What Qualifies as a Pre-Existing Condition?
What qualifies as a pre-existing condition varies. Your long-term disability insurance carrier may consider any medical condition you had before opening a policy with them a pre-existing condition. The rules vary from policy to policy and depend on the specific verbiage used. However, most long-term disability (LTD) policies have some form of pre-existing conditions clause.
These clauses generally limit your ability to receive benefits for a disability related to a pre-existing condition. This clause usually applies for the first year or two that you have this policy. This time period is sometimes referred to as an exclusion period.
The exact conditions included and how long they may prevent you from receiving benefits depend on the specific wording of the pre-existing condition clause in your policy.
Understanding What Qualifies as a Pre-Existing Condition
The list of medical conditions an insurance company may consider to be pre-existing is extensive. Almost any medical condition that is chronic or serious in nature and could cause you to miss an extended time away from work may be included, depending on the wording of your long-term disability policy.
If you have a medical condition that was diagnosed prior to the start date for your disability insurance coverage or even if there was mention of a specific ailment in your medical file, this may be a pre-existing condition according to your LTD policy. This could include:
- Heart disease
- Sleep apnea
Pre-existing condition clauses generally only apply for the first two years after a policy goes into effect. Reference your policy for the exact details of your exclusion period.
Pre-Existing Condition Exclusions
If you cannot work because of a medical condition, related symptoms, or complications, your long-term disability policy should provide regular payments to help you make ends meet. However, the pre-existing condition clause in your policy may allow the insurance carrier to block coverage of certain conditions while your policy is still new.
According to the Ontario Human Rights Commission (OHRC), these clauses usually apply for the first two years of an LTD policy. If you file a claim for coverage during this period, the carrier may attempt to deny your claim based on the pre-existing condition clause. This may be true even if your disability has no relation to your pre-existing conditions. This is one of the reasons why you may be forced to litigate your denial.
If your long-term disability claim is unfairly denied, you may be able to challenge the denial through an internal appeal or externally in a lawsuit.
You May Be Able to Challenge a Denial Based on a Pre-Existing Condition
In some cases, an insurance carrier may deny a claim that is not based on a pre-existing condition or that arises after the clause expires. When this occurs, you may be able to fight the denial and get the decision overturned or secure compensation through legal channels. Our personal injury lawyers may be able to help you understand your policy, including the pre-existing condition clause.
Some ways to challenge a long-term disability benefits denial include:
- Filing an internal appeal with the insurance carrier
- Filing a lawsuit and pursuing a court award
We may be able to help you understand your options for pursuing the benefits or compensation, if you qualify. However, it is important that you contact us soon after you learn about your denial. The Limitations Act of 2002, S.O. 2002, Chapter 24 puts a strict deadline on these cases, and filing an appeal or taking other action may not extend the time we have to act.
Talk to Our Law Firm About Your Pre-Existing Condition and Denial
If your long-term disability insurance carrier denied your claim because of a pre-existing condition, this may be stipulated in your policy. However, this could also be an unfair denial, depending on the wording of your policy.
Preszler Injury Lawyers represents Ontario’s long-term disability denial victims. We may be able to help you challenge the denial and hold your insurer responsible for the benefits you paid for.
An initial consultation with a representative of Preszler Injury Lawyers is free when you call 1-800-JUSTICE. We may be able to handle your case on a contingency-fee-basis with no up-front costs due for our representation.