Pre-Existing Conditions and Disability Claims
Over 40% of Canadians over the age of 20 have some type of medical condition. For most of us, our medical histories are complex. We may have had serious injuries or may be living with a chronic illness.
If you have long-term or short-term disability benefits at work, having a pre-existing condition can result in a denial letter if you ever apply for benefits. Even if you do get a denial letter, it’s not the end of the road. You may have options. To discuss those options, contact Derek Wilson Personal Injury Law for a free consultation with a disability lawyer.
Disability and Pre-Existing Conditions
To understand how a pre-existing condition can affect your disability claim, let’s discuss what a pre-existing condition is. In most cases, it refers to symptoms or a medical condition you had before your insurance policy was in place. More importantly, though, each insurer has a slightly different definition. Whether you get your disability coverage through a group plan or your employer, carefully read your policy to make sure you understand whether you have a pre-existing condition based on how the insurer defines that term.
How Having a Pre-Existing Condition May Affect Your Claim
Your short-term or long-term disability benefits are meant to cover illnesses, injuries, and medical conditions you develop while the policy is in place. Insurance companies don’t want to pay benefits for conditions you’ve had for years. For this reason, insurers will often deny claims if they think you’re applying for benefits for a medical condition you’ve had for months or years before the policy.
In your policy, your insurer should define pre-existing conditions and should outline when your condition may make you ineligible for benefits. In most policies, only specific, defined conditions should make you ineligible for benefits, and only if those conditions happened at specific times—such as before your policy was in place. In most policies, you must be treated for a specific condition or lose time at work because the condition for the illness is considered a “pre-existing condition.”
When you apply for disability benefits, it’s also important to understand the “look-back period” and the “exclusion period.” These are two additional terms that should be defined in your policy.
The look-back period refers to a specific time—usually three months to a year—before the policy is in place when the insurer will be looking closely at your medical records. For example, if you start a new job in May and your disability benefits start then, with a six month look-back period, when you file a claim the insurer will look at medical records dating back six months before May.
The exclusion period is usually six months to two years, and it starts after your policy is in place. It’s essentially a period of time when you do have insurance, but if you file a claim within that time that’s related to a pre-existing condition, your claim will be denied. For example, if you start the same job in May and have a one-year exclusion period, you will be denied benefits if you apply for benefits in June for a disability related to a pre-existing condition.
When you apply for long-term disability benefits, you’re asked about any health conditions you’ve had. If you don’t disclose health conditions, your claim can also be denied, so it’s important to be transparent and accurate when filing a claim.
In some cases, insurance companies try to get you to release all your medical records. This allows them to look back over your medical history and check when you’ve seen a doctor — and for what?
When an insurer asks you to release your medical records, it can seem like they need the information to give you your benefits and to prove you have a disability. In reality, they may use records to look for any condition or medical history that would allow them to minimize or deny your claim. On the other hand, if you refuse to release medical records, an insurer may assume you’re hiding something and seek to deny you. Insurers use lawyers and investigators to track down as many details as they need about your medical situation.
Always work with your doctor to get relevant medical records sent to the insurer.
Examples of Pre-Existing Conditions Affecting Disability
Let’s say you have a medical condition such as hypertension and visit your doctor to start treatment. Let’s say you’ve had hypertension for three years, and you started a new job three months ago, which caused increased stress, which in turn caused your blood pressure to rise to the point where you needed treatment. Let’s say your disability policy at your new work has a one-year exclusion cause. You may be denied benefits because your medical treatment for your pre-existing condition occurred during this exclusion period.
Or, let’s say that you have had back pain and symptoms of a slipped disc for months or years before your short-term or long-term disability benefits were in place. However, instead of seeking treatment, you waited and then sought short-term benefits after throwing your back out. The insurer may try to deny your claim, saying that you had a pre-existing condition that was untreated and that you should have already sought treatment.
Let’s consider another common example. Let’s say you have a long-term disability policy at work that has a one-year look-back period and a one-year exclusion period. You’re diagnosed with depression four months before starting the job, and eight months into the job, your depression gets much worse, meaning you need to miss work. Are you covered?
In this case, your claim may be denied. The insurer’s look-back period means they can look at your initial diagnosis from four months ago, and your claim occurred during the exclusion period.
