5 things to know if your long-term disability claim is denied over a pre-existing condition

Citing a pre-existing condition is often a way for an insurance company to try to avoid paying long-term disability benefits. Insurers rely on exclusions in policies that essentially say you cannot receive benefits if you suffer from a pre-existing condition.

This is usually defined as a condition for which you previously received treatment that is tied to the medical issue preventing you from working. But the definitions can vary by policy, so be sure to check yours. It should provide a precise description for a pre-existing condition.

These are the five key things to remember if your insurer tries to deny you benefits because of a pre-existing condition.

1. A pre-existing condition is defined by your insurance policy

A long-term disability policy should always define a pre-existing condition. If the definition is not in the policy or does not apply to your situation, the insurance company cannot rely on it to justify denying your benefits.

If your insurance company denies benefits because of a pre-existing condition, ask to see where in the policy it says that they can deny you on that basis. Ask for the pre-existing condition language directly from the policy.

2. A new disability cannot be classified as a pre-existing condition

If your inability to work is because of a completely new condition or symptoms you have never experienced or been treated for, and if you have continuously had long-term disability coverage for 12 months, the insurer should not be able to deny you for a pre-existing condition. (Some policies will specify that the continuous period of coverage required is less than 12 months.)

3. Having the same condition again doesn’t mean your claim should be denied

Even if you’re off work for a condition you previously suffered from or were treated for, you may still be entitled to long-term disability benefits.

In general, insurance policies will not rule out coverage for any and every related condition. They only exclude coverage if you were treated for that related condition during a time known as the pre-existing period.

As long as you were not treated for the same condition that is currently disabling you during the pre-existing period, then the insurance company cannot deny you benefits on this basis.

4. Can’t make sense of pre-existing condition clauses? Help is available 

If you are having trouble interpreting your policy, contact an experienced long-term disability lawyer as soon as possible. They can tell you if the insurer was wrong to deny you on the basis of a pre-existing condition. 

If your claim is denied, don’t panic. There are many instances in which insurance companies tried to deny claims because of a pre-existing condition and were later found to have done so incorrectly. A disability lawyer can often find a way around the denial.

5. Insurers may ask for medical documents to find out whether you have a pre-existing condition

If you do not give the insurer access to the medical documents they are requesting, they will likely use that as a basis for denying your claim.

If you’re not sure your insurance provider has the right to access these documents, contact me or any other disability lawyer at Samfiru Tumarkin LLP for a free consultation before you provide that information. We will tell you whether their document requests are reasonable or not.

Has your long-term disability claim been denied due to a pre-existing condition?

Contact the firm or call 1-855-821-5900 to secure assistance from a long-term disability lawyer in Ontario, Alberta or British Columbia. Get the advice you need — and the compensation you deserve — from the most positively reviewed disability law firm in the country.

Albert Klein is a disability lawyer and partner at Samfiru Tumarkin LLP, one of Canada’s leading law firms specializing in long-term disability claims and employment law. The firm also provides free advice through Canada’s only Disability Law Show on TV and radio.