Long Term Disability: Can a Pre-Existing Condition Cause a Claim to Be Denied?

Long Term Disability and Pre-Existing Limitations

It is very common for long term disability (LTD) policies to contain a limitation clause for disabilities that arise from a pre-existing condition. Simply put, if your disability falls into a pre-existing condition limitation, it is likely that the insurance company will deny your claim for LTD benefits. The Ontario Human Rights Commission states that “Because of competition, CLHIA reports that exclusionary periods are rather short, at a standard six months.”

There is no standard wording for a pre-existing condition limitation. Pre-existing conditions are defined in your LTD policy. You should review your LTD policy in order to understand what specific conditions will be treated as pre-existing by your insurance company.

Pre-existing condition limitation in LTD policies usually involves a disability that arises from a disease or injury for which you obtained medical care before you became insured. Therefore, your first line of defense against a pre-existing condition denial would be to dispute that you received such medical care. That being said, medical care is defined very broadly in LTD policies and includes any type of healthcare professional consultations, taking medications on the advice of your doctors as well as receipt of medical services, treatments, or supplies.

Do You Have a Pre-Existing Condition?

If you do happen to suffer some medical condition that existed before you became insured and you received medical care for, most LTD policies will allow you to still receive LTD benefits under the following scenarios:

1. if your disability starts after you have been continuously insured for 1 year (“1-year exclusion”), or
2. if you had not had medical care for the disease or injury for a continuous period of 90 days ending on or after the date your insurance took effect (“90-day exclusion”).

The 1-year exclusion is clear-cut: if your disability from work starts after you have been insured under LTD policy for at least 1 year, the pre-existing limitation does not apply and you are entitled to LTD benefits. In such scenarios, the insurance company is not likely to investigate your pre-existing conditions any further.

Providing Medical Records

But what if you become disabled within that 1 year of being insured for LTD benefits while having some pre-existing conditions as defined under your LTD policy? You might still be entitled to LTD benefits under the 90-day exclusion. Your LTD insurer will request and review your medical records going back at least 90 days from the date that you became insured. If the records demonstrate that you received no medical care for your medical conditions during those 90 days, you will be paid LTD benefits. It is important to co-operate with the insurance company in regards to medical records requests. If you refuse to furnish complete medical records to the insurer, your LTD claim will likely be denied.  This can be a confusing process, having an attorney there to help can smooth your path.

Get Help

The most common dispute in long term disability cases where an insurance company invokes a pre-existing condition limitation revolves around what constitutes medical care and whether one received such medical care within 90 days before his/her disability insurance came into effect. If you receive an LTD denial based on a pre-existing condition limitation, it would be prudent to have an experienced LTD lawyer review your policy and your medical records to see if you can still put forward a viable LTD claim.