Most long term disability insurance policies have preexisting condition exclusions.
This exclusion effectively means that the insurance company is excused from paying claims they believe may be related even remotely to any prior complaints made by the claimant within a specified period of time. These exclusions usually kick in when a claimant has been eligible for benefits for less than a year, but sometimes the stated period is 2 years. Besides the preexisting condition exclusion time period of a year, there is also a “look back” period, usually the 3 months prior. In a nutshell, if a claimant applies for LTD benefits less than a year after the claimant signs up for the benefit, the insurance company will look at all medical records and pharmacy records for the entire year plus the look back period. These exclusions are very, very broad.
For example, a claimant may have been prescribed a medication for the treatment of anxiety during the look back period. Later, the claimant develops a back problem with muscle spasms. The same medication that was prescribed to the claimant to treat anxiety is now being prescribed to treat muscle spasms. The insurance company will get the claimant’s pharmacy records and claim that the claimant was being treated for muscle spasms because they took the medication. The insurance company will then refuse to pay benefits based on the preexisting condition exclusion.
In order to effectively combat these unfair claim denials, it is critical that a disabled claimant seek the advice of an experienced attorney, especially if the claim is an ERISA preempted claim. Check the last several paragraphs of your denial letter for your rights to appeal and any mention of the word ERISA. Usually you have only 180 days to submit an appeal. Do not file an appeal without consulting with an attorney! For more information, please see our website at www.DisabilityDenials.com.