kotak: how does a pre-existing condition impact a ltd claim?
although the terms of each ltd group policy differ, almost all include an exclusionary provision preventing claimants from obtaining benefits for an illness or injury related to a previous condition.
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if your long-term disability benefit claim has been denied because of a pre-existing condition, you can challenge the decision. getty
if your long-term disability (ltd) benefit claim has been denied or benefits cut off due to a pre-existing condition, that doesn’t mean you should give up. there are ways to fight your insurance company’s decision.
typically, a pre-existing condition will be one for which an insured person has previously sought treatment, medication and/or medical services, and that can be linked or related to the current ailment preventing them from working.
although the terms of each ltd group policy differ, almost all include an exclusionary provision preventing claimants from obtaining benefits for an illness or injury related to a pre-existing condition.
pre-existing conditions are scrutinized when a claim occurs during the exclusion clause period of the policy. exclusionary periods vary depending on the policy. the most common pre-existing exclusion clauses give the insurer the right to investigate and inspect an insured person’s medical history if they initiate a claim within the first year of coverage, and the pre-existing period looked at is typically 90 days prior to the date the person’s insurance for ltd benefits became effective.
what constitutes a pre-existing condition?
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according to canada public health services, the top 10 chronic diseases among canadian adults are: hypertension, osteoarthritis, mood or anxiety disorders, osteoporosis, diabetes, asthma, copd (chronic obstructive pulmonary disease), ischemic heart disease, cancer, and dementia.
unfortunately, many providers are often very eager to quickly invoke the exclusion for any prior conditions or treatment they can find evidence for — however loosely they may relate to your current ltd claim.
for example, an insured person who is unable to work because of a back injury could find their ltd benefits denied because they were prescribed pain medication during the exclusionary period, without their insurer delving into any further details to determine whether the treatment is related to the same injury or condition.
disability cases often include a psychological aspect
an increasing number of disability cases involve a psychological aspect, with conditions such as anxiety, depression, post-traumatic stress disorder and obsessive-compulsive disorder. often the insurance company lumps them unfairly together as a group of interrelated, pre-existing conditions.
some insurers may interpret your policy such that mere consultations with a family doctor or other health-care professionals regarding certain conditions will be enough to invoke the exclusion, even if you never received any treatment as a result.
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when claims are denied unfairly, we start by collecting the client’s medical records, so that we can get a full picture of exactly when any consultations, diagnoses and treatment occurred. and we know it is important to act quickly to minimize the chances of an interruption in payments.
in many cases, we find that insurers have effectively manufactured pre-existing conditions in situations where workers suffer from multiple, unrelated conditions. in other cases, we find that the denial cannot be supported given the circumstances after a careful reading of the ltd policy at play, or as a result of ambiguities in its specific wording.
remember, you can often fight an unfair decision.
nainesh kotak, is the founder of kotak personal injury law, a firm focusing on protecting their client’s rights to justice and obtaining the compensation their clients deserve. he also serves as the chair of the long-term disability section of the ontario trial lawyers’ association.
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