Disability policies often exclude pre-existing conditions from coverage. A pre-existing condition is any medical condition an individual has before purchasing a disability insurance policy or before the policy’s coverage becomes effective.
The purpose of pre-existing condition exclusions is to protect insurance companies from individuals who purchase coverage only after they know they will need it. By excluding pre-existing conditions, insurance companies can avoid paying claims for conditions that the individual already had before purchasing the policy.
Pre-existing condition exclusions can vary from policy to policy, but they typically apply for a specific period, such as six months or a year, after the policy’s coverage begins. During this period, the insurance company will not pay claims related to any medical condition the individual had before the coverage became effective.
Always review the pre-existing condition exclusion language in a disability insurance policy carefully or else consult with disability insurance lawyer. Some policies may define a pre-existing condition broadly, while others may have more specific criteria. In some cases, the insurer might waive pre-existing condition exclusions if the individual can show evidence of continuous coverage or if the policy has a guaranteed issue provision.
Pre-existing condition exclusions typically apply for a specific period after the policy’s coverage begins. Every policyholder should review the pre-existing condition exclusion language in a disability insurance policy carefully to understand its scope and limitations.
If you have questions or received a denial of disability benefits due to a pre-existing condition, never wait to consult with a disability attorney.
Examples of Pre-existing Conditions for Disability Insurance Purposes
Pre-existing conditions for disability insurance purposes can vary widely depending on the insurer and the policy. Generally, a pre-existing condition is any medical condition that an individual has before they apply for or purchase a disability insurance policy.
Here are some examples of pre-existing conditions that may affect eligibility for disability insurance coverage:
- Chronic medical conditions: These are long-term medical conditions that require ongoing treatment or management, such as diabetes, asthma, or heart disease. Pre-existing conditions may also include chronic pain conditions like fibromyalgia or chronic fatigue syndrome.
- Mental health conditions: Pre-existing mental health conditions like depression, anxiety, bipolar disorder, or schizophrenia can also affect eligibility for disability insurance coverage. Mental health conditions may require treatment, medications, or hospitalization, leading to missed work or disability.
- Cancer or other serious illnesses: Individuals diagnosed with cancer or other serious illnesses before applying for disability insurance may have a pre-existing condition. Cancer treatments can require enormous sums of money and time off from work, leading to a disability claim.
- Previous injuries: If an individual has suffered a previous injury, such as a back injury or knee injury, they may have a pre-existing condition that can affect their eligibility for disability insurance. These injuries may cause chronic pain or limit their ability to perform their job, leading to disability.
- Substance abuse disorders: If an individual has a history of substance abuse or addiction, they may have a pre-existing condition that can affect their eligibility for disability insurance. Substance abuse disorders may require treatment, hospitalization, or time off from work, leading to disability.
- Pregnancy: If an individual is pregnant when they apply for disability insurance, they may have a pre-existing condition. Some disability insurance policies may exclude claims related to pregnancy or childbirth.
- Surgeries or hospitalizations: If an individual has had surgery or has been in the hospital for a medical condition before applying for disability insurance, they may have a pre-existing condition. These medical procedures may require time off from work, leading to disability.
Note that pre-existing conditions do not automatically disqualify an individual from being eligible for disability insurance coverage. However, the presence of a pre-existing condition may affect the individual’s premium rates or the terms and conditions of their coverage.
Those applying for disability coverage should disclose all pre-existing conditions during the application process, as failure to do so may result in the cancellation of the policy or a claim denial. Some disability insurance policies may offer a waiver of pre-existing condition exclusions when issuing the coverage to the policyholder.
If you receive a benefits denial due to a pre-existing condition, always discuss the matter with a disability attorney. There might be steps to take to prove you are eligible for benefits after all.
Symptoms of Pre-Existing Conditions Might Qualify for Disability Benefits
Pre-existing conditions can make it difficult for individuals to maintain employment and lead to missed work or disability. In some cases, symptoms of pre-existing conditions may qualify individuals for disability benefits.
Even if your policy excludes benefits for your underlying pre-existing condition, new effects of your condition might arise and prevent you from working. This might qualify you for benefits, and it is always worth discussing this possibility with a disability claims lawyer.
Here are some examples of symptoms of pre-existing conditions that may qualify for disability benefits:
- Chronic pain: Chronic pain is a common symptom of many pre-existing conditions, such as arthritis, fibromyalgia, or chronic fatigue syndrome. Chronic pain can make it difficult for individuals to perform their job duties, leading to missed work or disability.
- Fatigue: Fatigue is another common symptom of many pre-existing conditions, such as multiple sclerosis or lupus. Chronic fatigue can make it difficult for individuals to maintain employment or perform their job duties, leading to missed work or disability.
- Cognitive impairment: Cognitive impairment is a common symptom of many pre-existing conditions, such as traumatic brain injury, Alzheimer’s disease, or Parkinson’s disease. Cognitive impairment can make it difficult for individuals to perform their job duties, leading to missed work or disability.
- Mood disorders: Mood disorders, such as depression or anxiety, can be symptoms of pre-existing conditions or can be standalone conditions. Mood disorders can make it difficult for individuals to maintain employment or perform their job duties, leading to missed work or disability.
