Pre-existing conditions are one of the many reasons that insurance companies deny long-term disability (LTD) benefits. But pre-existing conditions are not exactly what they sound like. While you would think that it means any condition that you have ever had before, that is not the case.
Read on to learn more about pre-existing conditions, and how you can get the help you need if your long-term disability claim is denied due to a pre-existing condition.
LEARN MORE
2. Policy definition
3. Interpreting terms of policy
4. Example of term
5. Providing medical documentation
6. Pre-existing causing LTD denial
7. Can you fight a denial?
8. Disabled by many conditions
9. LTD Denied
10. Your questions
What is a pre-existing condition?
A pre-existing condition is defined as a medical condition that you previously received treatment for, and that is tied to the medical issue that is currently preventing you from working. The condition is one which you suffered from before becoming covered under your LTD policy.
A pre-existing condition should always be defined in your policy. If it is not in the policy, an insurer should not be able to rely on it to justify denying you your benefits.
According to the terms and definitions sections of most disability policies, only certain conditions will be excluded from coverage – and in fact, most will not.
The presence of a pre-existing condition is often one of the ways in which an insurance company tries to avoid paying you benefits.
How is “pre-existing condition” defined in your policy?
To understand what a pre-existing condition means in the context of your entitlement to disability benefits you must look at your disability policy. Your LTD policy should always define a pre-existing condition. It should provide a precise description for a pre-existing condition. That should always be your starting point.
If the definition is not in the policy or does not apply to your situation, the insurance company can’t use it to justify denying your LTD benefits. If your insurer denies your benefits because of a pre-existing condition, ask them to show you where in the policy it says that they can deny you on that basis.
Regardless of how it is defined, the policy will not rule out any and every related condition that you suffered previously – it only does so if you were treated for that related condition during a time which is typically called the pre-existing period.
How do I interpret the pre-existing condition terms of my policy?
While each policy has their own definition of a pre-existing condition, there are some common terms that you many find in yours. Some of these terms are:
- That you were treated or medicated for the condition
- That you went off work as a result of that condition within a certain amount of time after becoming insured under the LTD policy
- Or that you had the condition during a specific pre-coverage time period – in other words, if you only suffered from the condition a long time ago, it likely won’t be excluded.
What does a pre-existing condition term look like?
Here is an example of what a pre-existing condition term in policy looks like, and how it is written:
No benefits will be paid for a disability arising from a disease or injury for which the person obtained medical care before he became insured.
Medical care is considered to be obtained when he consults a doctor, uses medication on the advice of a doctor, or receives other medical services or supplies.
The exclusion does not apply if disability starts after:
-
- He has been continuously insured for 1 year; or
- He has not had medical care for the disease or injury for a continuous period of 90 days ending on or after the date his insurance took effect.
Translation: According to this example, a condition is only considered pre-existing if you obtained medical care for it before becoming insured under the policy. This example defines “obtained medical care,” and the insurer must rely on the definition if they try to deny your benefits based on a pre-existing condition.
For the condition to be excluded from coverage, you had to have gone off work on disability before having been insured under the policy for 1 full year; and you must have received medical care for the condition putting you off work in the 90 days immediately before you became insured under the policy.
To break this down even more, let’s consider the following dates:
- Oct. 3, 2021: 90 days before coverage started
- Jan. 1, 2022: Coverage started
- Jan. 1, 2023: One full year of coverage
If you applied at any time in 2022, and “obtained medical care” for the condition between Oct. 3, 2021 and Jan. 1, 2022 then your insurer may say that you are not entitled to benefits under this example because you had not been continuously insured for one full year.
My insurer is asking me for medical documents to find out whether or not I have a pre-existing condition. Do I need to provide them?
The reality is that if you do not provide the insurance company access to the medical documents they are requesting, they will likely use that as a basis for denying you. If you are ever unsure as to whether or not the insurer is entitled to access these documents, feel free to contact a disability lawyer at Samfiru Tumarkin LLP before you provide them to your insurer. We will tell you whether their document requests are reasonable or not.
Can a pre-existing condition cause a claim to be denied?
Yes, a pre-existing condition may result in your LTD claim being denied by the insurance company. Your insurer may not have to honour your policy if your prior medical condition is excluded by the pre-existing terms in the agreement.
What the insurance company can’t do is deny your LTD payments simply because you have a pre-existing condition. It depends on the circumstances and how the policy is written. In many cases you may still be owed your LTD benefits because the insurer’s definition of a pre-existing condition doesn’t apply to your situation.
Can you fight a denial of benefits due to pre-existing condition?
There are absolutely times in which we can fight the denial of an LTD claim based on pre-existing conditions.
LTD policies often leave a lot of room for interpretation. For example:
- What if you only consulted a nurse and not a doctor, and that nurse did not provide you any medical services?
- What is considered a medical service?
These are the types of things that your disability lawyer at Samfiru Tumarkin LLP will look for to help you get the benefits you deserve.
What if I’m disabled by multiple different conditions?
You may have more than on disabling condition. Your insurer may not have the basis to deny your LTD benefits if one of your conditions is not pre-existing while another is.
If your situation does not fit exactly into their pre-existing exclusion form, the insurer should not use it as a basis to deny your LTD benefits.
LTD denied due to a pre-existing condition
If you’re denied LTD benefits because of a pre-existing condition exclusion, contact an experienced disability lawyer at Samfiru Tumarkin LLP as soon as possible.
Don’t panic. There are many instances in which insurance companies try to deny claims based on pre-existing condition exclusions but were later found to have done so incorrectly. We can often find a way around these types of denials.
Call Samfiru Tumarkin LLP immediately at 1-855-821-5900 or fill out an online form for a 100% FREE CONSULTATION with a disability lawyer to find out what your options when the insurance company denies your claim. You are not required to sign anything, nor do you need to give a credit card number. Just ask questions and get answers. We will tell you what your rights are, if you are owed compensation, and how we can get it for you.
Before you walk away from what your insurer owes you, talk to the disability lawyers for Canada who once worked FOR insurance companies. We know how they operate, what their weaknesses are – and how to force them to pay you the money you are entitled to.
Get the advice you need, the compensation you deserve.
Questions? Concerns? Contact Us!
If you are experiencing an issue anywhere in Canada (excluding Quebec) with your long-term disability claim, your employer or the insurance company, we’re here to help. Call our team at 1-855-821-5900, email Help@DisabilityRights.ca, or contact us online for a FREE consultation.
You can also post your specific question about your long-term disability claim online for a quick answer by a disability lawyer at Samfiru Tumarkin LLP, at MyDisabilityQuestions.com.
As Canada’s most positively reviewed disability law firm, we have the experience, tenacity, and determination required to provide you with the advice you need, and the compensation you deserve.
Areas Served in Canada
Our team of experienced disability lawyers can help individuals in all Canadian provinces (excluding Quebec) when their long-term disability benefits are denied or cut off.
Alberta • British Columbia • Manitoba • New Brunswick • Newfoundland & Labrador • Nova Scotia • Ontario • P.E.I. • Saskatchewan