Long-term disability insurance (LTD) provides a financial safety net for many people who have to give up working due to a decline in their personal health. Unfortunately for anyone who has ever experienced less than perfect health before getting a long-term disability policy, filing LTD claims with pre-existing medical issues can often be frustrating. Pre-existing conditions’ impact on LTD eligibility can be significant, sometimes even when there is no clear connection between an individual’s current long-term disability and prior conditions. Understanding how insurance companies approach pre-existing conditions in evaluating LTD claims can put you in a position to file a strong initial claim, supported by effective medical evidence. The same background can also help you advocate for yourself if you receive an initial denial.
Pre-Existing Conditions: Impact on LTD Claim Denial
While it is not quite true that all pre-existing conditions are automatically excluded from LTD coverage, they may receive LTD denials more often than other types of claims. Insurance adjusters are paid to look for reasons to deny claims or reduce benefits, so often they will look for evidence that a new long-term disability claim is related to a pre-existing condition. Even if your long-term disability and prior conditions are unrelated, your claim may face enhanced scrutiny during the insurance provider’s internal review process if the adjuster handling your claim sees potential overlap between your current diagnosis and any symptoms or treatments documented in your medical history.
Considerations for Comparing Policies
A pre-existing condition’s impact on LTD claims may occasionally be a self-limiting problem: Sometimes LTD claims with pre-existing medical issues are subject to a temporary exclusion or period. After this period ends, long-term disability and prior conditions may be treated like any other type of LTD claim. If you are selecting your own long-term disability insurance policy, the terms regarding pre-existing conditions’ impact on LTD claims are an important point to compare across policies.
Planning Ahead
Even if you fully expect to be able to continue working until you reach retirement, evaluating how a long-term disability plan handles LTD claims with pre-existing medical issues can be especially critical for anyone who has been diagnosed with a condition that is known to be disabling in some cases. Conditions that cause chronic back pain can fall into this category, since back pain often gets worse with age. Several mental health conditions can also become disabling if previously effective treatments stop working, sometimes with little warning.
Pre-Existing Conditions: Impact on LTD Eligibility
A different type of concern regarding long-term disability and prior conditions sometimes comes up for people who are looking to purchase long-term disability insurance on their own. Group plans through employers often have an initial sign-on period during which new employees cannot be turned down for a policy. Individual plans do not typically have a structure in place to ensure this type of guarantee.
You are likely aware that life insurance companies often charge dramatically higher rates to individuals they consider “high risk,” and sometimes deny them coverage altogether. A similar logic sometimes applies to individual applications for long-term disability insurance plans. Filing LTD claims with pre-existing medical issues may never be an issue for people who are considered ineligible for individual LTD plans.
Long-Term Disability and Prior Conditions: Defining “Pre-Existing”
Most people will probably have no trouble guessing that “pre-existing” generally refers to the period before the person’s long-term disability policy went into effect. However, some people contemplating LTD claims with pre-existing medical issues may be surprised to learn that “before” may not encompass an individual’s entire medical history, from birth to the time an insurance adjuster or actuary is assessing his or file. Instead, many LTD policies make use of something called a “look-back” period in determining a pre-existing condition’s impact on LTD eligibility.
Understanding the “Look-Back” Period for LTD Claims With Pre-Existing Medical Issues
A “look-back” period means that when the insurance company receives a new LTD claim, their adjuster “looks back” through an individual’s medical records covering a specified period of time leading up to when their policy began. Interestingly, a date range after a policy’s activation date may be important to the function of a look-back period, as well as the range prior to the policy’s activation date that the look-back period actually covers. This is because many LTD plans only use a look-back assessment for claims filed within a certain period after the policy activates. This post-activation stage is often called an “elimination” period.
The date range that is considered open for review can vary, but the year leading up to the start date for the policy is a common choice. Your policy documents will specify whether this is the date range that applies to your plan. The post-activation stage during which any new long-term disability claims are subject to a look-back period review is also set out in the terms of each policy, but some of the most commonly-used ranges are from 90 days, at the shorter end, to a full year, for more restrictive policies.