- Respiratory problems: Respiratory problems, such as asthma or chronic obstructive pulmonary disease (COPD), can be symptoms of pre-existing conditions or standalone conditions. Respiratory problems can make it difficult for individuals to perform their job duties, leading to missed work or disability.
- Digestive problems: Digestive problems, such as inflammatory bowel disease or irritable bowel syndrome, can be symptoms of pre-existing conditions or standalone conditions. Digestive problems can make it difficult for individuals to maintain employment or perform their job duties, leading to missed work or disability.
- Vision or hearing loss: Vision or hearing loss can be symptoms of pre-existing conditions or standalone conditions. Vision or hearing loss can make it difficult for individuals to maintain employment or perform their job duties, leading to missed work or disability.
Note that simply experiencing symptoms of a pre-existing condition does not automatically qualify you for disability benefits. To be eligible, the symptoms must be disabling enough to prevent you from working and earning your usual income.
Disability insurance policies each have their own eligibility requirements and benefit limitations. As a policyholder, you want a lawyer to carefully review your disability insurance policy to understand the terms and conditions of your coverage.
Often, you might believe that getting benefits is hopeless due to your pre-existing condition, but a skilled disability attorney might see things differently. It is always worth consulting with a legal professional about your options for disability benefits or appeals.
Did an Insurance Company Deny Your Disability Claim?
If an insurance company has denied your disability claim, it can be a frustrating and overwhelming experience. You may feel that you have no options or recourse, but there are steps you can take to appeal the denial and fight for the benefits you deserve.
The first step is to carefully review the denial letter and understand the specific reasons why your claim received a denial. By law, insurance companies must provide a detailed explanation for a claim denial, including any specific policy provisions or medical evidence they used to support the decision.
Once you understand the reasons for the denial, you can begin the appeals process. Most insurance companies have an internal appeals process that allows you to challenge the decision and provide additional evidence in support of your claim. It is important to follow the appeals process outlined by the insurance company and provide any requested documentation or information in a timely manner.
If your claim remains denied after exhausting the internal appeals process, you may have the option to file a lawsuit against the insurance company. This can be a complex and time-consuming process, but it may be necessary to obtain the benefits you deserve.
Working with an experienced disability attorney can be beneficial during the appeals process and in filing a lawsuit, as they can provide guidance in navigating the complex legal system. An attorney can also help gather additional evidence and medical records to support your claim.
Remember that insurance companies are for-profit entities, and their primary goal is to minimize payouts and maximize profits. Denying disability claims is a common tactic that insurance companies use to save money, but it does not mean you do not deserve benefits for your disabling condition.
With persistence and the right legal representation, you can fight for the benefits you deserve and ensure your financial future is secure.
A Disability Insurance Claims Lawyer Can Help With an Appeal
If you have been denied disability benefits by an insurance company governed by the Employee Retirement Income Security Act (ERISA), you need to work with a disability insurance claims lawyer to appeal the decision.
ERISA is a federal law that sets standards for employee benefit plans, including disability insurance policies provided by employers. ERISA also governs the appeals process for denied claims. This process can be complex and time-consuming, and it is often beneficial to have an experienced attorney on your side to navigate the system.
A disability insurance claims lawyer can:
- Review the claim denial: A lawyer can review the insurance company’s reasons for denying your claim and identify any errors or inconsistencies in the decision.
- Gather additional evidence: If additional medical evidence or documentation is needed to support your claim, a lawyer can help gather this information and present it to the insurance company.
- Draft an appeal letter: A lawyer can draft a strong appeal letter that addresses the insurance company’s reasons for denying the claim and presents a compelling argument for why they should provide benefits.
- Represent you in administrative hearings: If an administrative hearing is necessary as part of the appeals process, a lawyer can represent you and present your case to the administrative law judge.
- File a lawsuit: If all other avenues have been exhausted and the claim is still denied, a lawyer can file a lawsuit against the insurance company on your behalf.
Always choose a lawyer with experience in ERISA disability claims and who understands the nuances of the law. Look for a lawyer who has a track record of success in handling similar cases and who is willing to fight for your rights and interests.
With the right legal representation, you can appeal a denied disability claim and obtain the benefits you deserve. The appeal process is complex, as ERISA sets out strict procedures you and your lawyer must follow. These include:
Administrative appeal – You must first appeal directly to the insurance company that denied your claim. This seems counterintuitive, but with legal help, you can provide additional information and evidence for the insurance company to consider. Once you have a complete claim file, the insurer will review your claim again and overturn or uphold the denial.
Federal lawsuit – ERISA appeals happen in federal court, and your lawyer can file your lawsuit in the proper district court. The court can only review the information you already provided to the insurance company, and the judge will decide whether they agree with the denial or not.
Working with a skilled lawyer in Louisiana can increase your chances of success in appealing a denied claim under ERISA. The appeals process can be challenging, and insurance companies often have legal teams working to minimize payouts and protect their profits. Having an experienced attorney on your side can level the playing field and protect your rights.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded J. Price McNamara ERISA Insurance Claim Attorney, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts