No insurance policy covers everything, particularly disability policies, which are designed to cover those who become disabled. Because disability claims can be so expensive, particularly long-term disability claims, it’s not uncommon for insurance companies to do everything they can to show that an injury falls outside the limits of a disability coverage policy, meaning they may deny their obligation to pay for it. These policy limits are known as “exclusions” and they are designed to help keep costs down while regulating what a company is and is not responsible for. Let’s take a look at some of the more common exclusions you could face as part of your injury claim.
As stated previously, insurance policies are designed to protect both their insureds in the event they are injured, and the insurance company from their financial obligation should an insured submit a claim that is excluded from coverage. One of the most common types of exclusions is a pre-existing condition, or any injuries or disabilities you had prior to the effective date of your insurance policy. If knowingly had one of these conditions before your policy began and even received treatment for it, you would become ineligible for long-term disability benefits if your disability pertains to this condition.
What is usually considered a “pre-existing” condition can vary between policies, however the most common timeframe is a 12-month exclusion. This means two things:
- You were aware of and treated for the condition in question within 12 months of your policy’s effective date
- You received treatment or took prescribed medications for your condition within three to six months of your policy’s effective date
How the Exclusion is Supposed to Work
The exclusion regarding pre-existing conditions is most commonly found in group disability insurance plans such as ones you would receive from your employer. However, individual policies may have this exemption as well. Unlike group policies, you may still be able to obtain coverage for the condition by paying higher premiums for a medical exclusion rider, provided you qualify.
For normal disability insurance policies, your insurance company often reserves the right to deny your claim in two situations:
- Your condition is part of a pre-existing condition you failed to disclose when you applied for your disability coverage in the first place
- Your condition started within a stated period after the policy became effective (usually two years).
Both of these situations are extremely broad, and as we’ll discuss in more detail in a moment, companies often use their vagueness to frame your condition in their favor and deny your claim.
Wrongful Use of Exclusions
Because insurance companies are in business to make money, they make it their objective to deny as many claims as possible in order to salvage their own bottom line. This is particularly true for long-term disability cases, which can cost millions more than a short-term disability case. As a result, companies will frequently stretch their definition of a pre-existing condition to cover a condition and therefore deny your claim.
Let’s look at a couple examples of how this can happen. Remember how we mentioned that companies may consider a condition “pre-existing” if you took medication for it within several months of your applying for disability? It’s not uncommon for companies to locate any prescriptions for the same medications you took for your condition in the time before your policy began. Even if the prescription was for an entirely unrelated issue, they often use it as evidence to support that your condition is pre-existing and therefore exempt.
Companies also use prior medical records to look for anything that might support your condition forming before you applied for you policy. If your disability is for something like Alzheimer’s, your company may attempt to use treatment for stress or anxiety as proof of a pre-existing condition and deny your claim.
What can you do in this situation? The first thing you should consider is reaching out to a long term disability attorney who has the skill and experience you need on your side to fight back when your insurance company misrepresents you and your condition. A lawyer can help you effectively appeal your decision and demonstrate that your condition in fact should be covered through the terms of the policy your company distributed and therefore you are entitled to benefits.