When your lifestyle and livelihood are built on years of hard work, a long-term disability can feel like an unexpected storm. The stakes are even higher when insurance companies exploit pre-existing condition clauses to deny benefits unfairly. These companies often treat pre-existing conditions as a convenient loophole to minimize payouts, even when your disability has little or no connection to prior health issues.
For many, navigating this process can be uniquely challenging. However, a denial does not mean the end of the road. With the right strategy and legal support, you can challenge their decision and assert your rights effectively.
Insurance companies often rely on complicated policy language and selective interpretations of medical records to justify denials. But you do not have to accept their decision at face value. There are ways to fight back, especially with the right guidance and support.
At Kantor & Kantor, we believe that everyone deserves a fair chance to receive the support they need. We understand the nuances of insurance policies and the tactics insurers may use to limit their payouts.
Our goal is to ensure that your side of the story is not just heard, but fully represented, so that your rights are protected, and you get the compensation you need to make your recovery easier.
We are people helping people and we are here to help you secure the benefits you deserve.
What Are Pre-Existing Conditions?
You need to be aware of pre-existing condition limitations, which typically apply only within the first one or two years of your disability insurance coverage. If you have a health condition that existed prior to getting coverage, it may be scrutinized by the insurer. However, the critical issue is whether the condition was treated, diagnosed, or had symptoms during the look-back period (usually one or two years before coverage began).
While insurers often attempt to link your current disability to a pre-existing condition, it’s important to remember that this determination can be contested. Just because an insurer labels a condition as pre-existing doesn’t mean they are correct. Many claims are unfairly denied and can often be overturned with the right approach.
How Insurers Use Pre-Existing Conditions to Deny Claims
Insurance companies are adept at using pre-existing condition exclusions to their advantage. Here are the common strategies they employ:
1. Broad Interpretations of Medical History
Insurers often dig into your medical records, looking for any mention of symptoms or treatments that could link your current disability to a pre-existing condition. Even minor, unrelated health issues might be used to justify a denial.
2. Blurring the Lines Between Old and New Conditions
If your disability is related to a condition you previously experienced but that has worsened or evolved into a new issue, insurers may still argue it is “pre-existing.” For example, if you had mild anxiety years ago and now suffer from severe depression, they might claim the two are the same condition.
3. Over-Reliance on the Look-Back Period
Insurance companies scrutinize the look-back period, trying to connect your disability to even the smallest treatments or symptoms during that time. If you saw a doctor for an unrelated condition, such as migraines, they might attempt to link it to your disabling condition, such as a neurological disorder.
4. Ignoring the Severity of the Pre-Existing Condition
Even if your pre-existing condition was mild or well-managed, insurers might use it as a reason to deny your claim, arguing that it contributed to your current inability to work.
5. Medication Use as Evidence
If you were prescribed medication during the look-back period, insurers may use this as proof of a pre-existing condition, even if the medication was for preventive purposes or an unrelated issue.
6. Misapplication of Policy Language
Sometimes, insurers will deny based on a pre-existing condition where such a denial isn’t supported by the policy language. For example, many policies require the same diagnosis during both the lookback period and the claim itself in order for a condition be deemed pre-existing. For many people whose conditions evolve and don’t receive a formal diagnosis until after they obtain coverage, this can be a critical distinction that your LTD insurer may ignore.
Steps to Take if Your LTD Claim Has Been Denied Due to Pre-Existing Conditions
Denials based on pre-existing conditions are not final. Here are the critical steps to build a strong appeal:
- Understand the Reason for Denial: Carefully read the denial letter from your insurer. It should specify why your claim was denied, including any references to pre-existing conditions.
- Review Your Insurance Policy: Examine your insurance policy details, especially the sections concerning pre-existing conditions. Look for the definition used, the look-back period specified, and any exclusions or limitations.
- Gather Medical Evidence: Compiling strong medical evidence is crucial, but the approach depends on your argument. If your claim is that you are disabled from a non-pre-existing condition, focus on gathering evidence that supports this, such as medical records and doctor’s notes showing that your current disability is unrelated to any prior conditions. However, if your argument is that the condition isn’t actually pre-existing, collect evidence that refutes the insurer’s claim, like a psychiatrist’s opinion that your depression is unrelated to an infection that occurred during the look-back period. In both cases, solid documentation can strengthen your case and challenge the denial effectively.
- Consult with an LTD Attorney: Navigating the complexities of LTD claims, especially those involving pre-existing conditions, can be difficult. Consulting with an LTD attorney who understands the intricacies of insurance law and policy language can increase your chances of a successful appeal. Our attorneys know the law and are prepared to review your case, offering strategic advice tailored to your specific circumstances.
- Prepare and Submit an Appeal: We will prepare an appeal that addresses all points raised in the denial. This appeal will include any additional evidence that supports your case and directly counters the reasons for denial. Timing is critical, as insurance policies have strict deadlines for submitting appeals.
How Kantor & Kantor Can Help
At Kantor & Kantor, we have handled countless cases involving pre-existing conditions, giving us the insight needed to counter these denials effectively. Here is how we can assist:
Policy Analysis
Disability policies are often filled with complicated legal jargon that can be difficult to understand. We will thoroughly review your policy to identify how pre-existing condition exclusions apply, whether your insurer has correctly followed the terms, and where their denial might be flawed.
Building a Strong Case
We work closely with your doctors to gather the medical evidence needed to show that your disability is unrelated to any pre-existing condition, or that the insurer’s reasoning does not hold up. Our team knows how to compile clear, compelling evidence to support your claim.
Appeals and Negotiations
If your claim has been denied, we will guide you through the appeals process, ensuring that every deadline is met and every piece of evidence is presented. Our team is skilled at negotiating with insurers and knows how to counter their arguments.
Litigation
When appeals are not enough, we will not hesitate to take your case to court. Our experienced attorneys are prepared to fight for your rights, presenting a compelling case that challenges your insurer’s decision.
Contact a Long-Term Disability Attorney Today
Insurance policies can be complicated, but they are not immune to scrutiny. If your insurer is unfairly using a pre-existing condition to deny your benefits, there is a good chance we can help.
Our team is experienced in challenging these tactics, working to ensure that you receive the benefits you have worked so hard to secure. Whether it is through negotiation, appeal, or litigation, we are prepared to stand by your side every step of the way.
Contact our experienced Long-Term Disability attorneys at 818-886-2525 for a free consultation.