On the other hand, if you had cancer or a chronic condition such as endometriosis years ago but haven’t needed treatment for seven years while your policy’s pre-existing period is one year, the insurer won’t deny — or at least should not deny — your claim based on a pre-existing condition.
This is especially relevant for cancer diagnoses, where you may go into remission only for the cancer to come back. Let’s say you have breast cancer and undergo treatment. You beat the cancer and go into remission. You have a group policy with a one-year look-back period and a one-year exclusion period. Three years after you go into remission, you’re diagnosed with thyroid cancer.
While it can seem that the two diagnoses are linked, you should still be eligible for benefits because the cancer occurs outside the exclusion period and is a different kind of cancer.
You may also be able to get benefits in other situations where a policy defines certain conditions by name. For example, a policy may define pre-existing conditions as heart disease, cancers, and pulmonary conditions, but you’re diagnosed with depression. This is why it’s so important to read and understand the policy. Anything not clearly defined in the policy should be covered.
Even if you’re denied benefits, you may have options, and you may want to speak to a disability lawyer to find out what can be done. Your lawyer may be able to get the insurer to review your claim or can appeal a denial. Your lawyer may also be able to prove that you don’t have a pre-existing condition.
With a medical condition, there are many ambiguities and situations where an insurer’s definition of pre-existing conditions may not apply. For example, a policy may clearly indicate that you need to see a doctor and get treatment for your condition to be considered a “pre-existing condition.” However, what if you saw a nurse practitioner and were told to simply observe your symptoms and report back? Or what if you were initially misdiagnosed?
In Ontario, it can take six months or over a year in some cases to see a specialist who can diagnose you with a medical condition. If your diagnosis is delayed because of this situation that’s beyond your control, is it fair for an insurer to deny your claim?
In addition, in many cases, it’s not clear whether a condition you’re diagnosed with is something you’ve had before. For example, let’s say that you had chronic pain a year ago and eventually overcame it through surgery and treatment. Now, let’s say you develop a repetitive strain injury at work that affects your mobility. The insurer may claim you have a pre-existing condition, but in fact, the injury may be a new one. Or the link between your previous condition and current illness may not be clear.
The definition of pre-existing conditions in insurance policies is open to interpretation, and medical diagnoses aren’t always definitive. For this reason, if you have received a denial letter after applying for benefits, consult with a disability lawyer to confirm whether the insurer is correct or whether you should be getting benefits after all.
Contact Us for a Free Consultation
Very few Canadians have never had a serious illness, medical condition, or treatment, and the last thing you want to worry about is whether medical conditions that are beyond your control could have an impact on your ability to get your rightful benefits.
Insurance documents about pre-existing limitations can be difficult to understand and interpret. For this reason, it can be difficult to determine whether an insurer’s definition of “pre-existing condition” applies to your situation. This is especially the case if you have complex, multiple medical conditions.
If you get a denial letter after applying for disability, it can be useful to speak with a disability lawyer. Whether your denial is because of a pre-existing condition or another reason, contact Derek Wilson Personal Injury Law, for a consultation.
My name is Derek Wilson, and I founded Derek Wilson Personal Injury Law because I wanted to put my more than 25 years of experience in disability and personal injury law to work helping people in Hamilton and surrounding areas. My sole focus is on disability and personal injury law, and I have purposely kept my boutique law firm small so that I can provide you with personalized attention. With my law team, I’m the one who handles your case and speaks with you—never a junior lawyer with less experience.
When I started my career, I worked for a Toronto law firm that specializes in insurance defense litigation. This allowed me to see how insurers sought to deny or minimize claims based on medical history. Now, I use that experience to seek rightful benefits for those who have been injured or have become ill.
At the end of the day, I get results. I also understand how challenging it is to be unable to work, which is why I offer no-cost consultation and contingency fee arrangements. This allows you to find out whether you might be able to fight a denial letter and even allows you to work with me without paying legal fees upfront. I get paid when I secure money for you, and I’m always transparent about the fees.
I know it’s discouraging to apply for disability benefits you’re entitled to only to get a denial letter. But please believe me when I say this isn’t always the end of the situation. I have helped countless hard-working employees in Hamilton and surrounding communities get their benefits and have their benefits reinstated.
Before you give up, give me a call at 1-855-769-0418 or reach out to me online, and let’s set up a free consultation. You have nothing to lose. Bring your denial letter when we meet, and we’ll go over it together so we can talk about any options you could have for getting your benefits.
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