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

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

Don’t delay discussing your matter with us to find out how to build a winning case.

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long term disability pre-existing condition

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.

Disclaimer: The content of this article is a general guideline made available for educational purposes only and is not intended to be used as legal advice for the reader’s specific situation nor in general. By reading our blog and website content, the reader acknowledges the above and understands there is no lawyer-client relationship created between you and Himelfarb Proszanski through this content. To get specific legal advice, we encourage you to book a free consultation with one of our lawyers to clarify the legal aspects of your situation.

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Timing is Critical. Help is Free.

Don’t delay discussing your matter with us to find out how to build a winning case.

Please enable JavaScript in your browser to complete this form.

You don’t pay us unless we win your case. No Out of pocket expenses required.

Note: Your Privacy is Safe with us. We will never disclose your information to external parties.

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I was very pleased with my decision to retain David and his team for my case. Melissa Gizzo was simply amazing and was able to secure a fair settlement for me.
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Andrew CoutoAndrew Couto
23:10 21 Nov 23
I'm so happy I chose David as my lawyer. I spoke to a few lawyers before finding David and I noticed majority of them spoke to me in a way that felt demeaning or that my case wasn't big enough or important enough to take. One phone call with David and my opinion on lawyers changed. He spoke to me as an equal and made me feel as if my case was definitely important and that I deserved to be fairly compensated. The whole process was wonderful. From dealing with David's law clerk Ingrid whom is an amazing and kind woman to his legal assistant Melissa whom is another amazing kind and talented young woman. I was so stressed about this case but from day 1 they helped ease that stress and always answered all my questions promptly and respectfully. I couldn't believe David got me to mediation within 6 months of being cut off my LTD and got me a settlement way beyond my expectations. I can't say enough good things about this law firm but I guarantee you that if you need a lawyer to fight for you David is your guy! . Believe me when I say this is the law firm for anyone dealing with personal injuries especially LTD denial claims. Thank you so much to David, Ingrid and Melissa you truly don't know how much I appreciate all you did for me and how this will help me get back on track with my life. Keep helping others you guys are doing amazing work! I wish you all the best!
Rose RegazziRose Regazzi
21:15 11 Oct 23
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