​Pre-existing Condition Exclusion for Life Insurance

May 27, 2023 | J. Price McNamara
ERISA Disability Lawyer
​Pre-existing Condition Exclusion for Life Insurance Fewer experiences in life are worse than losing a loved one—especially if that person is close to you. In addition to grieving their loss, surviving family members must ordinarily deal with estate plans, funeral expenses, and other financial debts and obligations. Following a loved one’s death, many survivors depend upon ERISA benefits to pay for their loved one’s final expenses. However, when some beneficiaries assert a timely claim under a life insurance policy, the insurance company denies the claim, alleging that it is subject to exclusion because of a pre-existing medical condition. Regarding life insurance policies, it can be challenging to interpret the various laws that may protect claimants. You might have legal options if you asserted a claim after your loved one’s death that the insurance company subsequently denied. A knowledgeable ERISA attorney can review your circumstances with you and determine if there is a basis for challenging the insurance company’s claim denial. Your lawyer can also help you pursue the full life insurance benefits you deserve after your loved one’s death. Even in cases where an insurance company excludes a particular medical condition, the symptoms may still fall under the life insurance policy if they brought about your loved one’s death. In those circumstances, you should speak with an experienced ERISA attorney in your area immediately for legal assistance. 

What Is ERISA and How Does It Apply to Life Insurance Claims?

ERISA is an acronym for the Employee Retirement Income Security Act of 1974, which is a federal statute. Congress enacted this statute on September 2, 1974, as part of the United States Code. The law contains provisions on minimum standards for employment benefits plans and pension plans in the private sector. The law prescribes various rules regarding employee benefit plans which purport to protect employees, but in reality, can make benefit claims more challenging, especially following a denial of benefits. Lawmakers intended ERISA to protect plan participants’ interests, as well as the interests of their beneficiaries, by:
  • Establishing the various conduct standards that plan fiduciaries must follow at all times.
  • Requiring that plan beneficiaries receive various disclosures regarding financials and other information
  • Providing plan participants or beneficiaries with access to the federal court system, as well as to appropriate remedies, depending upon the circumstances
However, plan participants and beneficiaries often face procedural difficulties with claims due to ERISA. Interpreting the ERISA statute and applying it to your individual circumstances can be difficult. This is due in part to the complexity of many federal laws and the language that legislators use when drafting these statutes. A knowledgeable ERISA attorney can help you interpret the appropriate provisions and apply them to the facts and circumstances of your situation.

Why Do Insurance Companies Frequently Deny Life Insurance Claims?

As is the case with most insurers, life insurance companies—including those that the ERISA statute governs—are not in the business of paying out large claims and settlements. In fact, insurance companies may lose a significant amount of money when they have to pay out a claim. Consequently, insurance companies and their representatives will look for any possible reason or loophole to deny a claim. In a life insurance policy, the ERISA insurer might attempt to exclude coverage under various provisions, including the pre-existing medical condition provision. Life insurance companies often use arbitrary and capricious reasons for denials. Some of the most common reasons for life insurance claim denials include failing to pay premiums, pre-existing medical conditions, and cause of death. First, an insurance company may deny a life insurance claim based on the insured’s alleged failure to pay the necessary premiums. To keep a policy in effect, policyholders typically need to pay a certain amount in premiums every month. However, insured individuals sometimes forget to pay their premiums, or they may not always afford their ongoing coverage for one reason or another. Before an insurance company cuts a policyholder off, they must typically notify the policyholder in writing of their intention to terminate coverage. In most circumstances, the insurance company may not simply remove coverage without first notifying the policyholder in writing. If the policyholder does not continue making their premium payments after receiving this letter, and if they do not ensure that their payments are up to date, the insurance company can legally cut them off. If a policy beneficiary later attempts to bring a claim after the policyholder’s death, the insurance company may validly deny the claim. Next, the insurance company may attempt to deny a life insurance claim based on a pre-existing illness or medical condition. In fact, many insurance policies have words to this effect in their list of policy exclusions. For example, if the insured individual passed away because of a heart attack, stroke, or another type of pre-existing medical condition—or if they had a history of heart disease—the insurance company may try and deny the claim that a beneficiary later makes. In addition, an insurance company may legally deny life insurance benefits under a policy based on the type of death that occurred. In fact, some life insurance policies specifically exclude deaths that arise from risky behaviors like scuba diving or skydiving. Finally, a life insurance company may deny your claim for benefits if the claim contains inaccurate, incomplete, or misleading information.

How Do State and Federal Laws Place Limitations on Pre-Existing Medical Condition Clauses in Life Insurance Contracts?

In some situations, state or federal laws may limit the pre-existing condition clauses that an insurance company inserts into its insurance contract. When that happens, a beneficiary under a life insurance policy can validly appeal a claim denial. In general, an ERISA life insurance company has the discretion to refuse a policy payout request if medical records (from before the decedent’s death) provide evidence of medical conditions that may have caused or contributed to the death. Such medical conditions may include heart disease or other chronic medical illnesses or problems. However, life insurance companies may be unable to include a pre-existing condition definition in their policy that is unnecessarily restrictive. At the very most, a life insurance policy may only define a pre-existing condition as medical advice, medical treatment, or a medical diagnosis that the decedent received (or a medical provider recommended) within the 12-month timeframe prior to the effective date of coverage under the policy. A knowledgeable ERISA attorney in your area can review the insurance policy language, including exclusions under the policy, and determine whether the insurance company may have wrongfully denied you the insurance benefits you deserve. If that happens, your attorney can help you take appropriate legal action against the insurance company to overturn the denial. 