Scope of Review: How Insurance Adjusters Screen for LTD Claims With Pre-Existing Medical Issues
What many people may not realize is that the review of medical evidence from the look-back period applies whether a specific claim under consideration has any connection to a pre-existing condition or not. All of the policyholder’s medical records from the look-back period may be subject to examination by the LTD insurance adjuster. The adjuster will look for signs of any medical tests or treatments, not just formal diagnoses, that might indicate a possible connection to the current claim.
For policies that employ an elimination period during which disabilities due to pre-existing conditions are excluded from coverage, this broad access to private medical records will usually end when the elimination period does. For policies that permanently exclude LTD claims with pre-existing medical issues, there may not be a “sunset” date on the insurance company’s right to review medical evidence, even if the look-back period itself is limited to a specific date range.
What To Do if You Are Denied Coverage for LTD Claims With Pre-Existing Medical Issues
LTD insurance providers are required to give a reason when they deny a claim. If you receive a claim denial that cites an incompatibility between long-term disability and prior conditions under the terms of your policy, your next steps for working through a pre-existing condition’s impact on LTD eligibility will likely depend to some extent on whether your current disability is actually caused by a condition you already had prior to the activation date of your policy.
One common problem with long-term disability and prior conditions is that insurance companies may deny claims based on treatment the policyholder received during the look-back period, simply because those treatments are sometimes prescribed for the condition that caused them to file for disability. Insurance adjusters may sometimes deny claims on this basis even if the condition was not suspected during the look-back period, and even if there was another explanation for the patient’s symptoms and treatments at the time.
Pre-Existing Conditions’ Impact on LTD: The Role of Medical Evidence
If your diagnosis is new, and during the look-back period you were not receiving treatment for symptoms caused by the condition, you may be able to overcome the claim denial by presenting medical evidence that shows your current LTD claim is not related to any prior conditions. If you were referred for medical tests or treatments during the look-back period, but you were diagnosed at the time with a separate condition that has since resolved, you may be able to present evidence from your medical records to show that those past tests and treatments were unrelated to your current disability. Even a policy with extremely broad exclusions for pre-existing conditions will not normally deny long-term disability claims for any and all past medical activity.
Understanding Exclusions for LTD Claims With Pre-Existing Medical Issues
If your current condition really is linked to symptoms you already had at the time the policy became effective, then showing otherwise is typically not a realistic outcome. In that case, the precise terms of your policy will go a long way toward determining your options for appeal. You will want to review the policy terms carefully to be sure of these two key pieces of information:
- How long the look-back period is
- Whether the elimination period has an endpoint
Sometimes there may be specific terms that address a pre-existing condition’s impact on LTD eligibility when a patient may have experienced symptoms for months or years, but only received a diagnosis after they were already on the long-term disability policy. Delayed diagnoses can be very common with some disorders, especially for progressive conditions. How your policy handles these issues may make a difference in your case.
Take Advantage of Key Resources
Navigating LTD claims with pre-existing medical issues can be frustrating, whether you expect your long-term disability and prior conditions to be related or not. Be prepared to advocate on your own behalf, but also take advantage of the full range of resources available to you. Read your policy terms thoroughly and refer to them often to make sure that you are meeting all the requirements for documentation. You may also wish to discuss those policy terms in detail with a disability rights attorney familiar with pre-existing conditions’ impact on LTD claims so that you can get advice directly tailored to your own situation.
Reach out to the medical professionals who have treated you over the years leading up to your long-term disability claim, especially if they would have reason to be familiar with your patient history through the look-back period. Collect records from your appointments and tests with those providers, and especially any notes in your patient files that indicate suspected diagnoses. If your current disability is truly unrelated to any past medical history, consider asking your healthcare providers for statements indicating what has changed and why your current situation should not be judged as a continuation of any previous medical experiences.
Build a Strong Foundation for Your Claim
Successfully pursuing long-term disability benefits when pre-existing conditions are involved starts with being proactive and informed. Gather detailed records, consult knowledgeable professionals, and stay organized throughout the process. With careful planning and the right support, you can protect your rights and improve your chances of a favorable decision.
