If your claim for long term disability benefits was denied because the insurance company said your disability was caused by a pre-existing condition, the ERISA Law Center may be able to help you.
Virtually all long term disability insurance policies and plans deny benefits if the disability was caused or contributed to by a “pre-existing condition.” Such pre-existing conditions exclusions or limitations are defined differently in different policies and plans. Some insurance policies or plans exclude disabilities caused by a condition for which you have been treated within a certain period of time, usually 12 or 24 months, before you became entitled to the disability benefit. Some policies or plans deny benefits if you were treated for the condition causing your disability in that timeframe, or other had diagnostic testing in that timeframe; others if you were treated or had diagnostic testing or took prescription medication; and yet others, if you were treated, had diagnostic testing, took prescription medication, or should have been treated in the insurance company’s opinion during the relevant time period.
Such pre-existing limitations and exclusions are generally legal and enforceable. But not always.
First, insurance company claims personnel are often not well trained and frequently apply the pre-existing condition provisions in insurance policies improperly. Second, there are also special rules that may apply to certain ERISA-governed long term disability policies. All long term disability policies and plans are not insured, although the claims administrator for most non-insured plans is usually an insurance company. If you are claiming benefits from an ERISA governed insured long term disability plan, there may also be other limits on the application of a pre-existing condition limitation or exclusion.
Insured long term disability policies are governed not only by ERISA, which is a federal law, but also to a certain extent by state law. At least one state limits the application of pre-existing condition limitations in insured long term disability policies issued in that state. In that state benefits cannot be denied, only delayed, due to a pre-existing condition limitation.
Other states control and limit the content of pre-existing condition provisions. So, for policies issued in those states, in order to determine whether the pre-existing condition provision in the policy is legal, you have to research the law of the state in which the insurance policy was issued (which may not be the state in which you live and work and may not be the state in which your employer is located) to learn whether that state regulates the content of a pre-existing condition provision, and, if so, whether the provision in the policy is proper under that state’s law.
And there is more. In ERISA governed claims for insured long term disability benefits arising in the Ninth Circuit (California, Oregan, Washington, Nevada, Arizona, Hawaii, Alaska, Montana, and Idaho), pre-existing condition provisions are unenforceable if they are not clear, plain and conspicuous. That requires a complicated analysis of how and where in the policy the pre-existing condition provision is described. Second, even when a pre-existing condition provision is clear, plain and conspicuous, in the Ninth Circuit it does not bar recovery of benefits unless the pre-existing condition “substantially contributed to the disability.” That often requires a different, also complicated, analysis. These Ninth Circuit rules have not been followed in other circuits in the country, yet, but they could be in future.
If your long term disability benefits have been denied because the insurance company claims your disability is due to a pre-existing condition, don’t give up. The ERISA Law Center may be able to help you.