disability or the medical evidence doesn’t support the insurer’s conclusion.
Get Help With a Pre-Existing Condition LTD Denial
A pre-existing condition doesn’t automatically disqualify you from long-term disability benefits.
If your insurer has denied your claim, the first question is whether the exclusion in your LTD policy actually applies to your medical history and the timing of your disability.
Samfiru Tumarkin LLP helps people challenge denied long-term disability claims across Canada, excluding Quebec.
Our disability lawyers can review the policy, medical records and insurer’s denial and determine whether the pre-existing condition exclusion was applied correctly.