If Lengthy-Time period Incapacity (LTD) protection is obtainable via an employer sponsored program accessible at your home of employment, most of those group LTD plans will include a “pre-existing situation” exclusion. All these insurance policies should not underwritten for every of the people within the group, so pre-existing situation exclusions are designed to stop the group LTD plan from insuring somebody who instantly presents a declare as quickly as their protection takes impact. The insurance coverage firm doesn’t take a look at the medical historical past of everybody within the group earlier than insuring them, so the corporate doesn’t know what the chance is of offering every particular person with insurance coverage protection. The insurance coverage firm desires to keep away from paying out claims to individuals who acquire employment with the only function of securing LTD protection to allow them to instantly make a LTD declare.
Have you ever made a declare for LTD
advantages inside the first 12 months that you simply had been insured by your employer’s group
incapacity plan?
The pre-existing situation
exclusion will apply when you make a declare for LTD advantages inside the first twelve
months that you’re lined below the plan. Whereas this time interval might range,
sometimes it’s the one-year interval after the efficient date of protection. If
you submit a declare for advantages inside this one-year timeframe, that may
set off a “pre-existing situation investigation” by the insurance coverage firm.
What’s a Pre-Present
Situation Investigation?
The insurance coverage firm will overview
all of the medical data supplied in help of your LTD declare after an
utility for advantages has been submitted. If a willpower is made that
you consulted with a physician, had any therapy, had been prescribed treatment, and/or
had diagnostic testing, for signs associated to your disabling medical situation
(bodily or psychological) previous to when your LTD insurance coverage took impact, the
insurance coverage can deny your declare primarily based on the pre-existing situation exclusion.
The
function of a “pre-existing situation investigation” is to judge your well being
simply earlier than your LTD protection turned efficient. It will contain a request for
all medical information for the related time interval. The time interval will range
relying on the coverage (so you’ll want to examine the precise coverage wording in
your coverage), however it’s normally for the interval 90 days previous to the efficient
date of your protection. For instance, in case your protection turned efficient on
January 1, 2021, the insurance coverage firm will look again on the window between
October 3, 2020 and December 31, 2020.
That is what is usually known as the “look again window.”
Figuring out Whether or not a
Situation Will Be Excluded as “Pre-Present” is Not At all times Clear.
In 2019 and 2020, we represented a person who had a protracted
psychiatric historical past that included analysis and therapy associated to attention-deficit/hyperactivity
dysfunction (ADHD), generalized anxiousness dysfunction and insomnia. He in actual fact noticed a
psychiatrist associated to those situations in the course of the 90-day look-back window so
the insurance coverage firm denied his LTD declare on the idea that his declare was
excluded by the pre-existing situation provision within the relevant coverage.
Through the administrative attraction, we supplied the insurance coverage firm with medical documentation establishing that the present LTD declare being pursued was primarily based upon impairment(s) trigger by main depressive dysfunction and agoraphobia. We satisfied the insurance coverage firm that whereas our consumer did have a big psychiatric historical past, he didn’t seek the advice of with a psychological well being skilled or search any therapy or analysis for main depressive dysfunction and/or agoraphobia in the course of the 90-day look again window. The insurance coverage firm reversed the choice to disclaim the declare primarily based upon utility of the pre-existing situation exclusion and paid the declare. If you’re experiencing a denial of LTD advantages as a result of the insurance coverage firm decided {that a} pre-existing situation clause within the group LTD coverage excludes your declare, please contact lawyer Kevin M. Zietz for a free session.
