My Insurance Claim Was Denied Due to a Pre-Existing Condition

Long-term disability insurance plans are available either individually, through contacting an insurance broker, or often through your employer. When an accident or illness strikes and results in disability, the policyholder expects payment for their inability to work.  Simple errors or omissions when filing a claim, however, can often result in delays and denials of benefits, leaving the policyholder confused and out on the proverbial financial limb.

As with any insurance policy, it’s important to read the fine print. Your long-term disability policy may include provisions that require you to jump through several proof-of-claim hoops and may even allow the insurer to deny your claim altogether based on your previous medical history of pre-existing conditions.

If you’ve filed a disability claim on your long-term disability policy in or around Minneapolis, Minnesota, or in St. Paul, Duluth, and the counties of Hennepin, Ramsey, Dakota, and Anoka, and your claim has been denied or canceled, contact Beedem Law. Our attorneys will review your case, help you gather the medical, vocational, and personal evidence needed for an appeal, and work with you to obtain the best possible outcome.

Long-Term Disability Policy Basics

With a few exceptions, if you are a participant in a long-term disability (LTD) policy through your place of work, your claim will likely be administered and governed under the terms of the Employee Retirement Income Security Act (ERISA) of 1974. ERISA provides protections and regulations and imposes requirements and deadlines on claimants filing claims and appeals and for insurers to respond to the same.

If your employer does not contribute to your LTD, if your employer is exempt from ERISA, or if you purchased a private policy on your own, most likely it will not be covered by ERISA, but by Minnesota law.

It is important to note that many employers also offer participation in short-term disability (STD) plans.  Many of these plans will pay up to two-thirds of your gross monthly salary for up to 26 weeks if you are disabled or pregnant. Long-term policies, however, are for periods that can stretch up to retirement age and beyond and are separate from the state’s short-term plan.

The difference between STD and LTD plans brings up an important feature of long-term disability policies, which is called the elimination, or waiting, period. The elimination period is the time you are on STD. Until that time concludes — say at the end of 26 weeks — you cannot receive any LTD benefits.

Pre-Existing Conditions and Exclusions in LTD Policies

Another term to familiarize yourself with when it comes to LTD policies is exclusions. LTD policies will often exclude coverage from self-inflicted injuries or injuries occurring while committing a felony.

Pre-existing conditions can also be excluded. Say you have high blood pressure and a stroke leaves you disabled, your LTD insurer might deny coverage, at least for the exclusionary period specified in your policy. Likewise, if you suffered a previous slip and fall at work, resulting in a concussion or traumatic brain injury (TBI), and now you’re claiming disability at a later date because of cognitive difficulties, an exclusion can keep you from your benefits.

Be sure to read the fine print about exclusions and pre-existing conditions. Some policies may exclude them permanently.

Common Reasons LTD Claims Are Denied

Let’s face it: insurance companies are in the business of making money. If they can find a reason to limit, deny, or cancel your benefits, it’s in their self-interest to do so. Common reasons cited by insurers to deny, limit, or cancel LTD benefits include the following:

Pre-Existing Conditions: As mentioned above, this is one of the most commonly cited reasons for denying a disability claim. Most LTD policies have an exclusionary period for pre-existing conditions of at least one year’s time, perhaps more. If your disability arises — in the insurer’s eyes — from a pre-existing condition within the first year (or whatever the policy specifies), it will likely be denied.

Late Filing: LTD policies often have “Proof of Claim” or clauses dictating when a claim must be filed. If you file too late, they can use this clause to deny your claim.

Insufficient Evidence: Insurers demand concrete proof of your disability. This often means submitting X-rays, MRI results, blood tests, and the like. A diagnosis by a doctor alone may be deemed insufficient.

Lack of Objective Evidence: This is similar to “insufficient evidence,” but it deals with conditions where hard evidence, such as X-rays, aren’t available. This objection will often arise when chronic pain, chronic fatigue, mental illness, and Fibromyalgia are claimed.

Refusal of an Independent Evaluation: Insurers may also order the claimant to undergo an independent medical examination (IME) with a physician of their choosing. If you refuse, your case may be closed.

Non-Compliance with Treatment Regimen: Some insurers will require that you stick to a prescribed treatment plan for your disability, even if you can’t afford it. They can use this to cancel or limit your benefits.

Change of Definition: Often, an LTD policy will pay out for 24 months if the disabled recipient is unable to perform the essential duties of his or her original occupation. After 24 months, the insurer can change the definition of employment to “any gainful occupation,” meaning you have to go back to work if you can.

Long-Term Disability Insurance Attorneys in Minneapolis, Minnesota

Many of these objections can be overcome, and many arise from the initial filing when the benefit seeker neglects to provide sufficient proof of their disability, or even fills out the form incompletely or inaccurately.

If your claim has been denied because of a pre-existing condition, many courts have held that simply receiving treatment for a condition is insufficient grounds for a disability denial. We can appeal or file a lawsuit based on the argument that treatment for a pre-existing condition is not a valid basis for denial.

Filing a claim may seem like a simple do-it-yourself proposition, but as mentioned above, insurers don’t necessarily have your back – they are protecting their own profitability first. They can trap you in an endless loop of questions and documentation requests. It’s better to let experienced attorneys guide you in the process and help you communicate with the insurance representatives.

If you’re disabled and unable to work in or around Minneapolis and you’re fighting for your benefits with your LTD insurer, rely on the knowledgeable and seasoned attorneys at Beedem Law to help you press your claim for the benefits you deserve. Don’t go it alone. Call us today.


Recent Posts