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If Lengthy-Time period Incapacity (LTD) protection is obtainable by an employer sponsored program out there at your house of employment, most of those group LTD plans will comprise a “pre-existing situation” exclusion. These kinds of insurance policies aren’t underwritten for every of the people within the group, so pre-existing situation exclusions are designed to forestall the group LTD plan from insuring somebody who instantly presents a declare as quickly as their protection takes impact. The insurance coverage firm doesn’t have a look at the medical historical past of everybody within the group earlier than insuring them, so the corporate doesn’t know what the chance is of offering every particular person with insurance coverage protection. The insurance coverage firm needs to keep away from paying out claims to individuals who receive employment with the only real goal of securing LTD protection to allow them to instantly make a LTD declare.
Have you ever made a declare for LTD
advantages inside the first 12 months that you just have been insured by your employer’s group
incapacity plan?
The pre-existing situation
exclusion will apply should you make a declare for LTD advantages inside the first twelve
months that you’re coated beneath the plan. Whereas this time interval might differ,
usually it’s the one-year interval after the efficient date of protection. If
you submit a declare for advantages inside this one-year time-frame, that may
set off a “pre-existing situation investigation” by the insurance coverage firm.
What’s a Pre-Present
Situation Investigation?
The insurance coverage firm will evaluate
all of the medical data supplied in assist of your LTD declare after an
utility for advantages has been submitted. If a dedication is made that
you consulted with a health care provider, had any remedy, have been prescribed medicine, and/or
had diagnostic testing, for signs associated to your disabling medical situation
(bodily or psychological) previous to when your LTD insurance coverage took impact, the
insurance coverage can deny your declare primarily based on the pre-existing situation exclusion.
The
goal of a “pre-existing situation investigation” is to judge your well being
simply earlier than your LTD protection grew to become efficient. It will contain a request for
all medical information for the related time interval. The time interval will differ
relying on the coverage (so make sure to test the particular coverage wording in
your coverage), however it’s often for the interval 90 days previous to the efficient
date of your protection. For instance, in case your protection grew to become efficient on
January 1, 2021, the insurance coverage firm will look again on the window between
October 3, 2020 and December 31, 2020.
That is what is usually known as the “look again window.”
Figuring out Whether or not a
Situation Will Be Excluded as “Pre-Present” is Not At all times Clear.
In 2019 and 2020, we represented a person who had a protracted
psychiatric historical past that included analysis and remedy associated to attention-deficit/hyperactivity
dysfunction (ADHD), generalized nervousness dysfunction and insomnia. He actually noticed a
psychiatrist associated to those situations throughout the 90-day look-back window so
the insurance coverage firm denied his LTD declare on the premise that his declare was
excluded by the pre-existing situation provision within the relevant coverage.
In the course of the administrative enchantment, we supplied the insurance coverage firm with medical documentation establishing that the present LTD declare being pursued was primarily based upon impairment(s) trigger by main depressive dysfunction and agoraphobia. We satisfied the insurance coverage firm that whereas our shopper did have a major psychiatric historical past, he didn’t seek the advice of with a psychological well being skilled or search any remedy or analysis for main depressive dysfunction and/or agoraphobia throughout the 90-day look again window. The insurance coverage firm reversed the choice to disclaim the declare primarily based upon utility of the pre-existing situation exclusion and paid the declare. If you’re experiencing a denial of LTD advantages as a result of the insurance coverage firm decided {that a} pre-existing situation clause within the group LTD coverage excludes your declare, please contact lawyer Kevin M. Zietz for a free consultation.
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