When dealing with a pre-existing condition limitation in a disability insurance policy, many policyholders end up with a denied disability claim. That’s when reliable information by knowledgeable experts in the field can be crucial. Disability insurance lawyers Greg Dell and Rachel Alters share some insights on how these policies work and what you can do to strengthen your claim.

The pre-existing condition limitation affects many people applying for disability benefits, according to attorney Gregory Dell. After helping hundreds of policyholders with the claim process, he notes that there are ways to potentially get around that pre-existing condition clause when a conflict arises.

What exactly is a preexisting condition limitation?

Disability attorney Rachel Alters explains that the pre-existing condition limitation is usually contained in group policies as part of a long term disability insurance plan. It’s a clause stating that if the plan has not been in force for at least 12 months, the preexisting condition comes into play.

“It’s really a way that the insurance companies can avoid paying claims that are made within or prior to one year of the plan being in force,” she says. “So, it’s really important.”

Most disability insurance policies have any combination of a three-month “look-back period” for the three months before the plan was in force, and/or a 12-month period after the plan became active. This means that when a person files a disability claim for a condition that was present and documented during those time periods (potentially a combined 15 months), it is likely to be denied by the insurance company holding the policy.

Defining the Preexisting Condition

It’s also important to realize that the insurance company will be looking at whether a claimed disability is something “related to” a pre-existing condition. If they can tie your current condition to a pre-existing one in some way, they can try to use it as a basis for rejecting your claim – whether or not the two conditions are actually related at all.

A recent case decided in the Tenth Circuit Court of Appeals is a prime example of this practice, explains disability attorney Rachel Alters. A truck driver filed a lawsuit against LINA, which is also known as Cigna. He had been working for the company for just under a year when he developed a macular degeneration issue in which his retina detached, and he went blind.

Though the driver had some prior health issues, he strongly believed that his current condition of macular degeneration, retinal detachment and resulting blindness was not caused by an earlier condition that LINA linked it to. But LINA hired two experts to argue that the condition was indeed related and was therefore a pre-existing condition, which they used as justification for the disability insurance claim denial.

The plaintiff appealed LINA’s decision in court, but the judge, unfortunately, sided with the insurance company in this case. The driver was deemed to have a pre-existing condition, based entirely on LINA proving that a prior condition “related to” to this one is what caused the disability.

When to file a claim

In a case like the truck driver, his blindness left little choice but to file before his 12-month period of employment had played out. A truck driver obviously can no longer drive. But in many other types of disabling conditions, the worker would have more leeway in the timing of his claim, explains attorney Gregory Dell.

For example, someone with chronic back pain who’s had a disability insurance policy for eight months may be able to stick it out for the additional four months (plus a three-month look-back period, if applicable) in order to avoid a pre-existing condition denial. According to Gregory Dell, many of the claims handled by disability insurance attorneys at Dell & Schaefer involve limitations due to things such as orthopedics, cognitive issues, rheumatoid-type conditions, fibromyalgia, lupus, Lyme disease, and various ongoing health issues.

He notes how important it is to know exactly when your plan coverage began and to only make a claim after the 12- to 15-month time period has passed. When you finally make a claim after that time, the insurance company will comb through your medical records to see if you have had any treatment or medications for your disabling condition within the prior 12 to 15 months. If so, that can work against you in getting approved for your disability claim.

Other considerations

There are many nuances in how insurance companies evaluate a claim, and there can be extenuating circumstances that make your claim vulnerable to interpretation. An example by Gregory Dell points out that you could have a pre-existing condition that is then “exacerbated” by a new event, such as an automobile accident exacerbating a prior neck or back problem. Things like this can be litigated in a court of law and can be successful if you have expert legal representation from a disability insurance lawyer.

Another very important thing to realize is that an insurance company can attempt to deny your disability claim based on any information contained in your original application. Even for something that happened 25 or more years ago, if you fail to disclose it in your application, they can deny your current claim if it’s related to that undisclosed medical issue from long ago. So, if there is documented evidence in a medical file, it will likely be dug up by the insurance company and used as evidence that you failed to disclose a pre-existing condition.

Considering the intricacies of disability policy claims and pre-existing condition limitations, Gregory Dell and Rachel Altars encourage you to call for a free initial consultation with disability insurance attorneys Dell & Schaefer. They will review your disability policy at no charge, identify potential concerns, and let you know whether they can help. The firm provides service anywhere in the country.