DISABILITY BENEFIT TIP OF THE WEEK: Pre-existing Conditions

When you file for Short and Long Term Disability, your insurance company will try to determine whether your disabling condition is a pre-existing condition. Depending on the provisions of your plan or policy, the period during which a condition would be considered pre-existing varies. Many plans/policies state that if you become disabled within the first 12 months of coverage, they will review your records for the year before you became eligible in order to determine if you treated for the same disabling condition. If so, they will consider it a pre-existing condition and deny benefits. For example:

Example A:

You begin working on January 1, 2006. You are eligible for Short and Long Term Disability coverage on April 1, 2006. You become disabled because of a car accident on October 1, 2006. Your plan/policy states that if you become disabled within the first 12 months of coverage that your insurance company will look back to your records for the 12 months before you were eligible for coverage - in other words back to April 1, 2005. Because you are disabled as a result of an accident after you became eligible for coverage, your insurance company will determine that your disablity is not the result of a pre-existing condition.

Example B:

You have a car accident on September 1, 2005, hurt your low back, and visit your doctor because of the pain. You begin working on January 1, 2006. You are eligible for Short and Long Term Disability coverage on April 1, 2006. On October 1, 2006, you stop working because your low back pain has increased to the point that you can no longer work. Your plan/policy states that if you become disabled within the first 12 months of coverage that your insurance company will look back to your records for the 12 months before you were eligible for coverage - in other words back to April 1, 2005. Because you went to the doctor for your low back pain during the 12 month period before you became eligible for coverage, your insurance company will determine that your disability is a result of a pre-existing condition.

Example C:

You have a car accident on September 1, 2005, hurt your low back, and visit your doctor because of the pain. You begin working on January 1, 2006. You are eligible for Short and Long Term Disability coverage on April 1, 2006. On March 1, 2008, you stop working because your low back pain has increased to the point that you can no longer work. Your plan/policy states that if you become disabled within the first 12 months of coverage that your insurance company will look back to your records for the 12 months before you were eligible for coverage - in other words back to April 1, 2005. Because you did not stop working until you were past the initial 12 months of coverage (i.e. April 2007), your insurance company will not look back to determine if you are suffering from a pre-existing condition.

Even if you have not been officially diagnosed with what your doctor concludes is the underlying cause of your disability, if you treated for the symptoms of the disability during the "look back" period, your condition will be considered pre-existing. For example:

You visit your doctor on December 1, 2005 because of numbness and tingling in your arms and your doctor diagnoses you with carpal tunnel syndrome. You begin working on January 1, 2006. You are eligible for Short and Long Term Disability coverage on April 1, 2006. Your symptoms worsen and you stop working on October 1, 2006. On November 1, 2006, your doctor discovers that you actually are suffering from Lupus, not carpal tunnel syndrome. Your plan/policy states that if you become disabled within the first 12 months of coverage that your insurance company will look back to your records for the 12 months before you were eligible for coverage - in other words back to April 1, 2005. Even though you did not have the same diagnosis during the "look back" period, you still treated for the same symptoms, and your insurance company will consider your condition to be pre-existing.

REMEMBER: It is extremely important to read your plan or policy to find out when you are eligible for benefits and when you are out of the "look back" period. If you suffered from any of the same symptoms during the period in question, your condition will be considered pre-existing. If you are not sure when you will be out of the pre-existing condition/"look back" period, consult with an attorney before stopping work.

Copyright (c) 2008 by John V. Tucker and Tucker & Ludin, P.A. All rights reserved. For assistance with your Long Term Disability claim, ERISA Disability benefit claim, Social Security Disability claim, or Veterans Disability compensation or pension claim, call Disability Lawyer John Tucker at (866) 282-5260.