When it comes to long-term disability claims, individuals may question whether their pre-existing conditions will impact their claim. While the path to securing disability benefits is already fraught with challenges, pre-existing conditions add an additional layer of intricacy, demanding a nuanced understanding of legal and medical considerations. So, how do pre-existing conditions affect the eligibility for long-term disability benefits, and what role do they play in assessing one’s ability to work and carry out daily activities?

This blog sheds light on the multifaceted impact of pre-existing conditions on long-term disability claims in Ontario, delving into the legal landscape and practical considerations that can significantly shape the outcome of a disability claim. By unravelling the intricacies of this interplay, individuals will gain valuable insights into how pre-existing conditions can influence their journey toward securing the financial support they need during challenging times.

What Is a Pre-Existing Condition?

In the context of long-term disability claims, a pre-existing condition can be any medical condition an individual has been diagnosed with or treated for before the commencement of a disability insurance policy. The definition applicable to your policy is critical to how insurance providers determine a claimant’s eligibility for disability benefits. Temporary illnesses and injuries (for example, a common cold) will not impact your claim.

An insurance provider will scrutinize a long-term disability claim closely, particularly when a claim involves a pre-existing condition. The more chronic and permanent a pre-existing injury or condition is, the more closely the insurance company will review your claim and supporting evidence. Assessment of a pre-existing condition will also determine whether the claim is directly linked to the pre-existing condition or if it is a new medical issue. In this assessment, a claimant’s medical history and the nature and severity of any pre-existing conditions are considered.

Exclusion Clauses and Exclusion Periods in LTD Policies

LTD insurance policies may contain an exclusion period or specific clauses that limit or deny coverage based on pre-existing conditions. As such, policyholders need to have a sound understanding of these terms and conditions to assess the impact on their claims. Insurance companies may consider various medical conditions as “pre-existing conditions”. Depending on the wording of your long-term disability policy, any chronic or serious health condition that could force you to miss extended periods at work may be included in the definition.

If you have a medical condition diagnosed before the start date for your disability insurance coverage, this may be considered a pre-existing condition according to your insurance policy. In some cases, however, an exclusion clause may only apply for a specified period of time after the policy goes into effect. If you file a claim for coverage during the specified period (often two years), the insurance provider may attempt to deny your claim based on the pre-existing condition or exclusion clause, even if your disability claim has no relation to your pre-existing conditions. However, if your claim for coverage is unfairly denied, you may be able to challenge the denial through an internal appeal or lawsuit.

It is also vital for individuals to be mindful of how changing employment might impact their coverage if they suffer from a pre-existing condition. If you can work but have a pre-existing condition and a disability occurs within the exclusion clause time frame, it is important to have an understanding of the possible consequences or denials you may face. In some cases, it may be possible to have the pre-existing exclusion waived.

LTD Claim Denials Based on Pre-Existing Conditions

It is impossible to anticipate and plan for every contingency. When a claim for long-term disability benefits has been filed, an insurance company will take a comprehensive review of your medical records, consult with medical experts, and may require you to attend independent medical examinations to better understand your disability and limitations or restrictions. While it is not uncommon for claims to be denied based on an insured’s pre-existing conditions or illnesses, this is not necessarily the end of the road.

Most insurance companies have an internal appeals process that can be exhausted before alternative legal avenues can be explored. However, with the right approach and legal guidance, appealing and overturning such a denial is possible. To ensure that your appeal has the best chance of success, a claimant must gather additional medical evidence, obtain expert opinions, and present a well-structured and comprehensive argument as to why the denial should be overturned. When appealing a denial, a claimant must know the strict deadlines and limitation periods applicable to their claim. If a filing deadline is missed, a claimant may forfeit their rights. Therefore, working with a trusted disability lawyer can help ensure your appeal documents are filed within the appropriate timelines.

Critical Takeaways for Claimants With Pre-Existing Conditions

It is essential to consult with an experienced long-term disability lawyer to ensure you are aware of your rights when going through the claims process. A disability lawyer can also help you navigate the challenges posed by your pre-existing conditions in your disability claim to ensure that you receive fair treatment and the benefits you are entitled to. If your long-term disability claim has been denied based on a pre-existing injury or illness, it is important to speak with a knowledgeable disability lawyer who can inform you of your appeal options, help you prepare an appeal, ensure filing deadlines are adhered to, and represent you if litigation is necessary.

Contact Mulqueen Disability Law in Markham for Legal Advice on Long-Term Disability Denials and Appeals

At Mulqueen Disability Law, our experienced disability law team, led by Courtney Mulqueen, regularly advises clients on their options following the denial of a long-term disability claim. When a claim is unfairly denied based on a pre-existing condition, it may be possible to overturn such a decision through an appeal or lawsuit. If you have questions about how your pre-existing condition might impact your claim for benefits, contact us online or by phone at 416-900-0368 (or toll-free at 833-363-3LAW [3529]) to learn how we can help you.