Successfully Appealing a Life Insurance Benefits Claim Denial

ERISA Violations Attorney Near Me The ERISA statute covers various types of insurance policies, including some life insurance policies. If you are the designated beneficiary on a life insurance policy and the insurance company denies your claim, you may be eligible to pursue an appeal. However, you must follow various steps to successfully appeal a claim denial. Otherwise, your appeal may be subject to rejection. Before you file a lawsuit against an insurance company because of a ERISA life insurance claim denial, you should gather certain types of vital information to support an administrative appeal. This documentation may include your deceased loved one’s medical records from the hospital, a coroner’s report, or a statement that an expert provides to you. The administrative appeal with the insurance company is your only opportunity to introduce new evidence to the case. If you later file a lawsuit against the insurance company in federal court, you cannot submit additional evidence to the case. You must exhaust your one-and-only administrative appeal option before filing a lawsuit against the insurance company. A knowledgeable ERISA attorney can help you gather all of this documentation so that you can present the best possible administrative appeal of the insurance company’s adverse decision.

ERISA Appeal Deadlines

In addition, when appealing a life insurance claim denial, you should follow all appeal deadlines in your case. The ERISA statute provides claimants with various benefits. However, in exchange, claimants must follow strict deadlines—especially when appealing an ERISA insurance company’s claim denial. If you wait until after the deadline to submit your administrative appeal, there is an excellent chance that you will receive another denial letter. Moreover, you may not be eligible to submit any additional appeals. If you win an administrative appeal in your case, the Court will require the insurance company to provide you with all of the life insurance benefits you are entitled to recover as a beneficiary under the policy. 

What to Do if You Receive an Appeal Denial Letter

If you receive an appeal denial letter, you have several legal options that you can consider. First, as the beneficiary under an ERISA life insurance policy, you can file a lawsuit directly against the insurance company in the federal court system. Since ERISA is a federal statute, the federal court system has jurisdiction over your case. Specifically, you can file a lawsuit against the insurance company for preaching a fiduciary duty. By making this allegation, you allege that the insurance company failed to follow through on their contractual obligations to you in good faith. If you ultimately appeal your case in the federal court system, you will likely need to attend a federal court hearing with your ERISA attorney. However, your lawyer cannot introduce new evidence at this time if they did not already introduce the evidence as part of the initial administrative appeal. At the conclusion of your case, a federal court judge will determine whether you are entitled to receive benefits under the insurance policy in question. If the judge decides the case in your favor, the insurance company will have to pay you all of the benefits the law entitles you to receive. 

How Can a Lawyer Help When Filing an ERISA Appeal?

An experienced ERISA attorney in your area can be beneficial when it comes to recovering the life insurance benefits you deserve in your case. Moreover, your lawyer can assist you at various stages during the claims-filing and appeals processes, helping you pursue the full benefits you are entitled to receive. First, your lawyer can read the initial claim denial letter from the insurance company and help you determine the specific reason(s) for the claim denial. They can also help you submit appropriate documentation and paperwork on time when you file your administrative appeal. Suppose the insurance company denies your administrative appeal, and you must file a lawsuit against the insurance company in federal court. In that case, your attorney can represent you in all legal proceedings and make compelling arguments in support of your case. A skilled ERISA attorney will also have the legal knowledge and experience to effectively research helpful ERISA cases throughout the country and cite them during oral arguments. Having a knowledgeable ERISA attorney on board in your case will increase your chances of recovering the life insurance benefits you deserve as a designated beneficiary under the insurance policy.

Speak With a Knowledgeable ERISA Attorney in Your Area Today

J. Price McNamara - Experienced Disability Insurance Lawyer Cases near Louisiana & Texas area
J. Price McNamara - Attorney for Disability Insurance Claims in Louisiana & Texas
Dealing with the death of a close loved one is one of the worst situations that a person must endure during their lifetime. Having to deal with life insurance companies and their representatives during this challenging time can cause even more problems. Therefore, if you recently experienced the death of a loved one, you should retain a skilled attorney to represent you when pursuing the life insurance benefits you deserve under a policy. A ERISA lawyer can take much of the burden off your shoulders and handle the legal aftermath of your loved one’s death—including pursuing life insurance benefits under a policy. Your attorney will do everything possible to help you secure the benefits you need and can help you pursue a successful appeal if the insurance company wrongfully denies your claim.

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J. Price McNamara


Losing my own brother, then my father and sister after long, disabling illnesses just a few months apart drove a career change for me. Before that experience, I never truly understood the place you’re in. I never understood the dramatic impact that receiving (or not receiving) the disability and life insurance benefits you paid for and counted on can have on your life especially when you need to focus on family and healing. What I experienced with my own family now drives the way I view my clients and my work, and I will never forget it!

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