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The term “pre-existing condition” has practically become synonymous with “claim denial” when it comes to disability insurance. There is a general expectation that if you had a medical condition before, you’ll have trouble getting any benefits if you suffer subsequent problems or complications that are in any way related to the original condition.

But you have rights when it comes to disability insurance, and insurance companies do not have blanket authority to deny all disability claims on the grounds of “pre-existing conditions.” Disability insurance attorneys know that insurance companies often deny claims or discontinue benefits wrongfully, so it is important to understand your rights under your policy and how a pre-existing condition can potentially affect your disability claim.

Understanding Pre-Existing Conditions

In general terms, a pre-existing condition is a health problem that affected you before the time you apply for new coverage or file a claim based on an illness or injury. Insurance companies view pre-existing conditions as both an indication that problems are long-standing and that they pose a risk of greater complications in the future.

However, sometimes insurance companies draw very tenuous connections between a past “condition” and a present health problem. One complicating factor is that there is no single industry definition of a pre-existing condition, so insurance companies generally establish their own definitions, which can differ between companies or even between policies.

With the varying, often under-publicized standards, it can be difficult to determine whether a condition truly existed before based on the policy terms. Sometimes, an individual suffers from a pre-existing condition that they are unaware of. All of these issues can complicate claims related to pre-existing conditions.

Pre-Existing Conditions May Be Handled in Different Ways by Insurers

Insurance companies address pre-existing conditions in a number of different ways, further adding to the confusion.

Outright Exclusions

Many short-term and long-term disability insurance policies include provisions that specifically exclude coverage for pre-existing conditions. While they might pay disability claims for injuries or illnesses that are clearly unrelated to a pre-existing condition, they will deny claims that they believe to be related to a medical condition that existed before the incident at issue or before you established your policy.

Waiting Periods

Instead of excluding all claims related to a pre-existing condition, some insurance policies establish a waiting period. The way the waiting period works will be determined by the contractual terms of the policy. For instance, if a long-term disability policy typically requires a claimant to suffer from a disability for six months before becoming eligible for benefits, the waiting period for a claim based on a pre-existing condition may result in you having to wait nine months or a year before becoming eligible for benefits.

Limitation on Coverage Term

Another way insurance companies approach the issue of pre-existing conditions is to limit the term of a disability policy. Instead of a one-year policy with an automatic renewal, your policy might be limited to six months or you may be required to re-apply and undergo thorough exams every time you want to extend the policy.

What Can Be Considered a Pre-Existing Condition?

Since the definition of a pre-existing condition is set by individual insurance companies, there can be considerable latitude in determining what constitutes a pre-existing condition that provides grounds to deny or delay payment of a disability claim. 

Examples can include virtually anything including:

• Elective surgery
• An illness from which you’ve recovered and tested negative for, such as COVID-19
• An injury from a prior accident, such as a neck injury
• A cancer diagnosis
• A test showing high glucose levels which could indicate the potential for diabetes

However, insurance companies often deny claims for injuries or conditions related to a body part where an individual has a pre-existing condition, even when there is a new injury that is clearly due to a separate cause. For example, if you had chronic muscular back pain before but suffered fractured vertebrae in a car accident, it should still be possible to file a disability claim for back injuries because they are clearly unrelated to the pre-existing muscular condition.

Medical Evidence is Crucial

While medical records and other medical evidence are always important in a disability claim, the evidence takes on added importance when a claim potentially involves a pre-existing condition. It is important to show the full extent of the condition previously to show why a claim should not be excluded or limited. 

This is one area where the assistance of both medical and legal professionals can prove invaluable. Attorneys who regularly assist in pursuing disability insurance claims know the evidence that insurance companies cannot ignore and documentation that is persuasive in court if necessary. This might include detailed statements from physicians, results of diagnostic tests, treatment records, medical images, and other evidence. It can also be helpful to keep records of how your ability to function has been impaired by the new injury. Showing that you were able to work before, but now a change has prevented you from working can form the basis of a successful claim when a pre-existing condition is involved.

Interpreting Insurance Policies

While disability insurance companies are able to set their definitions and determine their scope of coverage, once they establish terms in a policy, extend coverage, and accept payment for that coverage, the insurance company has a legal obligation to abide by the terms of the policy as well as any other legal requirements imposed by state or federal law. Often insurance companies will deny claims or terminate benefits even when claims should be allowed under the terms of the policy.

Many people accept denials without question because it can be very difficult to understand what is and what is not covered. Insurance policies are written in complex language with many terms of art that require industry interpretation. Insurance companies seem to count on this as a way to shield themselves from challenges.

However, attorneys experienced in dealing with insurance companies understand how to interpret the language in insurance policies and they can determine whether an insurer is properly following the terms set in the policy. These attorneys also know that insurance companies have legal obligations to act in good faith and the types of conduct that violate those obligations. 

Pre-existing conditions are an issue where contractual interpretation is extremely critical. Often, a disability that is treated as stemming from a pre-existing condition is not sufficiently related to provide grounds for denying coverage. Without knowledge of the industry standards and terminology, however, it can be difficult to successfully challenge an insurance company regarding the interpretation of its own policies. Assistance from the right attorney can make all the difference.

Can You Succeed in Obtaining Disability Benefits if You Have a Pre-Existing Condition?

The bottom line is that while insurance companies make it extremely difficult to get disability benefits if you have been diagnosed with a pre-existing medical condition or suffered injuries in an earlier incident, with the right approach, you can often succeed in showing that your current disability is not the result of the pre-existing condition. When you can make this showing effectively, then the insurance company should provide benefits.

Medical evidence presented persuasively to show how the current disability differs and stems from different causation is generally the key to obtaining disability benefits when you have a pre-existing condition on your record. A disability insurance attorney can work to obtain the right evidence, present it effectively, and make the right arguments to demonstrate why the insurance company should be required to pay benefits. When an insurer sees that your attorney has arguments that are likely to succeed in court, the company will often agree to pay benefits without the need to take the case to trial.

Seltzer & Associates Understands How to Pursue Disability Claims Involving Pre-Existing Conditions

If you need to file a disability insurance claim or appeal a denial or termination of benefits due to a pre-existing condition, the experienced team at Seltzer & Associates knows how to overcome the obstacles and help you gain the benefits you deserve. Call 888-699-4222 or contact us online to schedule a free, confidential consultation to learn more about the assistance we can provide with your claim.